Parasuicidality and Paradox: Breaking Through the Medical Model

Parasuicidality and Paradox: Breaking Through the Medical Model

Ross D. Ellenhorn, MSW, PhD

NEW YORK

Parasuicidality and Paradox

ROSS D. ELLENHORN, MSW, PHD, is trained as a sociologist, a social worker, and a psychotherapist. He has spent the last two decades dedicated to the work of helping individuals with psychiatric symptoms find the psychological and social means for remaining outside the hospital, even at times of great psychiatric distress. His most recent article regarding techniques for diverting hospital use appears in the American Journal of Orthopsychiatry. He has given workshops throughout the country, and has provided consultation to numerous mental health agencies and psychiatric hospitals on this subject. In the mid-1990s, Dr. Ellenhorn designed and then directed the first fully operating outpatient program in Massachusetts specifically aimed to provide alternative resources to the hospital. The program proved to markedly decrease the hospital use of the clients it served. Convinced that flexible treatment that occurs in the community was the best means to help individuals live lives outside the hospital, Ellenhorn started and directed one of the first Program for Assertive Community Treatment (PACT) Teams in the Boston area. Today, Dr. Ellenhorn co-owns and operates Prakash and Ellenhorn, LLC, a private PACT program serving people in the Boston area (see www.prakash andellenhorn.com for more information). He lives on a lake in central Massachusetts with his son, stepdaughter, and wife. You can contact Ross Ellenhorn at his email: Rellenhorn@prakashandellen horn.com.

Copyright © 2008 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Sheri W. Sussman Project Manager: Carol Cain Cover design: Joanne E. Honigman Composition: Apex Publishing, LLC 08 09 10 07 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Ellenhorn, Ross D. Parasuicidality and paradox: Breaking through the medical model / Ross D. Ellenhorn. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8261-1546-1 (alk. paper) ISBN-10: 0-8261-1546-2 (alk. paper) 1. Parasuicide—Psychological aspects. 2. Suicidal behavior— Psychological aspects. 3. Self-injurious behavior—Psychological aspects. 4. Psychotherapy patients—Psychology. 5. Psychotherapist and patient. I. Title. [DNLM: 1. Patient Acceptance of Health Care—psychology. 2. SelfInjurious Behavior—psychology. 3. Institutionalization. 4. Mentally Ill Persons—psychology. 5. Patient Readmission. 6. Physician’s Role— psychology. WM 165 E45p 2008] RC569.E44 2008 362.28'86—dc22 Printed in the United States of America by Bang Printing.

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To Rebecca

Contents

Foreword by Arthur Freeman Preface Acknowledgments Introduction

ix xiii xxiii xxv

Part I: A Theory of Patient Careerism CHAPTER 1

The Borderline Fallacies

3

CHAPTER 2

The Dialectics of Failure

15

CHAPTER 3

The Patient Career

29

Part II: The Practice of The Game The Game: Treating the Problem of Treatment Seeking

61

CHAPTER 5

The Attitudinal Conditions for The Game

75

CHAPTER 6

Relationship

105

CHAPTER 7

Clinician’s Authorship

115

CHAPTER 8

Motivation and Change

129

CHAPTER 4

Part III: Organizational Considerations CHAPTER 9

Deinstitutionalizing Institutions

151

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CONTENTS

CHAPTER 10

References Index

Conclusion: Alienation, Dehumanization, Conformity, and Their Influence on Parasuicidal Behavior

179 185 191

Foreword

Leonard came for his initial appointment with me subsequent to his latest suicide attempt. He was brought to my office by his mother. She carries with her a file of Leonard’s mental health treatment over the last 30 years. In that time, Leonard, now 52 years old, had seen literally dozens of therapists for periods of time ranging from a single session to several years of multiple sessions per week. His therapists read like a “Who’s Who” of Philadelphia psychotherapy. The list included psychiatrists, psychologists, his rabbi, social workers, and counselors. The theoretical approaches that this cohort represented covered the range from the psychoanalytic to the “eclectic.” Leonard had been hospitalized thirteen times over the 30 year period for self injurious behavior. His hospitalizations were of shorter and shorter duration over the years due more to changes in funding and reimbursement than to Leonard’s needs. His most recent hospitalization was for one week. He was taken to the emergency room by his mother after he informed her that he had taken 20 of her 5 mg. Valium. I wanted to interview Leonard but his mother insisted on being in the room to help him deal with the “stress” of the interview. It was clear to me that I too was being interviewed by Leonard and his mother to find out if I would be a proper therapist for him. From the time he entered my office, Leonard did not make eye contact with me. He spoke in a low voice while looking at his hands crossed in his lap. His mother, far more active, tried to answer almost all of the questions that I asked Leonard. I discovered that Leonard lived at home, his father, a surgeon, died five years earlier of a heart attack. Leonard had always lived at home, even when a student. He completed a bachelors degree in history at the University of Pennsylvania in the expected four years. He graduated at age 22, and soon after that had his first parasuicidal event where he cut his wrists. This resulted in a three month hospital stay. He was an only child who had no friends, had never dated, and spent his time reading and, in his words, obtaining the equivalent of a PhD through his reading. He currently spends hours each day surfing the internet, responding to blogs, being active in several chatrooms, and researching arcane ideas.

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When his mother’s litany of his problems, activities and attempts at therapy, Leonard finally raised his eyes, looked at me, and with more than the trace of a smile, asked, “Given that I have seen the most important therapists in Philadelphia, do you think that YOU can help me?” The effect of his question on me was not so much that of a plea i.e., “Please help me,” but rather a gauntlet being thrown down, “Ok, big shot, now it’s your turn.” Chrystal was a resident in a long-term care facility. 46 years old, she had lived in various facilities for the past 25 years. These included group homes, psychiatric hospitalizations, brief attempts to live on her own, and her present placement, a rehabilitation facility. Psychological testing showed an IQ of 120. Chrystal went to the library twice a week to get the latest books, and would spend her days laying in bed reading. When asked to be in therapy groups or to meet with a therapist, Chrystal refused. She just wanted to be “left alone.” Chrystal shared a two-bedded room, having the bed nearest the window. She overlooked a park and had a view of the city skyline. The same view was available to owners of the nearby high-rise condominium apartments at a very high rate. Chrystal had her room cleaned, had the hospital laundry wash and dry her clothes, ate in the hospital dining room not having to shop for, prepare or serve the meals, had entertainment planned for her (ice cream socials, movies, community walks, trips to local museums, and holiday celebrations). Chrystal, weighed 200 pounds at a height of 5’2”. When asked to participate in unit activities, Chrystal would demure. If the staff were insistent (as they sometimes were from their frustration in Chrystal’s noncompliance) Chrystal would threaten to hurt herself, cut herself, jump out of a window, bang her head against the wall until she bled, or run away. This was usually enough to have the staff back away from their therapeutic intent to engage Chrystal and “help” her. What ties both Leonard and Chrystal together are the intents of their caretakers to be therapeutic, caring, helpful, and connected with them in authentic ways. Further, a review of the rather voluminous case material for both individuals includes descriptors from treaters such as “fragile” (do not push this person too hard), “untreatable” (no matter which of our superb and valuable services are offered, the system and the treaters have been unsuccessful), “refractory” (they stay the same even though the treatments that have worked on other patients have not been successful here) or “borderline” (if the treatment is unsuccessful, we will assign the most pejorative diagnosis that we presently use). For Ellenhorn, these two individuals are both active actors in and victims of a medical system that at the same time encourages and discourages their behavior, a system that both holds them close and tries to evict them. Leonard and Chrystal seem to emerge fully formed as adults on a clinical service in

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an institution or part of the clinical caseload of the individual clinician. They are both active actors and victims of a medical system that at the same time encourages and discourages their behavior; a system that both holds them close and tries to evict them. They seem to emerge fully formed as adults on a clinical service in an institution or part of the clinical caseload of the individual clinician. Yet, we know that Leonard and Chrystal had histories that put them on the path and reinforced their traversing that path. For example, these individuals (and the type of patient that they represent, have been in the mental health system for many years. By virtue of their longevity in the system they have acquired certain status (witness Leonard’s experience of having seen every important therapist in Philadelphia). Inasmuch as their treatment was often crisis-based and related to their parasuicidality, they were offered emergency treatment. Often, they were treated only enough to prevent the loss of life, but in fact these multiple brief treatment preserved life but also served to create treatment-resistant strains of the borderline disorder. The systems often have reinforced and maintained the pathology. These brief therapeutic encounters whether as emergent or as part of ongoing therapy were often uni-faceted treatment approaches with the implied or overt promise of “cure.” This, even though the empirical support for therapeutic cures is sparse. More likely then cure, the present model offers the possible need for life-long treatment (Primary Care model). Interesting too is the fact that when the patient’s behavior is most acute in regards to their parasuicidal actions, the patient is placed in an institution where they receive treatment by the most inexperienced therapists (psychology externs, interns, counseling and social work students, and psychiatric residents). This model of “see one, do one, and teach one” is part of the medical model of treatment and training. Finally, temperament is often not factored into treatment. As we become better able to assess the human genome, we will likely find many of the disorders discussed as having a biological base. One way to view both Leonard and Chrystal is that they are not only refractory patients but suffer from what we might call “Helpless Narcissism.” While the term may appear to be an oxymoron, we see several distinguishing features. Both have the personal style of the Yes-But Patient. They may, on the surface, search for treatment, agree to treatment, accept treatment, but somehow not get treated. Ellenhorn succinctly and clearly describes the game played by both patient and the medical/therapeutic system. Perhaps it is less a game than a well choreographed dance sequence, possibly a quadrille. It is well scripted regarding the steps and accepted actions, with little tolerance for creativity or spontaneity. The Helpless Narcissist presents for therapy with apparent “low-self-esteem” expressed directly or interpreted by the therapist

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and associated with depression. Their affect suggests depression, their words suggest depression, and the therapeutic lexicon defines their behavior as that of a depressed individual. They may, in fact, be a manifesting “helpless narcissism.” Many refractory Axis I disorders (e.g., anxiety, depression) may be a manifestation of “helpless narcissism” wherein the patient ultimately hold great power and sway over their environment. Typical schema of the helpless narcissist might include: “If I surrender my symptoms I will be like everyone else.” “I am special and my weekly (or scheduled) meeting with my therapist attests to that.” “Some of the best known shrinks in this area (or in this hospital) have failed to cure me.” “I can’t be beat at this therapy game.” “I have the therapist all to myself for the session time.” “My fragile nature may crack at any moment and the results to the world will be horrific.” “Being ‘sick’ allows me to avoid uncomfortable or disliked tasks.” “Government or institutional subsidies have allowed me to take early retirement.” The gingerbread man called over his shoulder as he made his escape, “Run, run as fast as you can. You can’t catch the gingerbread man.” The parasuicidal patient is for many clinicians the gingerbread man. We find ourselves enlisted in their treatment only to find out that the apparently helpless patient has eluded us…….again. Ellenhorn has written a compelling, multi-layered and complex text. Its overriding strength is its erudition. Unlike other texts on “how to treat….” Whatever the disorder may be, Ellenhorn takes the reader through the theoretical, philosophical, empirical, and clinical issues involved in the paradox of treating the parasuicidal patient within the present system. His arguments for change must engender in the reader a goal of becoming part of the change. For many of us, we have been, over the years, part of the problem. Arthur Freeman, EdD, ABPP Visiting Professor Department of Psychology Governors State University University Park, IL Director of Training Sheridan Shores Care and Rehabilitation Center Chicago, IL Freeman Institute for Cognitive Therapy Fort Wayne, IN

Preface

This book is about people who repeatedly seek help from professionals for their suicidal or self-injurious behavior. The behavior of these individuals is often labeled by clinicians as parasuicidal. But it could also be called recidivistic, in the sense that it is typically viewed by both clinicians and clients as a relapsing or a falling back to an unacceptable state. It is recidivistic in another way, too; we often use the term recidivists for people who cannot seem to disengage themselves from institutions. We talk of recidivism rates, for example, when we study groups of people who repeatedly turn up at hospitals, jails, or prisons. Parasuicidality is a recidivistic behavior in the sense that it typically leads to an institutional response, for it is most often followed by a clinical intervention. In this light, parasuicidal individuals are also hospital or emergency response recidivists. The most common way of understanding the relationship between parasuicidality and institutional recidivism is to see parasuicidal behavior as an individual psychiatric problem that inevitably ends up in the hands of psychiatrically trained clinicians. I believe, however, that the behavior of parasuicidality and the outcome of contact with therapeutic professionals are actually intricately entwined. More specifically, I see parasuicidal behavior as a means some individuals use to access a kind of interaction and a type of social role that can only be achieved through a relationship with clinical professionals. From this view, I interpret parasuicidality as a treatment-seeking behavior, rather than a behavior that simply and inevitably falls into the hands of treaters. As I show in this book, parasuicidality is a means to a psychosocial end. It is a key to specific social resources that help placate a disturbing psychological experience. I am not the first person to claim that parasuicidality is a gesture aimed at attaining social goods. Indeed, clinicians often use words other than parasuicidal for individuals who repeatedly present as suicidal. They call such individuals attention seeking or manipulative. They often call them borderlines, referring to the psychiatric diagnosis of borderline personality disorder (BPD). In this view, parasuicidality is generally seen as a symptom of a broken individual attempting to advocate for herself 1 or as a person suffering a fractured and perpetually disintegrating selfhood attempting to engage with others. From xiii

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my view of parasuicidality as a behavior that is specifically treatment seeking, I take a sometimes radical departure from these common conceptions. I believe the social goods attained through parasuicidal behavior are specifically netted to medical institutions and the attitudes and behaviors of the people who work in these institutions. When a person presents to clinical professionals as suicidal, he enters a social role that can only be accessed through contact with medical institutions. This is the role of the medical patient. I call the perpetual access of this role a patient career or patienthood. In the book, I show how this role protects individuals from certain painful psychological experiences. Like other social roles (for example, husband/wife, employee/employer, child/parent, student/ teacher), patienthood is contingent on the corresponding roles of others. Specifically, patienthood is dependent on interactions with others who are engaged in the roles of clinical treaters. Indeed, patienthood would not exist without clinicians who readily view the world through the medical model. I call the role they assume, the doctor role or doctorhood. Role, of course, is not only a sociological term, but the central component of theater. And, indeed, there exists a strong relationship between the sociological view of role and how roles are played in the theater (alluding to this fact, sociologists [e.g., Goffman, 1959] often call the interaction between people assuming certain roles dramaturgy). Like in theater, social roles are not only contingent on corresponding roles, but are also dependent on certain settings and certain narratives. The roles of husband, wife, child, and parent, for example, cannot exist as viable social categories without a shared understanding of the family unit as a social fact and a shared narrative regarding what it means to have a home. This same social contingency holds true for people assuming the patient role and the role of doctor. Without the medical model and without medical institutions, the roles of patient and doctor would not exist. In the first half of this book, I address how parasuicidality is not simply a problem of patient careerists, nor the result of their relationships with clinicians, but also a symptom of the pervasive use of a medical worldview to define and respond to human behavior. Parasuicidality, in other words, is the result of a culture in which medicine is a driving narrative force. Clearly, this view is in stark opposition to one that sees parasuicidal behavior as appropriately defined by the medical model. If one concludes that parasuicidality is truly a problem that is caused, rather than cured, by clinical interventions, then an obvious question arises: How do we intervene to help individuals who exhibit behaviors that are abetted by clinical interventions? A simple, unrealistic, and rather cruel answer is to suggest that we end treatment, shut down institutions, and no longer respond clinically to parasuicidal behavior. The second half of this book attempts to

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answer that question in a more sensitive and realistic manner. In it, I suggest different strategies to use with parasuicidal behavior that aim to avoid medicalized behaviors and provide the right environment in which individuals may risk escaping their patient careers.

MY ROAD TO THE CONCLUSIONS IN THIS BOOK I began to formulate the ideas for this book over a decade ago. At that time, I was supporting myself as a leader of a psychiatric emergency team while working my way through a PhD program in sociology. Observing my staff on the emergency team, I became increasingly interested in their encounters with clients who habitually and voluntarily report acute symptoms, particularly the symptoms of suicidality and self-harm. Much in sociology has been written about the oppressive effects of institutionalization and stigma on the identities of psychiatric patients, but little had been said about individuals who appear to seek institutionalization and the inevitable stigma that comes when they are hospitalized. Soon, I was offered the opportunity to pursue these questions in depth. In the fall of 1994, I was assigned a day treatment program as one of the cadre of programs I now supervised. I knew many of the clients in this program; they represented the majority of the repeat callers to the crisis team. The staff and director of this program shared a special interest in individuals who suffered from multiple personality disorder (MPD). Alters was the term of the day for the many distinct personalities inhabiting a person suffering MPD. Believing that individuals with MPD often mask or repress their many personalities, the clinicians in the program strove to identify and unearth the alters in their clients. Vigilant for the subtle indications of this disorder, they would interpret a change in mood, a different outfit, a spontaneous gesture, as the possible sign of someone’s alter revealing itself. Remarkably, new clients of the program, with no prior history of MPD, would often rapidly begin to present with such signs. The fact that so many clients unearthed their hidden disorder in the program confirmed for the staff that MPD was much more prevalent than typically assumed (really, epidemic in proportion) and that their program was offering the right kind of milieu to coax out otherwise hidden alters. One type of alter was consistently reliable in all the presentations of MPD by the clients. This was a child alter, one who spoke in a quiet, child-like voice, who was shy and scared, who often sat hiding behind her knees or even lay down on the floor, sometimes in a fetal position. The staff most wanted to reach this alter. The child alter, however, was often inconsolable. The child alter complained consistently of feeling unsafe. One needed to tread lightly

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and sensitively with the child alter. Act too loud, too assertive, and she would retreat, or worse, she would harm herself. More than any of the other alters, the child alter would harm herself physically and threaten suicide. What does one do with a child so injured that she perpetually experiences the world as unsafe and, in turn, is unsafe towards herself ? For the staff, the answer was an environment focused on safety. By providing a soothing and sheltered environment to the child alter, the staff at the program hoped to initiate a corrective psychological experience. In pursuit of this experience, they supported clients bringing their favorite stuffed animals to the program, and they offered a special room with pillows, futon mattresses, soft music, and lights, in which clients could relax for hours at a time as they attempted to center themselves. I was convinced that this day treatment program was dangerously promoting a set of dubious symptoms, and I set out to fully reorganize it. Gone were the teddy bears. The “quiet room” became an office space. I initiated treatment groups focused on building skills and confidence. Over the next 6 months, the staff and their director resigned in protest. Soon, I had a new staff and a new director, all of my choosing. The prior employees warned me that the changes I implemented would not only cause a dramatic exodus of the program’s clients, but that many of these clients would also become seriously suicidal. Neither of these prophecies occurred. The clients remained, the census grew, and the amount of suicidal threats and hospitalizations decreased. Most remarkable was the reduction in reports of multiple personalities. By year’s end, the program was alter free. While the clients of the new program no longer presented with MPD, many still exhibited parasuicidal behavior. They also continued to describe their parasuicidality in a notably similar manner to their predecessors. Unlike the classic suicidal person who sees suicide as a pure and unequivocal act of control, these clients portrayed their suicidal impulses as forced upon them. Instead of identifying this source in a particular alter, however, they employed the lingua franca of people suffering medical conditions. Using the adjectives of illness, they portrayed their parasuicidality as caused by “my depression coming on,” “my illness taking over,” “my sickness making me do it.” They often used a passive voice, speaking of their self-destructive behavior as triggered by a force outside their control: “I’m becoming suicidal.” “The urge to cut is taking over.” “I’m unsafe.” Intrigued by the connection between themes of passivity and parasuicidality, I created two surveys that were disseminated to the clients in the program. The first survey queried clients on what questions typically asked by clinicians caused them the most discomfort. Parasuicidal clients significantly responded with greater discomfort to questions about autonomy and independence

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(for example, “How do you structure your day?” and “What do you plan to do when you leave the program?”) and with more comfort about questions regarding their illness (“What is your diagnosis?” “How has your illness affected your life?”) than other clients with severe and persistent mental health issues. The second survey asked clients for the qualities they sought in therapists and treatment programs. Again, the responses revealed a tendency in parasuicidal clients to seek relationships based on passivity. Regarding therapists, they were more likely to want, for example, “someone who focuses on the difficulties in my life,” than “someone who seeks to understand my strengths.” In a day program they would rather have “a place that offers a sense of a safe community, protecting me from the pressures of my life,” than, for example, “a place in which treatment is focused on how I can take charge of my life.” The staff of the program, their director, and I also conducted behavioral chain analyses of clients, following the course of events leading to any given act of parasuicidality. Repeatedly, we found at the origin of the majority of parasuicidal acts some threat to the client’s definition of himself as passive. Spurred by our growing body of data, I created a group for parasuicidal clients, called ambivalence and change. I periodically asked the group to list the 10 most important forces keeping them from changing their lives. This was an open group, so the group’s participants changed over time. Their answers, however, were remarkably consistent, amalgamating in what I now label in the book The 10 Reasons Not to Change (p. 24). All the 10 Reasons Not to Change focus on the struggle between enacting change and facing one’s agency and accountability by changing. At the root of this struggle is the person’s unending sense of failure. Engaged in the group, I began to realize how much failure, and the fear of facing one’s self as a failure, was an integral force in the lives of parasuicidal individuals. By remaining parasuicidal, these clients assured that they could remain in treatment. By remaining in treatment, they avoided changing. By avoiding change, they avoided confronting their failure. I began to think increasingly about the force of what I now call the dialectics of failure. I wanted to find a way to intervene effectively on this seemingly impenetrable dialectic. One last observation helped consolidate in my mind the need for a new approach to parasuicidality. Many clients of mental health services—no matter the severity of their psychiatric symptoms—work, go to school, or seek services that support them in such endeavors. The clients of our program, on the other hand, sought treatment as their predominant daily activity and jealously guarded their right to their daily treatment. As a sociologist, I thought of our clients as defined by a specific category, one that was, in many ways, more instructive than diagnostic descriptions. They were patient careerists, and

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they found support for their careers in the medicalized norms of typical treatment models. With my new understanding of both the dialectics of failure and the process of patient careerism, I viewed the conventional techniques clinicians used with their clients as often supporting parasuicidal behavior, rather than ameliorating it. Indeed, observing the activities of clinicians in numerous settings, I saw what I believed was an epidemic of iatrogenic encounters, in which the medical model caused more harm than it cured. I was convinced that clinicians needed a therapeutic model that both resisted medicalized norms, and facilitated an interaction between clinician and client that supported change. The techniques suggested in this book were my solution. In the mid-1990s, the staff of the day treatment program integrated these techniques into their treatment and assumed a philosophy of patient careerism as their core theory. Today, the program holds a no-refusal policy regarding parasuicidal individuals, a policy rarely seen in mental health programs. They accept all clients, no matter the severity or repetitiveness of their behavior, nor their level of commitment to treatment. As a last resort for many individuals, the program also rarely discharges its clients because their behaviors have become too difficult (again, this is a policy in sharp contrast to other programs). Inevitably, the program receives and retains those discarded cases, the ones where everything’s been tried, where their behavior is described as malignant and hopeless. Astonishingly, this humble program is often referred such clients from the most prestigious centers addressing the problem of parasuicidality and BPD in our state. When these clients come to our program and they are treated not as borderlines but as individuals suffering with the dialectic of failure, nor as parasuicidal individuals but as people engaged in patient careers, their self-injurious behaviors often decrease and their authentic presentation of their selves increase, often dramatically, and often rapidly. Three years ago I set out to write a paper on our findings at the day treatment program. To help formulate my ideas, I began giving lectures on the subject at local hospitals and community mental health centers. I initially felt a great trepidation about giving these talks, considering how the content was often critical of typical therapeutic techniques and of the mental health system in general. I was thus pleasantly surprised by how many professionals, in diverse roles, enthusiastically responded to the ideas. I expanded this talk into a day-long seminar that I have presented to thousands of people in New England and the Midwest. They have responded with resounding enthusiasm. From the seminars came requests for me to consult to mental health agencies. These agencies, too, have responded enthusiastically to my work. This book is my attempt to document what I’ve learned about individuals who engage in parasuicidal behavior and to suggest new strategies for working with them. The theories and techniques described in the pages

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to follow do not fit neatly into either a psychological or a social category. They are instead intrinsically psychosocial, focused on the intersection between person and environment. Specifically, they focus on the nexus between individuals with particular existential needs and medical institutions that fulfill these needs. As a trained psychotherapist, social worker, and sociologist, I believe both in the validity of private psychological experiences and in the effects of social forces on the individual’s sense of meaning and well-being. I bring this dual insight to the issue of parasuicidality, and that makes the book somewhat idiosyncratic. It is neither purely a treatise against medical institutions or medicalization, nor solely an investigation into psychopathology or the psychological experience of parasuicidal individuals. Instead, my eyes rest most acutely on the space between institution and person, while wavering at times more towards one than the other. This is not the typical way theorists look at a problem that appears to be as individual in nature as parasuicidal behavior is. And a book that suggests actual clinical interventions rarely places such emphasis on social forces. Nonetheless, I think an investigation of the margin between the personal and the public is a just way of understanding human behavior in general. It is justified in one simple fact: that we are social, organizational, and cultural animals, and thus to study our actions as purely psychological or only sociological misses a large part of what makes us human. It is like studying a fish without knowing it lives in water or that it swims. This book is partly an act of what C. Wright Mills (1959) calls a sociological imagination. For Mills, “The sociological imagination enables its possessor to understand the larger historical scene in terms of its meaning for the inner life and external career of a variety of individuals” (p. 5). Mills believed this kind of imagining was vital to a lively and engaged sociology, for it helped sociologists define problems otherwise deemed personal problems as social issues. Poverty, domestic violence, racism, these are issues that sociologists can help move in the social imagination from the personal realm to the public, defining them as netted to institutional issues rather than individual abnormalities. I believe parasuicidality, while a less politically charged issue than the ones above, is fruitfully captured within a sociological imagination. But I also believe that to understand parasuicidality, one must simultaneously assume what could be called a psychological imagination—a way of understanding how individuals look to the social arena to solve their personal problems. In this blending of sociological and psychological imagination, parasuicidality is seen as much as an iatrogenic symptom of medical culture—a behavior aided and abetted by a medical worldview—as it is an act of institutional transference— the enactment of individual needs on institutions.

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Two caveats before you begin reading this book. First, I take for granted that the concepts of self and soul are interchangeable. In other words, I see all psychological issues as spiritual ones, too; they concern the spirit of the individual and how this individual makes meaning of his or her life. This book is in no way religious, but it does concern itself with a particular spiritual crisis that is solved, albeit superficially and only momentarily, by parasuicidality. If you are used to texts that either describe individual psychology as a series of mechanical and easily defined dynamics, or a complex, but purely profane inner world, you might find parts of this book startling, as if the introduction of theological concepts just do not fit the study of something so clearly pathological as parasuicidality. I am convinced that they do fit, for there is nothing I am more sure of than the fact that each of us is more than our psychology or our social context. That “something more” is our consciousness, our soul, beingness—our spirit. The second caveat is that while this book is harshly critical of the pervasive influence of medical culture on our society, generally, and on medical institutions, specifically, it is not a critique of individuals who work in the medical professions, nor is it criticism of Western medicine as a practice. I am a partner with a psychiatrist in a business serving individuals suffering severe psychiatric issues. I have seen the positive effects of psychotropic medications and I have watched my partner work sensitively, kindly, and in an empowering and unmedicalized manner with our clients. I also have family members whose lives were saved through the intervention of modern Western medicine. I thank God that they could access traditional medical institution when they needed them. On the other hand, as a clinician in a field that is largely medicalized, I am also highly ambivalent about Western medicine. Working for over 20 years in the mental health field, I have seen a tremendous amount of bad done to people who avail themselves of psychiatric institutions. Not only are these institutions acutely dehumanizing and mechanical, but much of their practice seems thoughtless and negligent, especially in regards to the use of medications. Increasingly, medication has become the answer to most every human complaint, and psychiatric patients are consuming more and more medications, filling their bodies with an inordinate amount of psychoactive substances. Of course, this focus on pills-as-answers has invaded the general populations (and, to a frightening degree, with children)—we have truly become the Prozac-ZoloftKlonopin-Xanax-Ativan-Ritalin nation. This tendency to solve every human complaint with medicine coincides with the tendency to define every complaint diagnostically. Sadness, anxiety, distractibility, compulsions, obsessions, shifting moods—other than the dull homeostasis of conformity, nothing in the human condition is free from the scavenging grasp of medical culture.

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As a pervasive way of understanding and treating individuals, and as a cultural axis from which norms and rules for behavior emerge, Western medicine is dangerous. As a profession aimed at ameliorating illness and helping people become healthier, it is a field that can do good. This split between medicine as culture and medicine as practice is really the source of my ambivalence regarding modern Western medicine. It is important for the reader to understand that this book focuses on the sociocultural implications of medicine, not on medicine as an applied technique or practice.

NOTE 1. To avoid the awkward writing that is often caused by the attempt to use gender-neutral personal pronouns, I switch—typically by paragraph throughout this book—between female and male pronouns. Research evidences that more women suffer from borderline personality disorder (DSM–IV–TR), and thus some authors (e.g., Linehan, 1993a), have chosen to use the female personal pronoun throughout their books. I switch between gender uses (a) because I believe a significant amount of men engage in patient careers, and (b) because I am suspicious of both an exaggerated labeling of women as borderline, and an inaccurately minimal amount of labeling of men with this disorder. The latter group is often labeled as “sociopathic,” when, in reality, the roots to their behavior are often similar to women labeled as BPD.

Acknowledgments

I am nowhere without my family, and I could not have written this book without them. So, to my wife, Rebecca, I thank you for all your support, your admiration, your expectation that I always remain humble, your patience and your total faith in me. Kelsey, I want to thank you for your increasing selfreliance and responsibility. They have made things so easy around here. Max, you truly bring me nothing but joy. And Max, you dear, dear child, I am sorry I haven’t always been able to pay attention and listen; that I’ve broken promises in order to get back to “the book,” and that I’ve been difficult and irritated sometimes. I promise that I will be more fun now that the book is done. That is an easy promise to keep because you are so cool. I also want to thank my parents, Barbara and Lew Ellenhorn. They remain the best of parents: not “good enough,” but great. Even in my adulthood, they continue as an empathically accurate, insightful, gentle, and attentive source of support in my life. They have given me the confidence to write this book. Ted Ellenhorn and Kent Harbor’s enthusiastic response to an article of mine spurred me to extend it to book form. Michael McGrath, Ann Koplow, Steve Bauer, Suzanne Marcus, Rebecca Wolfe, and Lew Ellenhorn each helped at some point in my writing. Paul Bradford was instrumental in editing the book from beginning to end. In so many ways, Stuart Edelman was very helpful in helping me get organized to write the book and in developing an overall strategy for getting my ideas to print. My editor at Springer, Sheri W. Sussman, has been great, and very, very patient. Many of the ideas for this book are influenced by Raphy Ben Dror’s work on a psychosocial rehabilitation model called “Contextual Rehabilitation.” Raphy’s teaching regarding work with institutionalized mental health patients has had a profound effect on my ideas regarding interventions with patient careerists. For more information on his ideas, go to the web: http://www. crmodel.com.

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“The suicidal feelings are coming over me,” says Jane. “When did you start having these feelings?” her therapist asks. “Today. I felt unsafe in group.” “What happened in group?” “They were talking about how to get a job. It just felt like, ‘If they think I can work, they just don’t get how sick I am.’ That triggered my urge to cut. It’s just like last week when they let me out of the hospital too early. I wasn’t ready, I still felt unsafe, but those idiots let me out anyway.” The therapist leans back in her chair. She’s heard this story before and finds herself resisting the first pangs of frustration. “I want to ensure that you’re safe now,” she says. “What can we do to help you feel safe?” Jane pauses, and then repeats, quietly, “I just feel the urge to cut.” Despite her growing sense of futility, the therapist asks, “Can you contract for safety?” “No,” Jane whispers, looking down at the floor, “I’m too unsafe.” “Can’t we find a way to keep you out of the hospital? Lately, you’ve been in there more than out.” Again, Jane shakes her head. Mechanically, as if by rote, the therapist makes one last suggestion: “What if I schedule some check-in calls with you tonight?” “No,” Jane says, looking up. “I’m too unsafe. I need to go in.” “But these constant hospitalizations aren’t doing you any good. We need…” “I’m gonna cut.” Now, truly frustrated, trapped in an overriding sense of ineptitude, the therapist responds with what appears as the only alternative: “I’ll make a call and get you evaluated.” Jane’s therapist describes her client as “one of my most difficult cases.” She admits that Jane not only frustrates her, but that Jane is the cause of an unshakable anxiety that often lingers long after work. The sheer heft of Jane’s

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records attests to her hold on the therapist’s time and energy. They are filled with a conspicuous number of notes on ad hoc safety plans, case conferences, outside consultations, and emergency phone calls. Jane does not only require a disproportionate amount of time and energy from her therapist; she also utilizes a noticeable amount of other mental health services, including day programs, a psychiatrist, and psychiatric hospitals. Indeed, Jane’s daily life is often constructed around the use of mental health services. Her identity—who she is—is inextricably linked to her life as a mental health consumer. Yet Jane does not exhibit symptoms commonly associated with the stereotype of chronic mental illness. She does not hear voices, experience delusions, speak to herself, or seem eccentric in any other manner. Instead, Jane’s most pronounced behavior is best described, paradoxically, as chronically acute. She perpetually accesses professional help at points of crisis, and she presents as if perpetually in crisis. Rarely does a day go by without Jane reporting to a professional that she feels unsafe. In the United States, half a million people present to hospital admitting staff each year threatening, but not accomplishing, suicide. Indeed, over a quarter of all psychiatric emergency room visits are initiated by complaints like Jane’s. Jane is clearly not alone, nor is her therapist. Daily, in emergency rooms, therapist offices, hospital wards, and community mental health centers, versions of the prior scene play out repeatedly, as if caught in a continuous loop of acute complaints and ineffective interventions. Clinicians today will likely label Jane’s behavior parasuicidal, and assume that the person exhibiting this behavior suffers from a borderline personality disorder (BPD). More likely than not, they will also consider referring Jane to a specific kind of treatment called dialectical behavioral therapy (DBT; Linehan, 1993a). Today, in most community and mental health settings in the United States, DBT is considered a best practice for the treatment of borderline personalities. Over a dozen states have adopted DBT in their mental health systems, as have many other hospitals, drug treatment centers, and prisons in the United States, Australia, Britain, and Germany. DBT’s focus on “borderlines” as the target of a specific treatment contributes to an already well-established historical trend in which the disorder is endorsed as an objective signifier of a true illness, something individuals suffer that makes them measurably distinct from the rest of the population. Indeed, as sociologists would describe it, the diagnosis of BPD is increasingly intended as a medicalizing label. I view parasuicidality in a manner that is in stark opposition to the prevailing wisdom regarding this problem. I believe that the problem of parasuicidality is actually abetted by (and in bed with) a medical worldview, rather than a symptom that can be cured through interventions informed by the medical model.

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Parasuicidal behaviors range in their level of danger, from verbal threats to scratched skin and superficial wounds, to tissue damage and potentially lifethreatening acts. Regardless of their medical necessity, however, a majority of the outcomes of parasuicidal behaviors are conspicuously reliable: contact with a therapeutic professional at a point of crisis. I see the marriage between parasuicidality and medical institutions as not simply the result of an inevitable sequence of events, from symptom to treatment. Instead, I believe it is a much more symbiotic, culturally coordinated marriage in which each party shares specific cultural meanings and often arrives at mutually acceptable arrangements.

A DIALECTICAL RESPONSE TO DIALECTICAL BEHAVIORAL TREATMENT My ideas about parasuicidality lie in dialectical relationship to DBT. “Dialectic” refers to a mode of thought or argument, developed most famously by Hegel (1896), in which contradictions in one point of view, or thesis, are the fertile substance for further contemplation. In this mode of thought, each idea is more a starting point for other, often contradictory ideas, than it is a settled epistemological end point. My theory regarding parasuicidality is dialectically linked to DBT by three elemental contradictions in DBT. First, while DBT interprets parasuicidality as the signal and terminal behavior of a particular disorder and clinical interactions as the inevitable consequence of this behavior, I target the habitual access of clinical interactions as the focal point for study. By highlighting parasuicidal behavior as a distinct behavioral problem—like alcoholism or an eating disorder—DBT focuses on behaviors that are intrinsically linked to hospital and acute intervention recidivism. Focusing on a behavior inherently destined towards the outcome of a clinical response, DBT lays the groundwork for a competing interpretation of parasuicidality—one that identifies the cycle of acute treatment recidivism as a key to interpreting the behavior of individuals labeled by proponents of DBT as parasuicidal borderlines. In this view, individuals who habitually contact mental health professionals at points of potential self-harm do not fall into the hands of clinically oriented institutions simply by way of a logical sequence, from symptom to medicalized response. They employ parasuicidal behavior in order to access a particular cluster of psychological and social resources that are achieved only through interactions with institutions dominated by medical epistemologies. The switch in epistemological gaze, from parasuicidality to treatment recidivism, leads to the second dialectical response to DBT: that parasuicidally

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activated recidivism, rather than being a symptom that can be cured through interventions informed by the medical model, is a behavior abetted by the kind of medicalized vision at the base of DBT. Parasuicidally activated recidivism is inseparable from a medical worldview and the influence of the norms and roles of medical culture on the behavior and self-perception of both consumers of mental health care and the professionals who treat them. It is, in other words, culturally iatrogenic, the term social philosopher Ivan Illich (1982) uses for the disease caused by medicine’s hegemonic influence on how we think about and approach general problems in our lives. The insight that parasuicidally activated recidivism is contingent on medical culture leads to the third dialectical response regarding the individuals Linehan labels parasuicidal borderlines. While Linehan takes the validity of the diagnosis of BPD as a given, I see it as another example of medicalization gone awry (Horowitz, 2002). The epistemological (Kirk & Kutchins, 1992) epidemiological (Widiger & Weissman, 1991), and nosological (Perry, 1990; Rosegrant, 1995) validities of the diagnosis of BPD are questionable. As presented in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000), the diagnostic categories for BPD lead to a vast spectrum of potential permutations, constructing versions of the disorder unrecognizable in similarity. BPD is also portrayed throughout the literature as a sort of pastiche of comorbidity with other disorders (Gunderson & Phillips, 1990; Hudziak et al., 1996; Nurnberg et al., 1991; Silk, Lohr, Ogata, & Westen, 1990; Silk, Westen, Lorh, Benjamin, & Gold, 1990), often making it difficult to distinguish it as a diagnosis that stands on its own. Aware of its nebulousness as a diagnosis, I do not argue in this book for a new way of understanding BPD as a distinct psychopathology. Instead, I take a somewhat simple stance, rooted in the obvious. We know that individuals Linehan (1993a) labels parasuicidal borderlines are parasuicidal, and we know that parasuicidality leads to interventions by clinical professionals. I focus on the interplay between individuals who exhibit parasuicidality and the professionals who treat them. Parasuicidality is not only a problem of patienthood, but of doctorhood as well. Parasuicidality motivates (in large part from fear) the vigilance of medical professionals and their compliance to the norms of medical culture. Like their clients, mental health practitioners are powerfully influenced by the norms and roles of medical milieus. Whether physicians or not, they tend to enter a mode of interaction with their colleagues and clients that mirrors the doctor’s role in medicine. Focused on curing disease and seeking the homeostasis of a safe psychiatric baseline, and maintenance in the community, they are anxious not to exacerbate symptoms and cautious about upsetting a psychological

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equilibrium that appears to them as fragile and easily-disturbed. Accordingly, they often respond to even the most superficial suggestion of risk and liability with extreme protection. Doing so, they validate their clients’ roles as passive sufferers precisely at those opportune moments when these clients confront issues of independence and accountability.

BRINGING COMMON NARRATIVES TO THE FOREFRONT The idea that parasuicidality is actually abetted by clinical interactions is somewhat original. But the idea that some individuals present with this behavior in order to seek psychiatric care is nothing new. Indeed, this book addresses, in print, an issue exhaustively discussed between a diverse array of professionals working with parasuicidal individuals. From the mouths of emergency room nurses, crisis clinicians, psychiatrists, and therapists come a fluid articulation of a conception of patient careerism: “She’s making a career out of going to the hospital.” “He’s a frequent flier in the emergency room.” “The hospital’s a revolving door for her.” As a veteran of community mental health with 20 years experience working on and leading programs aimed to help individuals in crisis, I’ve heard (and said) it all. Having spoken to thousands of people on this topic as a lecturer, seminar leader, consultant, and supervisor, I am also consistently impressed by the large number of people, in vastly different professional positions, who share a view about patient careerism. From secretaries to social worker, to psychiatrists and hospital executives, a theory linking patient careerism and parasuicidality is a part of their commonplace, daily discussions. This theory, however, has remained unofficial and informal, a kind of folk narrative. While felt strongly amongst professionals, it is left to the casual bastions of coffee breaks, momentary contact in the halls, and social meetings after work. Why do clinicians resist the leap from the casual to the legitimate in regards to patient careerism and parasuicidality? I have three interlinked answers to this question that reflect three particular dilemmas facing clinicians and clinical organizations today. First, a narrative connecting patient careerism with parasuicidality remains informal because it has never been given theoretical form. Simply put, no one has legitimized this theory by comprehensively putting it in print. Second, without theoretical form, the narrative of patient careerism has never spurred a set of systematic interventions. Even if a clinician wanted to help coax a client from her patient career, the clinician would have no effective tool set to do so. Third, the narrative of patient careerism has never been given theoretical form (nor spurred a set of interventions) because, when taken to logical conclusions, it can lead to radical, counterin-

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stitutional ideas, ones that are likely disturbing for many clinical professionals. This book aims to resolve these three dilemmas. It offers what I hope is an intuitively compelling argument regarding the existential and organizational etiology of parasuicidality and patient careerism, introduces new therapeutic interventions that are effective in diminishing both these issues, and provides organizational strategies that work to facilitate a demedicalization of psychiatric milieus and other therapeutic environments. The last point for me is the most important. I am convinced that good work with individuals engaged in patient careers is dependent on the ability and willingness of clinicians to liberate themselves from a purely medical worldview. I thus seek to help clinicians in their own process of deinstitutionalization and demedicalization, to make a shift in epistemology, thinking outside that famous box, often returning to those narratives left to the informal but rarely pursued to their logical conclusion. This is why the book is both a theoretical and practical guide.

A THEORETICAL AND PRACTICAL ENDEAVOR In Part I, the theory section, I intend to persuade clinicians to view their clients with new eyes. In this sense, the theory section is my attempt at intervention; I seek to intervene on clinical epistemology, persuading the reader to remove himself or herself from a medical worldview. Part II, the practice section, is dependent on this change in epistemology. One cannot truly practice what I preach without this epistemological shift. More important, without this shift, one cannot creatively invent his or her own interventions on patient careers.

Part I: A Theory of Patient Careerism In Part I of the book, I argue for a way of understanding parasuicidal behavior that differs from the typical way of viewing this behavior as a symptom of BPD. I claim that individuals who consistently present with parasuicidal behavior do so in order to attain access to the role reserved for patients under medical care. This role is dependent on the norms and cultures of medical milieus, and is thus both a psychological and social phenomenon. I assert that patient careerism or patienthood are pivotal concepts for understanding and responding to parasuicidal behavior—often more appropriate, in fact, than the diagnosis of BPD. Taking an existential phenomenological approach, I describe how individuals who exhibit parasuicidal behavior are similar to one another in the fact that they access medicalized

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interventions in order to avoid or dull the intolerable psychic experience of totalizing personal failure. A patient career is inherently a career defined by themes of passivity and suffering. For someone who feels truly beaten by the world, who lacks any sense of hope for the future, whose life itself appears meaningless and without purpose, and whose access to enduring occupational or familial roles is limited, such a career gives relief from a sense of accountability for the way his life has evolved. While a patient career does provide relief from the unbearable recognition of one’s failure, it also comes with significant cost, since the chief function of such a career is to resist personal change. It is a simple fact that we are all most able to enact changes in our lives when we are able to withstand the recognition that we are the authors of these lives. This correlation between personal change and exposure of personal agency poses a difficult threat for an individual who identifies herself as a failure. For such a person, acknowledgment of life authorship inevitably means accepting her agency in a life she perceives as a blunder. Because change is a potent manifestation of her life authorship and any act of agency or efficacy brings the unbearable recognition that she is responsible for a life that has failed, she experiences even the simplest change as an arduous challenge. The self-defined failed person is thus trapped existentially between avoiding the recognition of her own accountability and facing her accountability by changing. I call this trap the dialectics of failure. I illustrate how a patient career is one means to bear a life within the trap of the dialectics of failure. In such a career, an individual finds a means to identify himself as someone who is changing (for he is appropriately seeking a cure), while maintaining an identity as someone who is passive (because he suffers an illness). He has, in this sense, defied the inseparable bond between change and accountability. Yet, to defy this bond, he must assure that no one actually witnesses his agency, and that others only see him as someone engaged in the appropriate therapeutic institutions aimed to cure him. That is a difficult assurance to maintain. Simply by living and acting among others, an individual will inevitably be exposed as an agent in the world, regardless of how intensely he might work to conceal this agency. Since an individual’s career is perpetually threatened by the possibility that others will witness him as an accountable existential agent, the legitimacy of this identity is always tentative. I reveal how the patient careerist employs parasuicidality to efficiently protect his career from such threats. By proposing that he is suicidal or by acting in a self-injurious manner, he spurs in clinical professionals a set of behaviors that complement and support the patient role. These behaviors conform to the basic norms of medical culture.

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Part II: The Practice of The Game The theoretical investigation in Part I of the book is balanced with a more practical approach in Part II. In Part II, I describe The Game, a cluster of attitudes and interventions modeled to help patient careerists relinquish their careers. Targeting three relational arenas (“Relationship,” “Therapist Authorship,” “Change, Choice, and Motivation”), The Game is a method of avoiding medicalized interactions while enhancing authentic encounters. The Game is a system-wide technique ready to be used by all manner of clinical professionals each time a patient careerist makes clinical contact. Part II makes extensive use of vignettes to demonstrate how The Game approach is effective with patient careerists regardless of the breadth or intensity of their relationship with a given clinician. When these strategies are used by tertiary treaters, they offer an alternative to the medicalized institutional response. Indeed, they are intentionally demedicalizing strategies. Because my approach is intended to be used by clinicians in many different professional positions and is, at base, an approach that counters current clinical trends, it is best applied within the context of some organizational change. Thus, in Part III, of the book I suggest organizational objectives that lead to environments in which clinicians are freed to practice The Game. These objectives do not seek large policy or institutional change. Instead, they are achievable and actionable today. They seek to (a) protect clinicians from concerns about issues of liability by introducing a way of documenting treatment that is not only molded to match the needs of The Game, but is actually more protective of clinicians than is typical documentation, and (b) enhance team treatment planning through a brainstorming process called The Hourglass. These objectives are modest and achievable in most organizations. Yet, accomplishing them while adhering to the tenets of The Game leads to a radically different, and, I believe, fundamentally more effective way of treating parasuicidal individuals.

PA RT I

A Theory of Patient Careerism

The real act of discovery consists not in finding new lands but seeing with new eyes. —Marcel Proust (1981) The range of what we think and do is limited by what we fail to notice. And because we fail to notice that we fail to notice, there is little we can do to change; until we notice how failing to notice shapes our thoughts and deeds. —Daniel Goleman (1985) Spectator, viewing, seeing; these are the roots of the word theory. Every clinician theorizes when working with his or her clients. Either the clinician flexibly contemplates (a word etymologically rooted in the act of looking) and speculates about his clients, or the clinician more firmly holds a view from which he interprets what he sees. Theory informs and precedes technique. What one does and how one does it is based on one’s own individual worldview. Indeed, effective technique is theory in action. It emerges from a way of seeing and informs the person using it to see in a certain way. Accordingly, therapy and therapeutic interactions are not the kinds of behaviors that emerge from a manual. Therapy is not manual labor—work of the hands—but a different kind of work, one based on insight—it is a labor of the mind’s eye. Portions of Part I are taken from Ellenhorn, R. (2005). Parasuicidality and Patient Careerism: Treatment Recidivism and the Dialectics of Failure. American Journal of Orthopsychiatry, 75, 288-303. with permission of American Psychological Association. 1

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PARASUICIDALITY AND PARADOX

In this section of the book, I aim to disrupt the effects of a medicalized worldview on how clinicians often interpret parasuicidal behavior and attempt to supplant this worldview with a different theoretical perspective, one based in existential phenomenology. In Chapter 1, I first interrogate the concept of borderline personality disorder (BPD) as a diagnosis that accurately describes a group of people as distinctly different from the rest of the population. Then, in Chapter 2, I offer a different theory regarding parasuicidality, a behavior most often associated with BPD. Following this investigation, I describe my theory of patient careerism in Chapter 3.

CHA PTER 1

The Borderline Fallacies The Borderline Epidemic The Medicalization of BPD The Disease of Being Human

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here once the term borderline personality disorder (BPD) referred to a type of personality organization or system, today it is most often associated with parasuicidality. A given client who presents as parasuicidal is most likely labeled by professionals as a borderline, and when a professional uses the term borderline, he or she is often employing a shorthand for someone who uses parasuicidality as a means of advocating for herself and manipulating others. Dialectical behavioral therapy (DBT) participates and contributes to this view of borderlines by focusing its treatment and research on parasuicidality. Considered the most evidence-based best practice in work with borderlines, outcome research on DBT has focused, almost exclusively, on the decrease of parasuicidal behavior. A study on the decrease in the actual psychopathology of BPD is conspicuously absent from this research. I am convinced that the seemingly inextricable marriage between parasuicidality and the diagnosis of BPD is directly related to the increasing medicalization of BPD. As I will show in this chapter, of all the criteria for BPD described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychological Association, 2000), parasuicidality/suicidality is the only criterion that captures a behavior out of the norm of the general population. It is also the most obvious and detectable of these criteria. Parasuicidality, in other words, is the only criteria for BPD that can be designated as a clear symptom. It’s viewable, measurable, and deviates from the norm. In this chapter, I focus on decoupling parasuicidality from BPD by questioning the validity of an overly medicalized view of the borderline diagnosis. As I’ve stated, my primary goal here is epistemological. If I can influence a reader who is set in the medicalized view of BPD to accept the actual weakness in this view, then the need to connect a detectible symptom to this disease will

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decrease. By showing how the emperor of a medicalized BPD has no clothes, I also aim to reveal how we can take for granted a medical worldview as a given and exact version of reality, even in instances where maintenance of this worldview reaches absurd proportions. These epistemological goals provide the theoretical grid-work for Chapters 2 and 3, in which I describe parasuicidal behavior in its existential and sociological context, divorcing it from an exclusive relationship to BPD.

THE BORDERLINE EPIDEMIC Below, I offer an example from an individual describing his basic internal life. Almost sentence-by-sentence, he describes criteria associated with BPD (I note these criteria in the text). I will discuss this paragraph and its source later in the chapter. I fall into opposite extremes (Dichotomous Thinking). I hate going to the office so much that I often come home sick. Then suddenly, out of nowhere, comes a phase of skepticism and indifference (everything in my life comes in phases), and I mock my own intolerance and squeamishness (Affective Instability), accusing myself of being dramatic. Either I don’t want to talk to any of my colleagues, or I get into a talking streak and even take it into my head to make friends with them (Frantic Efforts to Avoid Real or Imagined Abandonment). For no apparent reason, all my squeamishness suddenly disappears. Who knows, perhaps I never felt it at all, perhaps it was all pretense. I even become altogether chummy with them, visit them at home, play preferences and discuss office politics (Unstable Interpersonal Relationships). As Dr. Leland Heller (1999) describes it, “BPD is a horrible, insulting label for a real medical illness. The name alone reduces serious research, stigmatizes victims, and implies the person is crazy. It denies the medical nature of the process, and implies simply a personality problem” (par. iv). He goes on to say, “BPD is a medical problem, likely a form of epilepsy…. The borderline’s inappropriate moodiness, chronic anger, emptiness, boredom dysphoria (anxiety, rage, depression and despair) [are caused by a] dysfunction of the limbic system” (par. vii). Linehan (1993b) agrees that there is a biological root to BPD, pointing out, “The cause and the maintenance of BPD is rooted in biological disorder combined with environmental disorder” (p. 4). For Dr. Kenneth Silk (in Fleener, n.d.), the fact of BPD’s biological root, coupled with the inconsistencies in how the disorder is presented, causes a real conundrum for researchers.

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He writes, “Since all these people appear so different, you can begin to appreciate why it has been very difficult to pinpoint the specific particular biological or neurotransmitter disturbance in BPD. Nonetheless, it appears it is this very variety of symptoms and reactions that biological researchers will have to deal with” (par. xii). While not every theorist on this disorder agrees that it is etiologically linked to biology, many theorists share Silk’s concern regarding the difficulty in defining the disorder as they search for a means to describe it as a distinct phenomenon. BPD is not only difficult to detect, it is everywhere. In their popular book on BPD, I Hate You Don’t Leave Me (1989), Kleisman and Straus write, “The chances are good that you have a spouse, relative, close friend, or coworker who is borderline. Perhaps, you recognize borderline characteristics within yourself ” (p. 6). For these authors, the disease of BPD is ubiquitous, almost epidemic in proportion and in its ability to affect diverse segments of the population. The extent of the disease is matched only by its nebulousness; it is an extremely difficult disease to define. “Borderlines,” the authors write, “are walking paradoxes, human catch-22s. Their inconsistency is a major reason why the mental health profession has had such difficulty defining a uniform set of criteria for the illness” (p. 6). This last point is clear regarding the disorder. The criteria for BPD form more diverse permutations than any other disorder in the DSM–IV–TR. For example, one can use the criteria to define an individual as borderline who experiences a disturbance in identity, has stress-related paranoia, is affectively unstable, impulsive, and inappropriately angry. One can use these same criteria to define another individual as suffering BPD who avoids the abandonment of others, has unstable relationships, complains of a sense of chronic emptiness, and is impulsive and parasuicidal. These two individuals would be very different from each other, with quite diverse psychological complaints, yet they are defined as suffering the same disorder. Here lies another problem regarding the diagnosis of BPD: what that disorder is, exactly, is not defined by its criteria. It lacks substance as a phenomenon we can easily grasp within our consciousness. The problem with defining borderline personality does not stop at the issue of its vast permutations or the fact the diagnosis itself lacks the ability to define a particular psychiatric phenomenon. BPD is defined in the literature as very often comorbid with other disorders. Indeed, no other disorder in the DSM–IV–TR is so consistently described as sharing other disorders. Up to 87% of individuals described as borderline also suffer some form of affective disorder (Gunderson, 1991; Silk, Lohr et al., 1990; Silk, Westen et al., 1990); 82% of them suffer from other personality disorders (Nurnberg et al., 1991). With all these other disorders at play, it is quite difficult to discern a

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specific disorder that exists independent of them. Indeed, how does any clinician know what he or she is seeing in the symptoms of his or her client, if so many of the symptoms of BPD are the same as symptoms of other disorders? The fact that BPD is a kind of mongrel disorder, a pastiche of other psychiatric symptoms, is clearly another problem as one attempts to define it as a clear psychiatric phenomenon. BPD, as described by the theorists previously mentioned, is like a highly adaptable virus, striking thousands, coursing through the population, yet remaining undecipherable, hidden behind the facade of normalcy and the decoys of other disorders. “Walking paradoxes, human catch-22s” (Kleisman & Straus, 1989, p. 6) borderlines are enigmatic by nature. The more one attempts to grasp this disorder, to pin it down as a definable disease marking those diagnosed as measurably different from the rest of the population, the more the endeavor becomes kaleidoscopic. If only researchers could locate this ubiquitous yet invisible virus or gene, this enigmatic mutation that silently effects so many, then they could decipher the real root of the disorder and find a cure. This is the medical view of BPD. And it holds up as a recognizable narrative regarding the search for the source of disease. Yet it is hardly the only means of understanding the undecipherable nature of BPD. I believe that the reason theorists have had such a difficult time defining this disorder is not because the disorder, by its very nature, is difficult to define. I think the act of defining it as a specific category is disordering in itself. BPD, in other words, does not exist as a definable illness. Pinning it down as a real object in reality is like nailing Jell-O to a wall. The more one attempts to secure it as a real phenomenon, the more it falls to pieces. Indeed, as theorists, clinicians, and researchers attempt to attack the disease of BPD, their views often appear absurd, disfigured in logic. Note, for example, the strange and illogical relationship between Silk’s conviction that the disorder is biologically based and his insight that people who suffer from the disorder “appear so different,” suffering a “variety of symptoms” (in Fleener, n.d., par. xii). Working backwards from the supposition that the disease exists as a true biological phenomenon, his logic unravels as he attempts to grasp its nature. Silk is not alone. Undoubtedly, Kleisman and Straus’s (1989) proposal that BPD is both everywhere and indefinable should also give one pause. How can one legitimately stake a claim for a definable disorder, marking individuals who suffer from it as different from the rest of the population, if it is found in the behavior of functional adults and is inconsistent in its presentation? For these authors, BPD is both a real phenomenon and something that shares a place in reality with pornography (and, increasingly, torture)—a “we know it when we see it” phenomenon. The problem with defining BPD as a distinct phenomenon is not just one of logic. Scientific research attempting to detect the distinct nature of BPD often

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comes to similar conclusions. For example, Joahn Rosegrant (1995), concluding his research using projective testing writes that No specific psychological mechanisms have been identified that typify borderlines and are not also found among neurotics, schizophrenics, or both. It would be best if people realize when they use the term that unless they specify how they are using it, they are only communicating that the patient described is more disturbed than patients usually called neurotic, but is not usually psychotic. (p. 427) Following their extensive epidemiological study of BPD, Thomas Widiger and Myrna Weissman (1991) come to a similar conclusion. The high prevalence rates that have been obtained for borderline personality disorder call into question the validity of the disorder…. The frequency with which borderline personality disorder is diagnosed, may be inconsistent with the construct of the disorder as a distinct clinical condition….[T]he excessive prevalence may be more consistent with an interpretation of borderline personality disorder as indicating a degree of personality dysfunction or disorganization. (p. 1019) For these researchers, the term BPD is best left as a descriptive, rather than diagnostic, tool. Their conclusions return BPD to its original use; a means for clinicians to describe particular processes they witness in their clients that is also a part of the general human experience, something closer to neurosis than to a definable disease. The claim of a medicalized BPD remains strong because of sociocultural trends in which medicalized views are accepted as common facts. This is why a view of BPD as a true and definable disorder prevails in the mental health professions, while logic and even scientific research are ignored. Indeed, the medicalization of BPD is a testament to the power of the medical model.

THE MEDICALIZATION OF BPD Over 30 years ago, social philosopher, Ivan Illich (1982) described the growing power of a medical worldview in the definition of common human activities: “The disabling impact of professional control over medicine has reached the proportions of an epidemic . . . it destroys the potential of people to deal with their human weakness, vulnerability, and uniqueness in a personal and autonomous way” (p. 54).

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Illich’s observation of medicine’s growing influence on how we define human activities during his time is also an accurate prophecy of its increasing influence over the years. The medicalization of borderline has more to do with the medical hegemony he identifies, than it does a real detection of a disease. From the inability to pay attention, to sadness and despair, to hair loss and yellow toenails, we live in a culture in which any deviation from the impossible norm of a perfect human is defined as a medical problem. The medicalization of BPD emerges within this culture. BPD stands out, however, among the pantheon of medicalized phenomena. More than any other disorder or disease defined and appropriated by medical culture, the medicalization of BPD is specifically the diseasing of the darker, disturbing, yet nonetheless intrinsic, parts of our humanity. BPD, in other words, is the medicalization of the real norm of human experience; the broken, inexact, unpredictable and inevitably sinful humanity in all of us.

The Disease of Being Human The quote given toward the beginning of this chapter (under the heading “The Borderline Epidemic”) is not actually a record from a borderline patient. It is a modified paragraph from Dostoevsky’s Notes from Underground.1 Clearly, Dostoevsky was not attempting to write about BPD. He was attempting to grasp the chaotic, impure and indecipherable scramble of human existence. “I’m only human,” we say when we excuse ourselves from any expectation of perfection. To be human is to be imperfect, fallible, even disturbed. The fact that people are at base imperfect as personalities poses a problem when one attempts to define personality disorders as a distinct diagnostic category. Clearly one cannot define a deviation from the norm without also defining the norm. Yet the norm of a so-called ordered personality does not exist, for all of us are all too human. The pretzel logic of medicalizing theorists on BPD gives us a clue to this fact. Their central problem in defining BPD as separate from general human experience is that the many symptoms associated with BPD are impossible to extract from the simple condition of living as a human being. To clarify this point, I list below nine qualities that I believe form the parameters of what we mean to be human. I call these nine qualities The Disease of Being Human. The Disease of Being Human 1. Merger and Separation As social/cultural animals, people are generally anxious regarding the abandonment by others, especially their intimates. On the other hand, they also evidence the capacity to risk rejection, making strong

The Borderline Fallacies

2.

3.

4.

5.

6.

7.

8.

9

commitments to their relationships and communities. While unstable in their interpersonal relationships, becoming intense and cathected at times, human beings often feel most at peace in the presence of intimates. The Flux of Identity Human beings experience their identities as persistently unstable. While this is a source of great anxiety, the flexibility of identity is also one of the great modern human freedoms. Indeed, it is the central psychological gift of modernity. Modern human beings value the notion of being self-made and they find joy in the creation and everchanging nature of identities. Impulsivity and Creativity Human beings are often impulsive. Sometimes this impulsivity is selfdamaging, as if some destructive and uncivilized monster is loose. Other times, it is the wellspring of spontaneous and remarkable play. The Choice to End Life “There is but one truly serious philosophical problem,” wrote Albert Camus (1955), “and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy. All the rest—whether or not the world has three dimensions, whether the mind has nine or twelve categories—comes afterward” (p. 3). Their capacity to kill themselves makes humans unique within the animal kingdom. Yet humans most often will fight for survival despite overwhelming odds, even though they are endowed with the freedom to end their lives. The Unpredictability of Mood Human beings experience changing and unpredictable moods, for they are the source of tremendous energy and urges—some destructive, others creative. Emptiness and Solitude Human beings often feel empty inside, yet also face the world with great wonder and awe. They long for intimate connections with others, fear the loss of these connections, and yet also find pleasure in moments of solitude. Anger and Control While they have the tendency to lose their temper and become irrational, human beings are equally contemplative and self-reflective, often finding humor in their own frailty. Trust and Distrust Human beings can be irrationally distrusting of others, to the point of deep paranoia. When this distrust and paranoia becomes pervasive, they are known to become violent. When it is shared between

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people, they have evidenced a tendency to segregate each other, to even initiate mass killing and genocide. They are a self-destructive lot. Yet, despite their failings as communal animals, humans are imbued with enduring faith and hope and are trusting in the face of insecure circumstances. 9. Distractibility and the Here and Now Most humans do not live their lives consistently in the here and now. On the contrary, human experience is marked by fluctuations between what philosophers call a sense of “nonbeing” and “being.” Humans, in other words, experience moments of unreality, as if not fully here, in present time, and they can also feel alive, mindful, and present in the moment. In just nine statements, I have miraculously captured many of the basic paradoxes of the disease of being human. I have not, however, invented these paradoxes on my own. Indeed, I have used a text familiar to many people in the mental health profession to develop this idea of the disease of being human. From the DSM–IV–TR, I have taken the nine diagnostic criteria for BPD, used a minimal amount of poetic license defining these criteria in more philosophical or spiritual terms, and then described their opposite (Table 1.1). To be human is not easy. Human “beingness” is often the experience of being ill at ease. It is a diseasing and disordered experience. When we feel most acutely diseased, we are typically in the tangle borderline processes. We are angry, yet loathing of our anger, furious with people most intimate to us, yet confused and anxious about our dependency on them. We are afraid of isolation yet hate ourselves for needing others, anxious because we can’t predict our moods, and perpetually questioning who we are. In this view, parasuicidal individuals are seen as exhibiting borderline tendencies, but so are you or I. They experience these tendencies in a more potent and acute manner than other people, but this does not mean they fit in a diagnostic category marking them as distinctly different from the rest of us. While the label of BPD only vaguely captures the predicament of parasuicidal individuals (in the sense that this label captures most everyone’s behavior), these individuals do share two interrelated characteristics: (a) they are parasuicidal and (b) this behavior often leads to clinical interactions. Parasuicidality and treatment recidivism, in this light, are inseparable. Accordingly, approaching parasuicidality as merely a symptom of a psychiatric problem— an isolated individual problem—is artificially reductionistic. It misses the whole picture. It is like studying a key as something of isolated significance and function without understanding its relationship to a door.

The Borderline Fallacies TABLE 1.1

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Borderline Personality: The Disease of Being Human

The Disease of Being Human Diagnostic Criteria

Borderline Personality Disorder Diagnostic Criteria

1. Merger and Separation

a) Frantic efforts to avoid real or imagined abandonment b) A pattern of unstable and intense interpersonal relationships c) Identity disturbance; markedly and persistently unstable self-image or sense of self e) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) f) Recurrent suicidal behaviors, gestures, threats, or self-mutilating behavior g) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) h) Chronic feelings of emptiness i) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) j) Transient, stress-related paranoia dissociative symptoms, ideation k) Dissociative symptoms

2. The Flux of Identity 3. Impulsivity and Creativity

4. The Choice to End Life 5. The Unpredictability of Mood

6. Emptiness and Solitude 7. Anger and Control

8. Trust and Distrust 9. Distractibility and the Here and Now

PARASUICIDAL INDIVIDUALS AS CONSTITUTED/ CONSTITUTING SUBJECTS “The effects of being treated as a mental patient can be kept quite distinct from the effects upon a person’s life of traits a clinician would view as psychopathological,” wrote Erving Goffman (1961, p. 126) in his seminal work on what he described as total institutions. I view individuals who repeatedly act parasuicidal in a manner approximately similar to Goffman’s. I see these individuals as more like one another in the social psychological root of many of their behaviors than they are similar to individuals who might share their diagnostic label but do not repetitively deploy parasuicidality. While these individuals might suffer any number of psychological and psychiatric problems, the root of their parasuicidally generated recidivism is often the same. These roots are as embedded in particular social and institutional arrangement as they are in psychological predicaments.

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Moderately different from Goffman’s view of institutionalized mental patients, I view parasuicidal individuals as both constituted and constituting subjects (Figure 1.1). They are not passively molded by medical institutions or a medical worldview, but are active constituents in their reality. Yet they are also not free from the constituting force of a hegemonic medical culture. In this so-called structuationist interpretation (Giddens, 1986), individuals who habitually contact mental health professionals at points of potential self-harm do not fall by accident into the hands of institutions steered by a medicalized worldview. Instead, their parasuicidal behavior is a key to access a particular cluster of psychic and social resources achieved only through interactions with such institutions. In the chapters to follow, I investigate why and how parasuicidal individuals seek and maintain these recourses and how medical culture informs their behavior.

Personality disorders

Developmental disabilities

Thought disorders

Parasuicidality Treatment Recidivism

Mood disorders

Figure 1.1 The Psychological and Institutional link of parasuicidality.

The Borderline Fallacies

NOTE 1. The original paragraph from Dostoevsky’s Notes from Underground is as follows: I’d also fall into opposite extremes, I’d loathe going to the office so much that I would often come home sick. Then suddenly, out of nowhere, would come a phase of skepticism and indifference (everything in my life came in phases), and I myself would begin to mock my own intolerance and squeamishness, accusing myself of romanticism. Either I wouldn’t want to talk to any of my colleagues, or else I’d get into a talking streak and even take it into my head to make friends with them. For no apparent reason, all my squeamishness would suddenly disappear. Who knows, perhaps I never felt it at all, perhaps it was all pretense, picked up from books. (1992, p. 52)

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CHA PTER 2

The Dialectics of Failure An Existential Phenomenological Approach to Parasuicidality Existential Accountability Existential Anxiety Good and Bad Faith

16 17 18 18

Existential Guilt Existential Courage The Dialectics of Change The 10 Reasons Not to Change

19 20 22 24

Near the end of Arthur Miller’s play, “Death of a Salesman” (1949), Biff Loman yells at his father, Willy: “Pop! I’m a dime a dozen, and so are you!” (p. 105). Biff exposes the chasm between what his father dreamed both son and father might have been and what they were. Faced with this awful, unbearable truth, Willie turns on Biff in an uncontrollable outburst. WILLY: I am not a dime a dozen! I am Willie Loman, and you are Biff Loman! BIFF: I am not a leader of men, Willy, and neither are you. You were never any-

thing but a hard-working drummer who landed in the ash can like the rest of us (p. 105). Willie Loman represents the Welschmerz of American individualism—the recognition that life does not match one’s dreams of success. He never lets down his wall of defenses against his own sense of mediocrity, until finally, following the above argument with Biff and unable to defend any longer, he kills himself. “Tragedy,” wrote Miller (1949), “is the consequence of man’s total compulsion to evaluate himself justly” (p. xviii). To evaluate one’s self as a failure, a mistaken blunder of a being, is to be overwhelmed with an agonizing shame. Faced with the shame of failure, a person will inevitably focus an inordinate amount of energy to avoid his or her self-evaluation. Where Loman avoids confronting his failures through unrealistic narratives about his own and his son’s potency in the world, another easily accessible narrative is just the opposite: one of impotence and passivity. This is the defense of patient careerists.

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Individuals who exhibit parasuicidal behavior are similar to one another in the fact that they access medicalized interventions in order to avoid or dull the intolerable psychic experience of totalizing personal failure. Driven by the belief that they are inherently failed as people, they seek to diminish this sense of failure by entering the social role reserved for people who are ill and under medical care—a role that is defined by themes of passivity and minimal accountability. Parasuicidality is their means to both access the patient role and to protect a more consistent engagement in this role, what I call a patient career. In this chapter, I initially delineate the means by which failure-induced anxiety operates as a driving concept in regards to parasuicidal individuals. I believe this anxiety about failure is more of an existential concern than a psychopathological one. I thus begin the chapter discussing an existential approach to parasuicidality. Following this, I investigate how parasuicidal individuals enter the patient role as a means to avoid specific existential concerns regarding self-authorship and accountability. As I describe in the preface, social roles, such as the patient role, are clearly netted to specific social arrangements. One cannot participate in the role of mother or father without a shared social meaning of family, and one cannot participate in an occupational role without the existence of occupations. The patient role is contingent on the particular norms of medical culture. Accordingly, throughout the section, I delineate the symbiotic dance between patient careerists and the medical institutions that serve them. Finally, I also show how clinicians, informed by a medical worldview, participate in the coconstruction of parasuicidal behavior, specifically, and patient careers, more generally.

AN EXISTENTIAL PHENOMENOLOGICAL APPROACH TO PARASUICIDALITY Each of us is on this earth for a short period of time. And when we close our eyes to the world for the last time, each of us will do so alone. The fact of our aloneness, while highlighted when we contemplate our death, is actually a fact of life. While we can feel great moments of love, intimacy, and connection to individuals and communities, we are inevitably flying solo. This is an existential fact, in the sense that it is the basic fact of our existence. I take an existential approach to my understanding of patient careerism. I believe that the existential facts that we will die, and that we are accountable for how we experience our lives during the tragic race to make meaning of a finite life, form the basic parameters of human consciousness. I thus take an existential phenomenological approach, in the sense that I am interested in the intersection

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between an existential point of view and the structures of experiences, how we look out at and experience the world. Such psychological theorists as R. D. Laing (1969), Rollo May (1986), and Victor Frankel (1984) are considered existential phenomenologists. Their insights inform my point of view. So do the ideas of Jean-Paul Sartre (1956), the French philosopher whose philosophy (along with Heidegger’s [1962] and Kierkegaard’s [2005]) informed the use of existential thought in psychological practice. Lastly, I am also influenced by existentially informed theologians, such as Martin Buber (1970) and Paul Tillich (1952), who rest in epochal and intellectual orbit with the existential psychologists. Five particular insights from existential phenomenological thought help me understand the patient careerist: (a) Existential Accountability, (b) Existential Anxiety, (c) Good and Bad Faith, (d) Existential Guilt, and (e) Existential Courage. Existential phenomenological thought also provides a larger template for understanding human behaviors that counters a more diagnostic and medicalized worldview. I find it instrumental in my attempt to deinstitutionalize clinicians. Following my description of the five insights from existential thought, I describe how an existential phenomenological point of view trains the eye away from a medicalized approach to human problems, to one that recognizes these problems as being all too human.

Existential Accountability If I am alone in the world, that means I am accountable for the choices I make and for how fulfilling I make my life. In this light, such statements as, “I have to go to work today,” or even, “I have to obey the law,” are disingenuous, because both working and obeying the law are actually choices one makes. I choose to work because I need the money, or because, in the long run, my job gives me a sense of meaning and purpose. I choose to obey the law because I don’t want to risk arrest or because I have a set of values that I choose not to breach. Every day I am faced with a multitude of choices of which I am the responsible deciding agent. This is why adulthood, for most of us, is such a terrifying prospect. When we say “adulthood,” we are typically referring to that point in our lives when we are no longer dependent and are thus facing the world as accountable, existential agents. As I will show, entering the patient role is a means to avoid the anxiety of accountability. The facts of our existential aloneness and accountability form the base to existential phenomenological thought. Existential phenomenologists seek to understand how the angst-ridden fact of our aloneness in the world structures our experience. For them, anxiety—an experience that is all but monopolized today as a medical problem—comes, part and parcel, with human experience.

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The facts of our aloneness and responsibility to a life that will end are liberating, but also inherently anxiety provoking. Anxiety, what existentialist also call angst and anguish, is a fundamental part of the human condition. Being human and experiencing the anxiety of being are inseparable.

Existential Anxiety “[A]nguish,” wrote Sartre (1956), “is distinguished from fear in that fear is fear of being in the world whereas anguish is anguish before myself. Vertigo is anguish to the extent that I am afraid not of falling over the precipice, but of throwing myself over” (p. 29). For existentialists, the experience a person has when confronting his or her accountability and aloneness is anxiety. Anxiety is not a physiological disease, unattached to basic human experience, but an essential part of this experience that one cannot fully escape. A person experiences anxiety when confronting the very fundamentals of his or her existence. The stereotype of the existential philosopher as a dark and pessimistic sort is not completely inaccurate. In existentialism, self-actualization does not mean one transcends anxiety. Rather, the more one is actualized as a person, the more anxiety he or she faces. This is why most people avoid a fully actualized and meaningful life. On a daily basis, they choose what Sartre (1956) called a bad faith approach to life, denying their accountability and aloneness over a good faith one, in which they confront these existential truths.

Good and Bad Faith “Bad faith” refers to any behavior in which an individual attempts to avoid his or her accountability and the recognition of her aloneness in the world. When a patient careerist describes herself as “triggered” to harm herself, controlled by “the depression,” unable to resist “the suicidal thoughts,” or “control the urge to cut,” she is engaging in bad faith narratives. The patient careerist is describing herself as the object of forces outside her control, rather than the subject of a life. Good faith is the opposite of bad faith. When one acts in good faith, he witnesses his aloneness and accountability with eyes wide open. As I have alluded to above, good faith is an intensely anxiety provoking approach to life, for it means recognizing one’s aloneness and accountability in action. When one, for example, awakens in the morning to prepare for a job one hates, and sees this job, not as something imposed from an outside force, but a matter of choice, one is likely filled with a great sense of dread and anguish. Good faith may be an authentic approach to life, but it offers the prospect of overwhelming anxiety.

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Sartre’s concept of good and bad faith is a particularly important concept to understand in regards to many parasuicidal acts. Previously, I describe how the patient careerist will often describe her parasuicidal behavior as something outside her control. A person contemplating an actual suicide, on the other hand, is often very aware (perhaps too aware) of his or her aloneness and accountability. “I hate my life, I hate what I’ve done with it, and I do not want to live any longer,” is a good faith statement. There is nothing passive to it. Indeed, in many suicides, the suicide is a purely good faith act, as if the individual “throws” herself over the precipice described by Sartre earlier. The group at greatest risk for completing suicide is men over 85 years of age. Whether one finds the choice of killing oneself repugnant or not, for many of these men, the choice to do so is often an act of good faith because the individual, often widowed, alone, and physically ill, has made a clear-eyed decision that he no longer wants to live. Clearly, in existential terms, suicidality and parasuicidality are two very different behaviors. Good and bad faith roughly divide suicide from parasuicide. Suicides are more often acts of good faith, whereas parasuicides are more often acts of bad faith. Indeed, as I show, parasuicidality is a remarkably nuanced and sophisticated means to maintaining a social identity based on bad faith narratives—that of the medical patient.

Existential Guilt Take a five-second break from reading this book, counting from one to five. During the five seconds you just spent counting, you could have reached out to another person, decided a new course for your life, imagined a piece of art to create, appreciated the moment itself—any number of meaningful actions. If you feel a sense of remorse regarding these wasted five seconds, you are experiencing existential guilt. Existential guilt is the remorse one feels when one has not grasped experience to its fullest. “The extent to which people are experiencing is the extent to which they are being fully alive,” write Rugala and Waldo (1998, p. 67). “When people fail to experience, by denying awareness or avoiding opportunities, they waste their potential. Those who bypass experiencing carry the existential guilt of their unfulfilled potential” (p. 67). Existential guilt, as opposed to neurotic guilt, is an experience of what is real. It is based on the reality of the human endeavor. Neurotic guilt is always rooted in distortions or even falsehood (“I should have found a better way to please my abusive father.” “If I only behaved as a child my brother would have never been in that accident.” “I’m the reason my husband drinks.” “I shouldn’t have such thoughts about another woman.”). Existential guilt, because it is not based on distortions but on the

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reality of living, human experience, is an enduring feeling one can never escape. There is no working through or forgiveness for existential guilt. Because we are responsible for our lives, we are stuck with this guilt throughout these lives. R. D. Laing (1969) differentiated the two types of guilt as false guilt and true guilt. Daniel Burston (1998), Laing’s biographer succinctly describes his view: By false guilt, Laing meant (a) a sense of worthlessness or self-loathing occasioned by a patient’s inability or refusal to live up to the expectations of others, to be what others say the patient really is (or ought to be); and (b) a more pervasive and diffuse sense of guilt at merely being, brought on by routine parental inability (or refusal) to affirm the child’s authentic sense of self. False guilt prompts the individual to acts of self-negation or self-annihilation, and is properly speaking the guilt of the “false self,” which conducts all its commerce with others and the world at large under false pretenses. Conversely, true guilt emanates from a patient’s inability to actualize his or her own potential for authentic experience and self-expression and, if keenly experienced and acted on, prompts greater self-affirmation. (p. 83) The problem with most patients, Laing suggests, is that their guilt feelings are completely undifferentiated. True, existential guilt is rooted in good faith, while false, neurotic guilt is rooted in bad faith. True guilt comes from one’s contemplation of one’s existential accountability and the inevitable loss of meaning in one’s life. False guilt comes from one’s belief in something immanently wrong with oneself. The patient careerist is trapped within an undifferentiated space between true and false guilt. He feels that his life has been wasted and also believes that he does not measure up to others, that his waste of a life is the product of a terminally dysfunctional person, someone who is faulty at the core and, in this immanent dysfunction, someone who is alien from the rest of the population.

Existential Courage To live an existentially honest life takes courage, for every moment is a leap of faith that one can continue to make meaning and engage with the world. Courage (which is rooted etymologically with the word heart), in other words, is intrinsically intertwined with hope and faith. To take this theologically leaning view of existential thought, one looks at the maladies associated with the human condition quite differently from a psychopathological point of view.

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What we see when we view individuals in psychological distress who engage in futile patterns of behavior are individuals struggling with the anxiety of engaging in the world in an authentic, self-authored manner, and often experiencing a failure of courage. At first glance, the idea that psychological problems are intrinsically problems of courage likely appears as harshly judgmental. However, no one escapes the struggle to overcome existential anxiety. Indeed, unlike psychiatric diagnoses, which mark a set of behaviors as deviating from a norm, an existential point of view sees so-called normal behavior as often being the product of flight from reality. If, for example, one sees authenticity as the goal of an existentially honest life, then conformity and the consumerism of mass-produced goods is the ultimate insanity. Conformity, the very opposite of psychopathology, is a form of existential death, for the conformist embraces the serial, the known, the imposed. Frightened by the prospect of choice and accountability, she vigilantly watches for the next trend and assumes it. Her home, the very domestic center of her life, and the greatest potential wellspring of individual creativity, is a mimeograph taken from a magazine or catalog. She dresses in the morning for work in clothes quite similar to everyone else at the office. Conformity, in this light, is the ultimate sign of cowardice. Yet it is not a deviant behavior. Indeed, it is the norm. An existential phenomenological point of view prioritizes the courage to be (the title to Tillich’s [1952] most famous book) over a healthy psychological baseline or psychological stability. It thus looks at the human condition in a radically different way than diagnostically based psychology and psychiatry. Where the latter disciplines search for dysfunctions that deviate from some model of normality, existential phenomenology views the diagnosis and categorization of people as itself perverse. In an existential phenomenological point of view, there is no majority of healthy people to compare to psychiatrically deviant individuals because no one transcends his or her existential struggle. Ben Franklin is often attributed with saying, “The definition of insanity is doing the same thing over and over and expecting a different result.” Doing the same thing over and over in pursuit of sameness and a deadened existence is also a form of insanity. Conformity, in this light, is also a form of suicide. It kills our psychological or spiritual self; that part of us that is our aliveness. Awe, wonder, creativity, love, intimacy—these are the fruits of a fully engaged existence. They are all but nonexistent at the food court in your local mall. Like conformity, parasuicidal behavior trades the safety of concealing one’s agency with the risk of a deadened existence. Thus, while parasuicidal behavior may be witnessed by others as deviant, its purpose hardly deviates from the general population. When an individual seeks a clinical response in order

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to avoid her accountability, she joins in purpose not only with the conformist, but with the religious fanatic, the egomaniac, the sex addict, persons who seek merger in their relationships with others, bullies, masochists—the list is truly infinite. While the patient may participate in the so-called sin of concealing her agency, this is a sin no one transcends. In this light, her parasuicidality, while a true hindrance to a more engaged and meaningful life, can be understood as the normally bad choice in which all of us participate. Through the eyes of existential phenomenology, I see the core cause of parasuicidal behavior as linked to the fundamental existential issues of accountability and life authorship. Moreover, I see one particular dynamic associated with BPD, which Linehan identifies as the lynchpin of borderline processes, as intrinsically important to understanding parasuicidal behavior, yet emerging not from an illness but from existential struggles. This is the dynamic that emerges when one contemplates change and is faced with the anxiety of one’s own agency in that change. I call this the dialectics of change.

THE DIALECTICS OF CHANGE For Linehan, as with many theorists who address BPD in general (Gunderson, 1984; Kernberg, 1967; Masterson, 1975), parasuicidal borderlines respond to the world through a lens of dichotomous splits. They cannot synthesize competing values, thoughts, or emotions simultaneously. In Linehan’s cognitive behavioral theory of splitting (1993b), “Dichotomous and extreme thinking, behavior and emotions, which are characteristic of BPD, are viewed as dialectical failures” (p. 2). According to Linehan, their tendency to fail dialectically affects borderlines in all manner of circumstances. Their inability to bear ambivalence, however, is most obstructive when borderlines face issues of change. Because personal change requires that one tolerate the specific opposing poles of accepting oneself as one is and changing, Linehan believes that the dialectical dysfunction in borderlines makes “progress extremely difficult” (p. 2). Linehan (1993b) offers an insightful vision regarding the struggle over the ambivalence of change. However, her insistence that the borderline’s inability to withstand the polarities associated with change is rooted in a particular cognitive dysfunction limits her analysis to reductionistic assumptions. In Linehan’s view, the disability of dialectical failure is fixed within the individual. It is most pronounced whenever the borderline encounters the many and diverse challenges to ambivalent thinking. Thus Linehan sees the process of change and dialectical failure as autonomous phenomena. People suffering BPD are damaged in their ability to endure any number of ambiguous situations. Change, coincidentally, is one such situation. Contrary to this vision, I identify the challenges of change, rather than dialectical failures, as the axis

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of parasuicidal behavior. In this theory, parasuicidality and many other behaviors exhibited by the individuals Linehan treats are the gestures of people contending with the vicissitudes of change, not the signifiers of a cognitive dysfunction which is most pronounced when these individuals contend with ambivalent situations (change being one of them). When an individual makes changes in his life, he inescapably brings into relief his innate power to master this life. Thus, personal change and exposure of one’s personal agency go hand in hand. Change, in this view, is an existential issue, rather than a cognitive behavioral problem. It poses a dialectical challenge to a person, but this challenge is a universally human one, part of the “web of manifold tensions” (Cooper, 2003), spun by the unbearable recognition of existential freedom (Farber, 2000; May, 1980; van Deurzen, 2002; Yalom, 1980). The ability to risk change depends on the ontological security of a person (Laing, 1969). A person is able to most fluidly enact change when he is able to withstand the recognition that he is the author of his ever-changing life. The inherent correlation between personal change and exposure of personal agency poses a particularly difficult threat for an individual who identifies herself as a failure. For such a person, acknowledgment of life authorship inevitably means accepting her agency in a life she perceives as a blunder. Because change is a potent manifestation of her life authorship, and any act of agency or efficacy brings the unbearable recognition that she is responsible for a life that has failed, a person who has defined or herself as a failure experiences even the simplest change as an arduous challenge. This self-defined failed person is thus trapped dialectically between avoiding the recognition of her own accountability and facing her accountability by changing. Contending with this trap, the self-defined failed person will often behave in a manner that is perversely self-fulfilling. She will choose to continue the life that she hates and remain disappointed, rather than change this life and face the awful recognition of her own life authorship. Individuals who engage in parasuicidal behaviors as a means to access a therapeutic response are trapped in this difficult dialectic of failure. They are driven by the horrible cognition that somewhere their life courses went terribly wrong. More awful than that, they feel and believe they are failures in their very being—as if, in common terms, they never amounted to anything. Their repetitive engagement with therapeutic professionals is a means to endure a life within this trap. In a group I facilitated at a day treatment program, largely comprised of parasuicidal women and entitled “Ambivalence and Change,” I periodically asked the group to list the 10 most important forces keeping them from changing their lives. This was an open group, so the group’s participants changed

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over time. Their answers, however, were remarkably consistent, amalgamating in what the group has labeled The 10 Reasons Not to Change. All the reasons not to change focus on the struggle between enacting change, facing one’s agency and accountability, and, consequently, confronting one’s sense of failure. The first seven of these reasons illuminate how anxiety about one’s accountability hampers change. While the dynamic between change and accountability is particularly difficult for individuals who identify themselves as failures, it is a general dynamic, inherent to change. The remaining three reasons not to change address valuable resources the individuals in the group felt they would forfeit if they made changes in their lives. These resources are more specific to individuals who repetitively engage in treatment.

The 10 Reasons Not to Change

Reasons One to Seven: The Threat of Accountability and Rising Expectations 1. Raising one’s own expectations about change. When a person enacts change, the person raises his own expectation about his ability to change further. For someone who has experienced multiple failures, acts of competence are thus threatening because they mean the potential of failing to meet the expectations generated by change. Keeping one’s expectations low about success is a central means of avoiding this threat. If one does not have high expectations about oneself, then there is little possibility of disappointment. One can only keep one’s expectations low, however, by resisting change. 2. Raising the expectations of others. To make a positive change in life, a person not only raises her own expectations, the person inevitably raises the expectations of others. Doing so, she risks that others will witness her failing from the new, more positive status she has achieved. The self-defined failed person fears that her failure in one project will confirm for others her total failure at life. 3. Facing where one is in life. Progressive change requires that individuals assess what they need to change. This confrontation is particularly difficult for an individual who believes his life is an awful disappointment. For this person, evaluating his life at present is synonymous with evaluating his failure at life in general. 4. Taking small steps. To change her circumstances, an individual is not merely required to face the status of her life momentarily, but to do so repetitively, as the individual takes the incremental steps towards a goal. Thus, when a person forges into change, she is potentially confronted by her current (self-authored) predicament each step of

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the way. For an individual who defines herself a failure, these incremental steps towards change feel injurious, for each one reflects her status. The individual sees that many small steps are required to reach her goals, and is thus confronted every step of the way with her overall lack of accomplishment. 5. Being accountable for what’s next. The more a person changes, the more the outcome of the person’s life is potentially seen by himself and others as within the person’s own hands. For someone overwhelmed by a sense of personal failure, positive change is like stepping onto a slippery slope of accountability in which there is no return to a previous life shielded from expectations regarding autonomy and personal agency. 6. Facing the unknown. Enacting change in her life, a person faces the unknown possibilities of a life created by her own free actions. She must thus contend not only with an inherently capricious world, but also with the unpredictability of the future created in part by her own actions. The self-defined failed person sees little information in her past to predict a successful future. For this person, facing the unknown means facing a menagerie of possible failures. 7. Feeling alone (existential aloneness). Anxieties about one’s aloneness as an existentially accountable actor in the world invade all of the first seven reasons not to change. Whether one is concerned about rising expectations, recognizing one’s own status in life, or facing an unknown future, change poses a particularly difficult challenge, for it inevitably brings with it the revelation of a person’s agentic powers. The final three reasons not to change are less about the intrinsic angst of change than they are about accessing important social resources through contact with clinicians. They highlight how engagement in treatment can operate as a means for some individuals to defend against the anxieties inherent to the process of change.

Reasons Eight to Ten: Engagement in Treatment and Staying the Same 8. Losing a network of treaters. Therapy aims towards change and the amelioration of symptoms. Thus, when a person makes positive changes in his therapy, he inevitably forges the path that leads out of this therapy. For the self-defined failed person who is well invested in treatment, this polarity between change and loss is threatening. For him, losing therapy means losing vital social psychological resources. The daily activities and the types of relationships that comprise the social lives of individuals engaged in the mental health system provide

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a full prescription of artificial and often superficial psychological and social panacea, mimicking basic social supports: pseudointimacy and quasifriendship found in relationships with therapists, day programs, and hospital staffs, and an extended family of providers. These tangible resources also offer more subtle psychological goods—the guarantee that someone is paying attention and the promise to understand an individual as comprehensively damaged—the loss of which one client called destroying the negatives. 9. Losing the guarantee that someone is paying attention. To approach life securely, every individual needs a sense that she exists in the consciousness of someone else; that, while alone, she matters to others. Therapy and, especially, therapeutic communities provide this sense. With their charts, their tendency to “begin where we left off,” their propensity to remember and remark on the progress of each client’s life, they promise continuous attention to individuals. Therapists and therapeutic communities offer an enduring recognition to those they treat, providing their clients the important sense that they exist in the mind’s eye of someone else, even when they are out of physical sight. As I describe further, they typically provide this attention without the pressures of expectations regarding existential accountability. 10. Destroying the negatives. Therapy is partly a process of sharing the daily memory of the daily life of an individual. It is also a process of commemorating the individual’s past hardships. For someone overwhelmed by a sense of failure, the need for others to recognize past damage is often insatiable. For this individual, the therapist’s recognition of his difficult history is not only therapeutically empathetic, but a means to a life narrative imbued with themes of external forces and individual passivity. For the self-defined failed person, acts of independence are signs to others that the past was not as bad as he portrays it. Independent functioning signals that past events may have been painful, even traumatic, but not so oppressive as to destroy the individual’s ability to survive. As one of my clients describes it, change is like destroying the negatives to her past (a remarkable term, for it can mean both destroying the memory of negative experiences and, more metaphorically, destroying the snapshot record that they occurred). Becoming better, for her, means partially obliterating the proof of her hardships. Therapy, and belonging to a therapeutic community, on the other hand, offer the hope that someday, someone will merge with her in her pain and endorse her narrative of total passivity.

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For the self-defined failed person, failure is intrinsically biographical. It is the personal road this person has taken until now, her disappointing destination at present, and her destiny. The first seven reasons not to change match this biographical continuum of failure. People avoid changing because of concerns about the past (their accountability for previous decisions and actions), the present (their responsibility for who they are in the moment), and the future (which threatens unpredictability and potential for disappointment). The final three reasons not to change give evidence to how some individuals engage in treatment as a means of developing an alternative biographical self-description that avoids the anxieties of change. I call this form of selfdescription a patient career. In Chapter 3, I investigate the patient career and its relationship to failure and the dialectics of change.

CHA PTER 3

The Patient Career The Passive in Patient The Patient Career Modulating Being Seen and Not Seen Conditional Enduring Attention Maintaining Low Expectations Medusaization Effective Ineffectualness Threats to a Patient Career and Parasuicidality The Threat of Authorship

30 31 34 34 36 40 41 43 44

The Threat of Aloneness 45 The Threat of Change 45 The Threat of Agency in Others 45 Doctorhood 46 Nonjudgmental Judgmentalism 48 The Clinical Gaze 50 The Focus on Mending 52 Absurdity: The Existential Context of Doctorhood 54 Conclusion: The Social Ecology of a Patient Career 57

A

patient career is an understandable means of defending against existential anxiety and guilt. Not all individuals, however, avoid existential accountability by seeking an identity so intensely defined by passivity as a patient career. Indeed, many people take the opposite tack of narcissistic omnipotence, while others simply choose conformity (Spinelli, 2003). A patient career is distinct from other forms of existential bad faith because it both provides shelter from existential accountability by means of a self-definition of total passivity and it maintains this self-definition in relationship to medical institutions and the professionals who occupy them. This said, a patient career is still not the sole province of parasuicidal individuals. In addition to individuals who sociologists typically define as having the patient role thrust upon them, such as those with chronic illnesses (Parsons, 1951; Scheff, 1963; Whitt & Meile, 1985) or the institutionalized psychiatric patient (Augoustinos, 1986; Goffman, 1959), a host of individuals can easily be described as habitually and actively seeking medical attention as a means of sustaining and generating an identity formed by the parameters of the patient role. Factitious disorders are the most obvious example of this latter group. As described in the DSM–IV–TR, the hallmark of a factitious disorder is the exhibiting of symptoms in order to “assume the sick role” (p. 517). Individuals exhibiting behaviors associated with Munchausen

29

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disorder, conversation disorder, somatization disorder (Wooley & Blackwell, 1975), and hypochondriasis can also all be understood as employing certain behaviors in order to assume the sick role. What differentiates parasuicidality from these other treatment-seeking behaviors, however, is that it directly and potently threatens the liability of clinical professionals. I argue in this chapter that parasuicidality is primarily an other-oriented gesture aimed to engender in clinical professionals an anxious need to attend to the person exhibiting it. Parasuicidality not only facilely attains access to the sick role for those who exhibit this behavior, it motivates (in large part from fear) the vigilance of medical professionals and their compliance to the norms of medical culture. Parasuicidality, in this light, is both a role-seeking and role-generating behavior—for while it is a means to assume the sick role, it is also a means towards generating the kinds of complimentary medicalized behaviors that support this role.

THE PASSIVE IN PATIENT “Like victims of epilepsy, muscular dystrophy, and neurofibromatosis (the ‘Elephant Man’s’ disease), victims of borderline neither asked for, deserved or caused their affliction,” writes psychiatrist Leland Heller (1999, par. 9). “They are terrified of being abandoned, yet are powerless to keep the illness from destroying relationships. Borderlines are VICTIMS—they did not cause their illness. They do not want their illness. They want to be treated and possibly cured.” People who habitually present as distressed and at risk in clinical milieus often use a particular language to describe their experience. This language is often similar to Heller’s. Employing adjectives of illness, they often use a passive voice, speaking of their self-destructive behavior as triggered by a force outside their control. They “become suicidal,” “cannot control the urge to cut,” “are hospitalized.” Such individuals use the lingua franca of people assuming the role of patients under medical care. The word patient, in the medical sense, means to passively suffer. Similar to the roles of victim and child, the patient role is differentiated from other social roles by its sanctioning of passivity (Morrison, Bushnell, Fentiman, & Holdridge-Crone, 1977; Parsons, 1951; Scheff, 1963; Whitt & Meile, 1985). Parson’s original definition of the sick role is illustrative here. Every role in society carries with it certain rights and obligations. The rights and obligations of the sick role all orient towards passivity. A person who enters the sick role has the right to be exempt from normal social activities (for example, calling in sick to work), and is defined as not responsible (the

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insanity defense for example). He is obligated to define the sickness as undesirable (one would typically be seen by others as deviating from the sick role if one enjoyed, rather than passively suffered, an illness) and seek and cooperate with treaters (it is no mistake that patients who engage in treatment are often called compliant, meaning to passively respond to the will of others). To be defined as a patient, a person must shed agency and accept passivity. This is the threshold across which a person must pass as she enters the patient role. For someone trapped by the dialectical tensions of failure, this role is a haven in which he can partially escape the difficult struggle of accountability by entering socially authorized status, congruent with his own self-description (Warren & Messinger, 1988). In this light, being a mental patient is not a purely macrosociological phenomenon, defined simply by the parameters of the role itself. It is, instead, a form of identity. In the sense that patienthood is an identity easily accessible for the description of oneself to others and is based on biographical accounts that are used to forecast the future, it also has all the hallmarks of a career.

THE PATIENT CAREER Careers are social and psychological resources that fluidly link one’s internal experience of self with the world of others, allowing “one to move back and forth between the personal and the public, between self and its significant society without having to rely overly for data upon what the person says he thinks he imagines himself to be” (Goffman, 1959, p. 127). Careers are efficient in simultaneously portraying a depiction of a person’s private experience with his public status because they capture a concise chronological portrait of the individual. By definition, a career (with its linguistic relationship to carry, careen, and of course, car) connotes an ongoing endeavor, articulated in stories about where one has been, where one is located at present in a life course, and where one is going. Linking the psychological with the social and telling stories of movement over time, careers offer cohesive narratives regarding each person’s existence in the world, and his effect on this world (Goffman, 1959; Warren & Messinger, 1988). Careers are remarkably efficient social tools with which a person can easily locate herself, both within a life history and within the social strata, while also depicting the individual as an agent in this life history. Envision attending a party or even meeting people as intimate as family members. When you

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describe yourself, you will typically articulate at least three specific kinds of data. You will describe (a) a social identity within professional and social strata (“I’m a social worker.”), (b) your place or context in the world as reflective of your own agency (“I just graduated social work school and I’m about to take my first job.”), and (c) a life course that got you to where you are, and will take you towards a future (“Before social work school, I took a few years off and worked at an agency serving the poor. With my new degree I hope to work more directly on this problem.”). Careers balance issues of personal agency and effectiveness with a linear narrative about change and movement. They are, in this sense, an existential compromise. Typical careers blend good faith acceptance that an individual is fully accountable for his existence (the individual built his career) and bad faith denial of his existential choice to be who he is in the moment (he is on the right career path). Careers offer both a means for an individual to personally and socially acknowledge his own authorship of his life and a chronological narrative construction about a logical progression of life events that delivered the person to his current status. They safely contain issues of authorship in an easily comprehensible package of biographical steps. The patient career is both similar to other careers and exactly their opposite (Table 3.1). It offers a biographic explanation for an individual’s existence and identifies this individual as assuming a particular status in society, yet it is comprised of bad faith narratives only, denying the individual’s agency in this career. In a patient career, the polarities between having a career and making a career are skewed significantly towards the former attitude—that the careerist was not only led by a career path, but had no agency in its navigation. While the typical career offers an individual a means to efficiently portray her status in society as partially reflective of her effectualness (she is self-made), a patient career identifies the individual’s current context as reflective of events acted upon her (she suffers a mental illness). Similarly, while the typical career is generally employed by an individual to identity herself to others as an active agent in the world (we do not ask a new acquaintance, “What is your job?” but, “What do you do?”), a patient career is a means for an individual to efficiently identify herself without raising the expectations of others or risking their assumption regarding the individual’s authorship or accountability (we do not ask the mental patient, “What do you do?” but, instead, we query about her rehabilitation, “How are things coming?”). In a similar paradoxical mode, while experiences of failure are precursors of crises of identity and social standing for individuals participating in typical careers, success is the ultimate threat to the patient careerist. Indeed, for the patient careerist, success is the precursor to a career crisis. Accordingly, consistent failure, rather than success, is the means to maintain a patient career.

The Patient Career TABLE 3.1

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The Typical Career and the Patient Career

Typical Career

Patient Career

1. A social status reflective of one’s effectualness 2. A life course with a progression of steps that one has taken A narrative about a life now that is connected to one’s actions and decisions

1. A social status reflective of one being acted upon 2. A life course with a progression of steps forced upon the individual A narrative about a life now that is connected to an illness one did not choose and to the decision of others A narrative about a future based on the decision of others 3. A way of easily identifying oneself to others without raising their expectations or risking their assumptions regarding one’s authorship or accountability 4. A way of maintaining an extreme polarity between being gazed upon by others and concealing one’s inner self 5. A vehicle through which one can experience one’s effectiveness in the world without revealing that one is effective

A narrative about where one is choosing to go 3. A way of easily identifying oneself to others as an effective social agent

4. A way to be seen without being completely vulnerable 5. A vehicle through which one can experience his or her effectiveness in the world

A patient career gains a strangely paradoxical form of status and social acceptance, based on the denial of the very attributes we often associate with self-actualization, achievement, and even mental health. It is thus remarkably reflective of the existential needs of individuals who have defined themselves failures. While such a career is contingent on the negation of accountability for one’s place in life, the expectation of personal agency, or a respect for one’s life-authorship, it provides individuals the opportunity to take part in a collective identity and offers a social network of people familiar with this identity who validate it as legitimate and justifiable. In its paradoxical nature, a patient career achieves two important relational and psychological resources typically associated with both independence and self-awareness, without raising the risk of exposing the patient careerist’s agency in the world. It provides the ability to modulate the intimacy and distance with others, providing the patient careerist a sense that he is held in the gaze and consciousness of others—what I call conditional enduring attention—while controlling his experience of agency in these others—what I term medusaization. Concurrent with its access to these resources, a patient career attains for the self-defined failed person the ability to affect the world around him while shielding his own effectiveness. I call this process effective ineffectualness.

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MODULATING BEING SEEN AND NOT SEEN Linking the personal with the public and compromising between good and bad faith, careers mediate our social proximity and intimacy with others. Indeed, without a career, it is very difficult to describe oneself in social situations. Someone asks, “What do you do?” and you will likely not answer with a description of your thoughts and feeling, your aesthetic sense, political beliefs, your bad habits and your neuroses. Instead, you will offer a depiction of your career. By doing so, you will give the person a vague sense of your social identity and an approximate idea of your personal inclinations, and thus be seen and appreciated by them as an active, choosing person in society. You will announce yourself as counting in the world—part of the count, a real and substantial presence. You will do so, however, without letting on too much about your internal life. This is an important aspect of careers for most individuals, because most people want to be recognized as active agents in the world, but simultaneously conceal their more complex, specific, and private natures for those with whom they are most intimate. A patient career offers this modulation of one’s social presence, but in an extreme manner. As Laing writes (1969), the ontologically insecure person “is caught in a dilemma. He may need to be seen and recognized, in order to maintain his sense of realness and identity. Yet, at the same time, the other represents a threat to his identity and reality” (p. 113). As we have seen, the patient careerist lives directly within this dilemma, wanting to be seen by others, but wanting to conceal her agency, vacillating constantly between these simultaneous needs. A patient career offers a means to modulate these needs, limiting the extremes of a see me/don’t see me vacillation through a socially sanctioned identity. An individual engaged in a patient career is able to maintain a sense that people are paying attention to her in a continuous manner, while controlling both how much these people are witnessing her own agency and how much she experiences their active participation in her own life.

Conditional Enduring Attention Like most individuals, people who seek a patient career as a means of alleviating the pain of failure find a sense of comfort and safety when they are held continuously within the consciousnesses of others. They want and need reverberating, enduring attention—not simply a sense that someone is paying attention to them in the moment, but that they remain in the consciousness of others long after these others are out of sight. While the self-defined failed person yearn for the assurance that someone is paying this kind of

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attention to him, he does not want to be looked at too closely. He needs to be seen, but not seen in the glaring light of full authenticity. To be seen by others in the latter manner means the possibility these others might observe his success, begin to expect more from him, possibly watch him fail again, or simply accept him as an active social agent. Wanting to be seen, but not seen too closely, he perpetually vacillates between seeking witness from others and fleeing from their gaze. A patient career provides a partial solution to this anxiety-ridden vacillation. It guarantees that someone is paying attention in an enduring manner, yet it attains this attention through highly conditional and fairly inauthentic ways. An example of how a sense of enduring attention is achieved through parasuicidality: a client has been unexpectedly absent from her day treatment program. Returning to the program, she is dissatisfied by the staff’s lack of concern regarding her absence. That night, she presents at a local emergency room (ER) after superficially cutting her wrists. She meets with a member of the intake staff there. The staff member attempts to counsel her, inquiring about any particular precipitant to her current crisis and attempting to engage her in a conversation about her emotional state. The client becomes increasingly agitated in response to this line of questioning, explaining emphatically that she simply “felt the urge to cut.” She is hospitalized. The client’s behavior in the above example is not motivated by her wish to manipulate a singular treater, but by a need to influence a more dispersed social spectrum. Indeed, she does not seek others who might understand how difficult her day was or who could exhibit a full and authentic empathy regarding her plight. Instead, she seeks a more automated interaction from hospital professionals with only tertiary relationships to her care. Doing so, she attains an acute surveillance from these others with a low expectation regarding her agency. She reinvigorates the experience of enduring attention that she had lost in her day program. This example is only one illustration of many in which the patient careerist attains a sense of continuous attention from others devoid of the threat that these others will hold her accountable. When a client begins scratching her wrists during a group session, lays hints of a potential suicide near the end of a session with her therapist, or simply leaves repeated messages on her therapist’s voice mail, these behaviors—all typically associated with BPD—are signs of an individual seeking a means to be held in the consciousness of others without being held accountable for her actions. Parasuicidality is not the only means at a patient careerist’s disposal in her pursuit to be seen by others but not seen as accountable. The patient role itself, and milieus populated by patients, often offer the possibility of regulating the expectations of others.

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Maintaining Low Expectations In large part, the dialectics of change are influenced by the fear of the expectations of others. By approaching clinical interactions as part of a clinical routine, as if on an assembly line, and by behaving in a manner aimed to increase the pessimism of treaters, the patient careerist is able to deaden these potential expectations. Routinization of treatment. When clients approach treatment primarily as a matter of repetitiveness and routine rather than a source of unpredictable change, they attempt to form relationships with their treaters that are more automated than autonomous. Routinizing treatment, they attempt to submerge the likelihood that others might see them as sentient individuals—the flesh and bone vessels of real possibility. Indeed, they attempt to enforce a relationship devoid of expectations regarding possibility and change. In a day treatment program I once supervised, new clients often described their reason for attending as a need for “day structure.” This term, often also used by professionals in community mental health settings, portrays the treatment program as merely a scheduled apparatus offering a routine to an otherwise unstructured day. The client, in this view, simply moves, assembly line–like, through the apparatus, each day no different than the last. This is one of many examples of how clients approach treatment as a matter of routine. Good, motivating therapy occurs when clinicians are engaged in an active, lively process. Routinization is the opposite of this and it is a process that is abundant in hospital and community mental health settings. When clients complain that changes within a milieu are making them feel unsafe, or when they express anxiety about a new clinician or a particular clinician’s high energy or intensity, they are stating a concern about routine being disrupted. When they ask for particular techniques of crisis intervention repetitively, such as phone check-ins, reevaluations of safety plans, or so-called contracts for safety, they are requesting immediate implementation of certain routines. When they present, day after day, as if their treatment is more like a factory job than a means to personal recovery, they are participating in a routinized approach to treatment. Below is an example of a client approaching treatment as routine. He is meeting with a clinician near the end of his treatment in a partial hospitalization program. CLINICIAN: So, how has it been for you in the program? CLIENT: It was OK. CLINICIAN: It looks like you met many of your treatment goals. CLIENT: Yeah, I guess I did.

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CLINICIAN: Did you like the program? CLIENT: Well, it gave me a place to go and my case manager feels I need that. CLINICIAN: Yes, but did you think it helped? CLIENT: Well, it helped me with a place to go and a way to structure my days, which

people tell me I need. CLINICIAN: Do you think you need this sort of program? I want to refer you to the

right kind of program. CLIENT: I can’t be alone all day because my suicidal thoughts will come back. I need

day structure. CLINICIAN: So it sounds like you need something like a clubhouse or a day treatment

program. CLINICIAN: If you think they can give me some structure then that would be a good

idea. Most notable in this interaction is what is missing. The client does not discuss treatment per se. Instead he focuses on the milieu as a source of structure to his day. He also does not discuss his interactions with clinicians on staff. On the contrary, he describes the partial hospitalization program as “a place to go,” as if the fact that the place is peopled with individuals seeking to help him matters little. This individual’s view of treatment is of a place that helps him avoid his symptoms by offering a predictable routine to his day. It is in stark opposition to a place in which he actively engaged in treatment. Enforced pessimism. As discussed, the ontologically insecure person, overwhelmed by a sense of personal failure, typically feels threatened when others express hope or encouragement about her future. Fearful that she will disappoint others, the person shrinks from their positive expectations of her. When these expectations are expressed, she is likely to respond with behaviors aimed to decrease them. Thus, behaviors clinicians often describe as selfdefeating or sabotage, exhibited by a given client following positive change, are actually a means of self-preservation—the only way the client knows to fend against the annihilating experience of high expectations. Like the routinization of treatment, the client seeks to enforce a level of pessimism in her treaters in order to maintain in them a safe and, accordingly, minimal level of hope and expectation. The following is an example of a clinician becoming increasingly pessimistic in her interactions with a parasuicidal client (for brevity’s sake, her fall into pessimism is likely more dramatic than in a real therapeutic situation). The client uses the hospital often, but met at the hospital prior to discharge with the clinician this time, developing a plan with the clinician for decreasing her suicidality.

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CLIENT: I thought things were going well when I got out of the hospital, but this week

I felt the urge to cut again. CLINICIAN: Oh, I’m so sorry to hear that. Did something happen today to get you

upset? CLIENT: Well my mother called and it got me all mixed up. She was asking me about

what I do with my days, and I didn’t have a good answer. CLINICIAN: I can see how that could make you feel upset. I’m so sorry you had that

interaction today. Let’s you and I figure out how to get you out of these feelings. We should go back to the techniques we discussed at the hospital. WEEK 2 CLIENT: I feel the urge to cut again. CLINICIAN: I’m sorry to hear this again. Did you try the techniques we discussed last

week to help you stay safe? CLIENT: No, I couldn’t do them. I’m not smart enough. CLINICIAN: I’m sure you’re smart enough. CLIENT: Well, I was too upset to use them. CLINICIAN: What happened that made you feel like harming yourself again. CLIENT: Nothing really, the suicidal thoughts just take over. CLINICIAN: But something must have happened to make you feel this way. CLIENT: I don’t think so, they just take over. CLINICIAN: Maybe we could try something else that can make you feel safe. Are you

willing to try something else? CLIENT: I guess, but don’t make it too complicated. CLINICIAN: Is there anything from our list of self-soothing exercises that we came up

with at the hospital that might help? CLIENT: Maybe we could find something.

WEEK 3 CLIENT: The suicidal thoughts took over me this week. CLINICIAN: Really? Did you use the techniques we discussed? CLIENT: Oh, I forgot. What were they again?

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CLINICIAN: I’m not sure this is working. Maybe we need to try something else. CLIENT: You’re frustrated with me, I can tell. CLINICIAN: I’m not frustrated with you. I want to find a way to help you is all. CLIENT: God, I feel like such a failure. I’m so screwed up. Please don’t blame me. CLINICIAN: I’m not blaming you. I just want to find a way to…. CLIENT: I can tell you are frustrated with me. Please don’t get that way, I can’t take

that. CLINICIAN: I’m honestly not frustrated. We just need to find a way that helps. Do

you think it might work to call the crisis team when you’re upset? CLIENT: I feel like you’re pawning me off. What are they going to do? CLINICIAN: Well, they can talk to you a bit and help you pull yourself together be-

tween our sessions. CLIENT: Well, if you think that might work, I could give it a try. WEEK 4 CLIENT: Things got worse this week with my suicidal thoughts. CLINICIAN: What happened? CLIENT: Well, I called the crisis team as you told me to and they were no help. I got

off the phone and just felt worse. CLINICIAN: Worse? Wow. I’m sorry that didn’t work. Maybe you need to go into the

hospital if you’re feeling worse. I’m not sure we can find a way to keep you safe in the community. CLIENT: I feel like you’re giving up on me. I’m really trying. CLINICIAN: I know, but it doesn’t seem like anything is working. CLIENT: God, I am such a failure. I fail at everything. I can’t even do this right.

You’ve got to help me. CLINICIAN: I’ve been trying, but at some point it’s up to you. I don’t know what else

I can do. CLIENT: Yes, I think you’re right. It’s just hopeless. I can’t do this on my own. I need

to be in the hospital. In the above example, the clinician and client are trying something new, developing a crisis plan before the client leaves the hospital. For the clinician, initiating a new procedure makes sense, considering the fact that treatment, so far, has not decreased the client’s suicidality. For the client, however, a new

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procedure threatens her with the potential of her therapist’s rising expectations. She aims to influence her therapist to become pessimistic, lowering her expectations regarding the client’s ability to change. Doing so, she reaches a more ontologically safe homeostasis in which hope and expectations are held at a minimum. As Laing writes (1969), the ontologically insecure individual forgoes his “autonomy [as a] means to secretly safeguarding it” (p. 51). For such a person, “To play possum, to feign death becomes a means to preserving one’s aliveness. To turn oneself into stone becomes a means of not being turned into stone by someone else” (p. 51). A patient career is a social sanctuary in which individuals both activate and maintain this possum-like stance. So far, I have described how the patient careerist modulates how his own agency in the world is perceived by others. However, in order to feel himself held within the consciousness of others without feeling threatened by their gaze, he must not only regulate his own agency, but theirs as well. I call this regulation of the other, medusaization.

Medusaization The self-defined failed person fears authentic interactions with autonomous others because these interactions always pose the threat that others, left to their own agentic capacities, will judge the person or see the person’s actions as the evidence that fuels their expectations regarding change. On the other hand, for the self-defined failed person, total isolation from others is as awful an alternative to being captured within an authentic gaze, leaving the selfdefined failed person alone in her shame, without human contact. In order to attain a sense of being held continuously in the consciousness of others without being threatened by the authenticity of these others, the patient careerist seeks a medusa-like relationship with them (Laing, 1969), one in which these others watch the patient careerist (often intensely) but are experienced by her as muted in their own agency. Patient careerists can most easily gain medusa-like relationships by entering hospitals. Here, they are likely guaranteed interactions in which they are studied and observed, but treated by individuals who will approach them in a somewhat automated manner. In the hospital, the patient careerist is a transient occupant, and specific tasks must be performed on him before he can be discharged. While therapeutic in their stated mission and populated by caring and empathetic professionals, hospitals follow an organizational course steered by instrumental rather than interpersonal objectives. Treatment protocols are followed, and a client moves through a sequential system of care. Thus, the opportunity to reach the particular compromise sought

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by a patient careerist between being watched but not seen is preset in the hospital. Indeed, as I will explicate further, in these environments, surveillance, rather than authentic, spontaneous interactions, is the driving cultural norm. Outpatient settings are less formalized in their interactions than inpatient settings. In outpatient settings, where staffs are more familiar with the client and where treatment is not overly determined by protocols, the patient careerist’s need for medusa-like relationships is more often threatened. When this occurs, the patient careerist reverts to parasuicidal behavior in order to regain more automated relationships. For example, a client is waiting to meet with her therapist. It is the therapist’s lunch break and she is meeting over lunch with her colleagues. The client hears laughter from the staff office. When the clinician finishes her break and asks to meet with the client, the client angrily refuses to enter her office, stating that she “heard you laughing about me in there.” Despite the clinician’s assurance that the client was not the topic of the laughter, the client continues to assert, “You were making fun of me in there.” Finally, the client tells her therapist, “I feel like cutting myself because you triggered bad thoughts.” Here, the client has dampened the perceived spontaneous agency of her therapist, while simultaneously attempting to divert the therapist’s gaze away from her colleagues and on to the client. Clearly, direct threats of suicide engender a watched/not seen relationship, for the immediate experience for the clinician is typically to tread lightly on issues of accountability, while spending an exhaustive amount of energy caring for the surveillance of the client. Indeed, in such circumstances, the clinician’s goal is often to muster appropriate resources so that someone other than the clinician will watch the client. Here, the clinician hands over surveillance to other professionals and institutions. In situations when a client presents as parasuicidal, the clinician may attempt to reach out to the client, to provide empathy, but in the back of the clinician’s mind is the more instrumental imperatives of the type, duration, and quality of observations the client requires. Thus, parasuicidality is an effective means of initiating an interpersonal dynamic that is as powerfully defined by the automated surveillance of one individual by another as it is vacant of a process in which each individual sees the other as an agentic human being.

Effective Ineffectualness Individuals who define themselves as failures find a means in the patient career to be effective while simultaneously denying their effectiveness in the world. Through their careers, they have (as it is colloquially and appropriately

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called) impact, but only as if they are an inert object propelled within this world by a force outside their control. As described above, many parasuicidal individuals do not immediately call on their primary treaters when distressed, but instead enlist clinicians employed to respond to emergency situations who have a more peripheral involvement in their care. In most cases, it is the job of emergency clinicians to act as gatekeepers for managed care and insurance companies. They are also charged with the more general social responsibility of seeking the least restrictive environment for the clients who present to them. A particular interaction between emergency clinicians and clients is thus predetermined in such circumstances. The client seeks something from the clinician that the clinician is hesitant and, at times, resistant to offer. At the onset, then, this interaction is marked by one party coveting a particular good and another party withholding this good. By guarding hospital admittance, hospital personnel inevitably raise the perceived value of an admission, for it is demarcated by their actions as a resource worth guarding. They also present hospital admission as a benefit that one can only achieve through interpersonal effectiveness. One must engage in the thrust and parry of assessments and interviews to attain it. Once attained, a hospital admission itself is quite significant, for the client has not only obtained the concrete resource of a hospital bed, but has moved an entire organizational system, as intake staff, social workers, and psychiatrist prepares to admit her. In most cases, a client can gain admittance to the hospital by asserting that she is not able to control her ideas or plans for suicide. Thus, through the effective portrayal of her own ineffectualness, the client is successful in influencing a complex system that is resistant to serving her. While the example of a client seeking admittance to the hospital is a rather conspicuous version of how an individual creates a process of effective ineffectualness, many patient careerists develop a more subtle repertoire. For example, near the end of a therapy session, a client presents to her therapist in a markedly passive manner that has historically preceded her parasuicidal behavior. Hugging her knees to her chest, she responds to her therapist with noticeable poverty in speech and withdrawn affect. The therapist, anxious about the client’s well-being, yet also concerned about maintaining the confines of the therapeutic hour, attempts to assess the client’s safety by asking direct questions regarding her potential self-harm. The client responds only minimally. The therapist is now under pressure, concerned about her next therapy session with another client, and anxious that her current client may behave in a self-destructive manner once she leaves. The therapist offers to telephone the client later in the day, in

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order to check in, asking if the client can maintain her safety “at least until I reach you.” The client agrees that she can do so. She leaves the session 15 minutes later than her allotted time. In this example, the client has affected her therapist precisely through her presentation of ineffectualness. By simply being passive, she has facilitated a context in the session in which her therapist verbally introduces the possible threat of suicidality and then responds to the threat that she, the therapist, has introduced. The therapist then offers the client a plan for safety in which the therapist extends attention outside the typical therapeutic bounds. For people overwhelmed by a sense of failure, who might also have few occupational outlets in which they can witness their own social impact, parasuicidality is often their most effective skill for attaining recognition of their own presence in the world. On a daily basis, an individual can find in a patient career a safe balance between personal efficacy and an identity that is socially sanctioned as passive in nature. When this balance is threatened, the patient careerist typically exhibits parasuicidal behaviors. Linehan (1993a) describes parasuicidality as treatment or relationship interfering, precisely because it hampers the therapist’s ability to remain authentically engaged in the therapeutic process. A theory of patient careerism interprets parasuicidality as treatment and relationship generating, for it creates and sustains a particular interaction with treatment providers that feels somewhat safe for the client, one in which the agency in these providers is muted and potentially modulated. Parasuicidality interferes with the therapist’s authenticity in service of an automated treatment relationship.

THREATS TO A PATIENT CAREER AND PARASUICIDALITY Traditional theorists on BPD (Gunderson, 1984; Kernberg, 1967; Masterson, 1975) generally view issues of abandonment as the precipitants to suicidal behavior in their clients, while DBT theorists believe the precipitants are rooted in any number of emotional or often biological points of distress that the borderline cannot regulate. In a theory of patient careerism, on the other hand, precipitants to parasuicidal behavior are seen as rooted in four specific, interrelated psychosocial threats. These threats endanger the central dynamics of patient careerism: conditional enduring attention, effective ineffectiveness, and the regulation of the agency in others. When they are in force, the patient careerist is threatened with a career crisis. His or her ability to defend against existential concerns with the armor of a career defined by passivity is weakened (Figure 3.1). These threats are as follows.

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Typical Psychological Crisis B T PE

CR Mobilized

C Every day we are faced with psychological threats (T). In a typical psychological crisis, a person does not have the coping resources to respond to a particular threat. The point at which threat does not meet with coping is the precipitating event (PE) for a crisis (C). Unable to return to a sense of stability, the individual frantically searches for coping resources (CR). Once found, these resources help the person return to the previously held level of baseline (B) psychological function.

Patient Career Crisis B T PE

Threats of…. *Authorship *Aloneness *Change *Others’ agency

CR

PC

Mobilized through parasuicidality

Medical response *Conditional enduring attention *Effective ineffectualness *Mute others’ agency

The patient careerist is faced with multiple threats to his or her baseline daily, threats most individuals typically must face. But the particular existential threats of being confronted with the patient’s authorship of his or her life, his or her aloneness in the world, the potential of change, and the agency of others throws the patient into a patient career crisis (PC). By behaving in a parasuicidal manner, he or she is able to regain the basic coping resources of a patient career. For the typical individual, contact with clinical professionals is one of many means to regain coping resources. For the patient careerist, contact with clinical professionals and engendering a medical response from them is his or her coping resource.

Figure 3.1 The typical crisis and the patient career crisis. Source: Jacobson (1980).

The Threat of Authorship When the patient careerist realizes that he has been witnessed by others as accountable for his own behavior, he feels threatened by the potential that others will define him as the author of his own fate. Here, the condition of passivity, intrinsic to a patient career, is broken, because the patient careerist is seen by an agentic other as actively effective in his own life.

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The Threat of Aloneness The patient careerist is threatened by the potential of her own aloneness in the world when others do not exhibit continuous and secure attention to her. Conversely, the patient careerist also faces her aloneness when these others offer a full and existentially authentic attention in which she is seen as an autonomously effective being.

The Threat of Change When others express hope or optimism about the patient careerist’s potential for change or when they directly express their wishes for this individual to enact specific changes in his life, they, as sentient perceivers of his behavior, simultaneously express a message regarding their belief in his potential for effectiveness in the world. They take a stance of watching the patient, but watching him as a potential author of change.

The Threat of Agency in Others A person’s patient career is threatened when she perceives others, whom she depends on to maintain her career, as exhibiting their own individual life authorships. For the patient careerist, perceiving these others as agents in their own lives means that they cannot provide enduring attention to her. Furthermore, their agency threatens the possibility that they will witness her as an effective individual. All four of the threats described above potentially reveal the patient careerist as an alive and active agent in the making of his life, exposing the patient careerist as alone in the world without conditions and as a social agent whose gestures affect his own environment. Parasuicidality is the patient careerist’s means to defend against these four threats. By behaving in a parasuicidal manner, he potently reinvigorates the enduring attention of others, is able to feel immediately effective and able to regulate how others behave towards him. The reason parasuicidality is so effective in reinvigorating a patient career is only minimally a psychological one. More importantly, parasuicidality is a social gesture, with particular social meanings and effects. Specifically, it is a powerful means of access to social resources within medical culture. Like any profession, patient careers do not exist in a vacuum. They are contingent on particular professional norms, roles, and beliefs. Specifically, patient careers are contingent on medical culture—a culture distinctive in its designation of particular members as passive and other members as charged with the responsibility of both observing and mending them. Patient careers, in other words, are coconstructed between clients and clinicians.

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Clearly, harming oneself physically can become a medical problem and is a behavior most often defined as a symptom best ameliorated by psychiatric interventions. Yet the marriage between parasuicidality and medical institutions is not simply the result of an inevitable sequence of events, from symptom to treatment. It is, instead, a much more symbiotic, culturally coordinated marriage in which each party shares specific cultural meanings and often arrives at mutually acceptable arrangements.

DOCTORHOOD Writes Linehan (1993b): I once had a client in skills training who every week reported doing none of the behavioral homework assignments and insisted that the treatment was not working. When after 6 months I suggested that maybe this wasn’t the treatment for her, she reported that she had been trying the new skills all along and they had helped. However, she had not let me know about it because she was afraid that if she showed any improvement, I would dismiss her from skills training. (p. 2, italics hers) For Linehan, the client above exhibits a dialectical failure, etiologically located in the borderline disorder. Linehan sees the client’s resistance to leaving treatment as a generic example of a particular dilemma borderlines experience in a spectrum of relationships and circumstances. She does not see the unique social contours of therapy, themselves, as the specific psychic goods the client fears losing. In a theory of patient careerism, on the other hand, Linehan’s client is understood as wanting to remain in therapy because therapy, as part of a unique cultural and epistemological field, offers a social arrangement in which she can withstand the powerful dialectics of change. Conditional enduring attention, effectual ineffectualness, and medusaized interactions are readily accessible from medicalized institutions, precisely because these types of interactions are elemental to the norms of the professional culture of medicine. Four entwined and elemental epistemological tendencies in medicine reciprocate the ontological needs of individuals who have defined themselves failures. First, at the base of modern western medicine is the belief that the field is objectively scientific. Doctors, in this light, are often seen as making judgment calls but not being apt to judge the moral decisions of others. Simply put, doctors are expected to define what is sick, but not what is bad. Psychiatrists are seen, for example, as imbued with the expertise to define whether individuals are capable of making moral decisions, but not with

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the expertise to judge these decisions themselves. They are associated with this kind of judgment precisely because their techniques are accepted generally as scientific, objective, and above the fray of repugnance or admiration regarding behavior. This view of doctors is, of course, a myth, for medicine, like any culture, has its own culturally specific way of defining deviance. I call the way in which medicine judges while claiming objectivity nonjudgmental judgmentalism. Medicine’s claim of objectivity is intrinsically entwined with ideas about seeing and viewing the world. Indeed, modern Western medicine is an epistemological field marked by a way of seeing. With X-rays, stethoscopes, thermometers, weight scales, blood tests, and so forth, observations of human beings are elemental to medicine. Modern Western medicine would simply not exist without the surveillance and inspection of people. Foucault (1975) called this form of gazing the clinical gaze. The clinical gaze is the second epistemological trend in medicine that I will investigate. The clinical gaze participates in a pervasive modern epistemological phenomenon of making human beings the objects of knowledge. It is distinctive from other modern epistemological fields in the fact that it is focused on categorizing people in the service of fixing their diseases. Thus, at the epistemological spine of medicine is a way of viewing the body and issues of health and illness that always seeks a status quo, shifting individual from a category of illness to one of health. This is the third tendency in modern medicine, intrinsic to patient careers. Medicine focuses on mending. Steered by the target of facilitating a return to a previous or an average level of functioning, it seeks to conform its patients to the status of a larger group. Doctors, within the basic medical epistemology, do not create, but fix. The basic doctors’ tools vividly demonstrate this tendency; stethoscopes, thermometers, blood pressure tests are all set to test the patient’s conformity to a number derived from an average. When clinicians in psychiatric institution speak of maintenance in the community, the return to a safe psychiatric baseline, the need for day structure for their clients, they participate in the norm of mending intrinsic to medical culture. When clinicians break from an objective stance, the clinical gaze, or the focus on mending, they defy the very epistemological foundation of the field in which they work. Doing so, they typically face the central societal sanction for deviance from the norms of medical practice—the threat of liability. Like its etymological siblings ligament and obligation, liability means to bind. When one is liable for another, one is bound to him by a responsibility for his wellbeing. One experiences the threat of liability when one fails in this responsibility. Clinicians encounter the threat of liability when they deviate from their responsibility to maintain objectivity, the doctor-to-patient bind of the clinical

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gaze, or are derelict in their practice of mending. Concerned about a possible lawsuit, loss of licensure, or investigation, clinicians may encounter the threat of liability overtly. More frequently, however, they experience the liability of medicine as an unconscious yet consistent social force guiding their behavior. Again, Foucault (1975) proves instructive, for the threat of liability, in this latter subtle and socially introjected sense, disciplines clinicians to behave in a certain manner. Clinicians experience it as an anonymous source of social surveillance, guiding them to conform to the norms of their profession. The pervasive threat to clinicians of liability is the fourth tendency in modern Western medicine contributing to the coconstruction of patient careers. It is also a resource to individuals attempting to invigorate and maintain their patient careers. Below, I describe further the nexus between nonjudgmental judgmentalism and the clinical gaze and the focus on mending. In all these descriptions, I show how concerns about liability guide these three tendencies in medical culture.

Nonjudgmental Judgmentalism The great myth of a medicalizing approach is that it is nonjudgmental, sheathed as it is in the objective world of science. This claim of scientific objectivity is also a claim that medicine exists above the fray of value setting or moral judgments. However, as sociologists have pointed out, a medicalized approach to social and psychological problems, while switching labels from ones based in “badness” to ones defining “sickness” (Conrad & Schneider, 1992), is one of the most influential processes in society today defining deviance. To be called sick is to be automatically labeled as deviating from the norm of human experience, as abnormal, dysfunctional, and broken. A medicalized approach goes one step further in judgment, especially in regards to psychological and behavioral problems. If a person defined as sick does not comply to the central obligations of the sick role, which are defining his sickness as undesirable and seeking to cooperate with (Western-trained) treatment agents (Parsons, 1951), he is perceived by others as doubly deviant—not only sick, but unwilling to get better, refusing to return to society as a full participant; bad, in other words. Medical culture, in this light, has its own version of sin. If one participates fully as a patient, one is viewed within this culture as broken, imperfect, but righteously a part of the flock. If one is viewed as resisting participation in treatment, one is accepted as sinfully neglecting his obligation to get better and thus falling outside the fold. As a social behavior, parasuicidality initiated patient careerism rests between both sick and bad designations of deviance. Patient careerists clearly seek entry into the sick role, but they also desire this role, and, to maintain

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the role, they do not fully comply with treatments that may help them escape it. This is one reason clinicians participate in their own splitting behavior and black-and-white thinking when it comes to individuals they see as borderlines. They typically either marginalize patient careerists as intentionally unethical (as manipulative, dependency seeking, and selfish) or they accept them into the fold of medicine (not accountable for their actions and thus deserving, in their sickness, of a medicalized approach). Later, when I describe the clinical gaze and the focus on mending, I will describe in detail the basic parameters of a medicalized approach. Currently, I will describe the way in which a marginalizing approach influences the treatment of patient careerists. No group of psychiatrically diagnosed individuals is derided by professionals more than people labeled with BPD. Typically, professionals rationalized this derision as an anomaly, a problem of poor professionalism, or an understandable blowing off of steam for clinicians working with these most difficult clients. They also describe it as a problem of countertransference, something to expect from borderlines—a negative feeling the clients engender. The negative countertransference to borderlines, in this view, is part of the illness. In both views, the derisive attitude towards borderlines is understood as outside the basic culture of medicine, either a problem of bad clinicians or an expected emotional response to difficult clients. If, as I suggest, we view derogatory feelings of clinicians to their borderline clients as emerging partly from the fact that people engaged in patient careers resist the central obligations of their role, then we see these feelings as actually an intrinsic part of medical culture. They emerge from the fact that patient careerist are deviants within this culture. In this view, the more a clinician approaches a client as appropriately fitting the patient role, the more he will inevitably become frustrated with the client. He will feel some of the same feelings a law-abiding citizen feels about a criminal or church congregations feel about someone who has acted profanely in a sacred space. A marginalizing approach to patient careerists, in which the patient careerist is seen as deviant, is clearly detrimental to the pursuit of helping individuals escape patient careers. First off, a marginalizing approach, because it is based on a view that a person is deviating from her basic social responsibilities, is inherently threatening to a person trapped within the dialectics of failure. Indeed, the four threats to a patient career are encapsulated in a marginalizing approach. When a clinician approaches a person engaged in a patient career as basically unethical in her neediness, the clinician threatens to reveal the patient careerist’s authorship in her actions, thus exposing her as accountable and existentially alone. Intentionally misusing the medical system, the patient careerist, in this view, is just as able to leave this system—to change

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and improve herself, in other words. Clearly, such a derogatory view of the patient careerist also threatens her with the negative judgment of an active other. Parasuicidality is the most easily accessible resource for the patient careerist as she attempts to escape these threats. By becoming parasuicidal, the patient careerist threatens the clinician with the clinician’s own liability for the patient careerist’s actions. Faced with the threat of liability and concerns that her own behavior has exacerbated the client’s symptoms, the clinician will likely return to actions that endorse the patient role, taking a more modulated attitude, avoiding risk, and thus taking the most cautious of actions, such as placing the client in the hospital, offering periodical check-in calls, and so forth. A marginalizing approach does little to resist the patient careerist’s fixation on conditional enduring attention, nor his need to create situations in which he is able to engage in effective ineffectualness or to modulate the expectations of others. By acting as if the patient careerist has done something wrong, a clinician shows this individual that he has acutely affected a professional, so much so that this person will break from the medical norms of objectivity. Held within the gaze of someone who feels he has sinned, the patient careerist can expect that his behavior has affected the clinician in an enduring manner, causing a level of confusion for the clinician about her own role and competence. A patient careerist can expect that when a clinician acts judgmentally—even spitefully—towards him, the clinician will feel sinful herself, as if the clinician has broken a central code of the profession. The marginalization of individuals defined as borderlines, which is intrinsic rather than anomalous to a medicalized approach, likely brings some relief to clinicians as they approach individuals who feel to them as much a part of their work as they do apart from it. But this is the relief of shunning, banishment, and condemnation. It is the relief that comes when one sets things right within one’s culture, by excommunicating individuals who challenge its central beliefs. That kind of relief is typically fleeting and shameful for individuals who take part in a profession founded in the ethics of “do no harm.” A devoutly objective approach in which the clinician gazes upon the patient careerist from a clinical distance and sees the patient careerist as an object of mending is a clear alternative to a marginalizing approach.

The Clinical Gaze When an adverse event occurs in psychiatric and psychotherapeutic milieus, the point of liability that investigators typically identify as the site of clinical negligence involves the staff’s level of observation during the incident. When, for example, a client completes a suicide, the first question clinicians are typically asked by investigating parties regards the level of intensity of

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surveillance these clinicians prescribed to their client. “Why,” the investigators might ask, “did you decide to let your client go home?” instead of placing the client under observation in the hospital. The second question typically regards the level of accuracy of the surveillance. “Did you detect a difference in your client’s behavior that night?” Understandably, the pervasiveness of the clinical gaze is most pronounced at points of crisis. It is, however, a norm that is intimately tied to the majority of processes associated with psychiatric care. Indeed, clinical attention and inattention are not simply the preoccupation of patient careerists, but the central measures of normative behavior in the psychiatric and psychotherapeutic professions. Influenced by the medical model, therapists are bound with their clients by the responsibility to gaze at them. The clinical gaze is infused in the elemental functions of most clinical milieus. In case conferences, for example, social workers, case managers, psychiatrists, psychologists, and other professionals gaze upon the patient as the patient reports on symptoms. Often these conferences vacillate between simple reporting on concrete progress and quasitherapy sessions, in which patients are requested to open up and describe feelings, cognitions, and attitudes. Charting is another example of the pervasiveness of the clinical gaze in psychiatric milieus. Clinical charts are intrinsically the documentation of contiguous observations made by one party gazing upon another. They are, in this sense, similar to an experiment log, in which the scientist documents observations each time she conducts the experiment. While sterile and quasiscientific, charts are also a form of biography, holding within them a personal history. They are documentations of an existence of a life, but the life they document is one defined by medicalized observations that render their subject passive. Like case conferences and charting, the actual therapeutic interventions, designed and implemented by clinicians, are intrinsically imbued with an epistemology that targets the individual as an object of knowledge. As it is commonly understood, therapy requires a certain surgical maneuver, in which an individual opens up a hidden world to the therapist—a world often obscured to even the patient—that is then deciphered, perhaps even adjusted (by new introjections, altered cognitions, and behavioral adjustments). Wondrous, creative, and spiritual experiences occur in therapy, but the ethos of analysis and observations intrinsic to most therapeutic approaches can also become distorted and skewed, especially within institutional settings. Here, the interpretation of the nebulous inner life of the individual is replaced with a deductive analysis of the client’s experiences as objective phenomena easily grasped and understood by the therapist. Life problems, in these situations, are interpreted as symptoms, and the overall therapeutic process is marked by an investigation into pathological mechanisms rather than a more human and intimate interaction.

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Clearly, the clinical gaze is intrinsic to the basic practices of the psychotherapeutic and psychiatric professions. Foucault viewed the clinical gaze as part of a modern form of power and oppression, rendering people passive. However, for the ontologically insecure person struck by a totalizing sense of failure, being seen by others through this gaze is experienced more as a haven from existential loneliness and accountability than as a site of oppressive observation. The clinical gaze is both penetrating and analytical while simultaneously recognizing its subject as void of agency. It thus offers two simultaneous relational resources conspicuously mirroring the needs of the patient careerist: being witnessed by others and being marked as a passive sufferer. Availing themselves of institutions steered by the clinical gaze, patient careerists are witnessed as if under the harsh light of an operating table. They are viewed, watched, observed. Yet, while they are acutely seen by others, their agency is just as acutely denied. They are surveyed, but only as passive objects of attention. For the patient careerist, the clinical gaze is an institutional provision of conditional enduring attention. When this provision is threatened, the patient careerist is able to reinvigorate it by exhibiting parasuicidal behaviors. She is able to do so because clinicians are held by normative expectations embedded in the defining epistemology of gazing within medical culture. Guided by this epistemology, clinicians, as a rule, intensify their gaze or seek an institutional arrangement for their patients in which their patients can be gazed upon further, when these patients threaten them with behaviors that potentially render the clinicians liable.

The Focus on Mending The central tenet in the Hippocratic Oath of “do no harm” touches the surface of an elemental ethos in medicine: do not generate, only rehabilitate. The term used for deviations in medicine—those instances when medical interventions do harm—emerges from this worldview. Iatrogenic means doctor generated. Tellingly, this term is only used for the negative consequences of medicine. One does not speak of iatrogenic wellness, but of iatrogenic symptoms. In the psychotherapeutic and mental health professions, the norms of mending and concerns about iatrogenesis translate as concerns regarding the agency of clinicians. Since Freud, therapists have either accepted or struggled against a tableau of therapy as a sterile operating room in which the therapist’s free will is like a contaminant (Bettelheim, 1984). Indeed, while other contradictory and demedicalized norms in these professions also exist, such as the importance of relationships, humor, authenticity, and hope, the norm of a tightly harnessed

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agency in the clinician is pervasive within the psychotherapeutic professions. When therapists comply with this norm, they view the exacerbation of symptoms activated by their own authentic gestures as therapeutic failures. Accordingly, they often respond to even the most vague suggestion of risk and liability by restricting their own authenticity. With clients who repetitively present as parasuicidal, therapists often respond in this manner, even in situations in which their clients have made no direct threat of self-harm. The threat is always implied, and accordingly, therapists take extra caution in intervening on even the most mundane behaviors associated with a patient career. They act out a script that is partially generated by the patient, in which their behaviors conform to the patient’s need to be witnessed, yet not fully and authentically seen. When therapists are guided in their attitude by concerns about the iatrogenic consequences of exposing their own agency, they participate in a medical dramaturgy in which the doctor interviews the patient about the patient’s disease. In this dramaturgy, both the client’s and the therapist’s agency are muted. Both parties participate by rote, following a familiar routine. The client reports on the symptoms being suffered, while subtly threatening that the therapist’s authentic, creative gestures will exacerbate these symptoms. In turn, the therapist complies with the norms of sterility within medical culture by treating the therapeutic arena prophylactically, guarding it against the contaminant of the therapist’s own authenticity. An ethos of mending also invades the way many individuals in the mental health field respond to patient careerists. Concerned about their own liability for the patient’s behavior, they are often apprehensive about their interactions. Thus, for the patient careerist, the threat of liability is a means to regulate the level of authenticity in these professionals. When she senses their potential agency, the patient careerist becomes more symptomatic, often to the point of direct threats regarding her own life. Through the threat of liability, via the norm of mending in medical culture, the patient careerist is able to efficiently access ontological resources, primary for her psychic homeostasis. She is able to gain the experience of being watched but not seen by others, regulate the level of personal agency others assert in their relationship with her, and experience her own gestures as affecting the world around her while remaining defined by this world as ineffective. With its guiding norms of gazing, mending, and liability, medical culture is shaped in a particular manner uniquely conducive to the social and ontological needs of individuals who define themselves as failures. Entering medical institutions, these individuals find a social psychological configuration—an identity, a career—that then informs their behavior. They also find a psychologically conjunctive experience between their needs to be both witnessed by

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others and to be effective, while remaining defined as passive. The liability assumed by doctors towards patients—the said and unsaid expectations that doctors are bound and obliged to observe their patients and to restrain from contaminating milieus through their own generativity—is the foundation for this molding interaction. When patient careerists experience the environment around them as failing in its obligation to watch (but not see), to allow for agency (without witnessing effectiveness), they resort to the threat of liability as a means to regulate this environment. A patient career not only defines the person engaged in it as entitled to a medical role, but it often succeeds in influencing a mirroring medical role assumed by treating clinicians. Struggling to effectively intervene with a person engaged in a patient career, clinicians are often more likely to revert to norms of medical culture rather than risk breaking from this culture. Doing so, they will tend to either see the patient careerist as a vessel for an illness or a deviant. This hypermedicalization, as I will call it, aids and abets the patient career of a parasuicidal individual. It offers a safeguard from a patient career crisis. When a person engaged in a patient career feels his career is threatened, he reverts to parasuicidality as a means to engender a hypermedicalization from the people who treat him. One reason patient careers, in general, and parasuicidality, more specifically, influence clinicians to merge devoutly to the doctor role is the fact that such careers intrinsically bring this role into question.

ABSURDITY: THE EXISTENTIAL CONTEXT OF DOCTORHOOD Patient careers potentially threaten clinicians with what I call a doctor career crisis. Just like the patient career crisis, the reason for such a crisis is existential. While the effects of this crisis are miniscule compared to the repetitive and acute crises felt by patient careerists, I believe it influences the way clinicians approach individuals engaged in patient careers. The source of a doctor career crisis is different from the source of a patient one. Where the central existential threat to a patient career is success and autonomy, the threat posed by patient careerists to clinicians is absurdity. The Latin root of the word absurd is to be out of tune, senseless. To be absurd is to be dissonant, incongruent with reason. Camus (1988), the existential novelist and philosopher, and Ionesco (in Esslin, 1986), the playwright, describe how absurdity becomes a threat to a person’s sense of meaning in a world increasingly decoupled from religious explanations. “In a universe that is suddenly deprived of illusions and of light, man feels a stranger,” writes Camus (p. 18). “This is an irremediable exile. . . . This divorce between man

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and his life, the actor and his setting, truly constitutes the feeling of Absurdity.” For Ionesco (in Esslin), a person “cut off [from] his religious, metaphysical, and transcendental roots … is lost; all his actions become senseless, absurd, useless” (p. 23). (The inscription on Ionesco’s tombstone speaks to these concerns: “Pray to the I don’t-know-who: Jesus Christ, I hope.”) If, as I have described, existential anxiety is the experience of confronting one’s aloneness and accountability, then the realization of the absurdity of life—that life comes with no ready-made purpose—is like a hard slap to one’s defenses against such anxiety. It pushes the individual to the terrifying, frigid crevice of meaninglessness. Conformity is the most powerful and readily available defense against the existential crisis of absurdity. By conforming to a group, one is offered a logical narrative about how life works and a place to belong. Conforming to the norms and roles of a profession offers this protection from the intrinsic absurdity of life. It likely does so more powerfully than any other affiliation in modern society. As I have described, a professional career provides a person a role within society and an identity based on purposeful activity. To take part in a career in which the central purpose is helping others offers even more resistance to absurdity than other careers, for the purpose of this career is laced with altruistic goals. Indeed, as it is often described, a career aimed to decrease human suffering brings with it a clear sense of purpose. Mental health professionals take part in such a career. Patient careerists needle them with the absurd. Patient careerists threaten clinicians with the absurd because, in their behavior, they create and reveal nonsensical relationships that decenter the supposed purposeful and serious profession of medicine. Below are a few such absurdisms: My patient turns to me, not necessarily for a cure, but to act out a scene in which he is validated as unaccountable for his life. Even though playing the role of an objective and distant clinician may only support destructive behavior in my patient, I play this role because I know, somehow, that I will get in trouble if I don’t. I’m responsible for whether this person kills herself, but, deep down, I know that the relegation of this responsibility really doesn’t make any sense. Even though it doesn’t make sense, I live by it, behaving as if I have the psychic power to keep this person alive. The central problem for my patient is his wish to be a patient. Faced with such absurdisms, clinicians potentially question the parameters of their own professional identities. Just as patient careerists have resources

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that help them regain their patient careers at their disposal, such as parasuicidality or other liability-raising behavior, clinicians have other resources just as potent in recovering their sense of career. By conforming more devoutly to a medicalized vision, clinicians are able to escape from absurdity, distancing themselves from their relationship with their clients and seeing their clients’ behavior, not their particular relationship to their clients, as illogical and dissonant. Gazing upon their parasuicidal clients as either sick or bad, they approach them in a highly clinical manner or in a manner that marginalizes them as deviant. Through this hypermedicalized lens, nothing appears absurd. Below are examples of such a medicalizing approach: Objective Stance My patient suffers from malfunctioning self-advocacy skills. While she repeatedly presents as suicidal, and likely does not want to kill herself presently, her behavior is understandable, considering the fact that she knows no other way to advocate for herself. I am the target of my patient’s projective identification. By acting parasuicidal, he is attempting to transfer his sense of helplessness and incompetence to me. For his own good, I must remain as objective as possible, allowing him to see his behavior as it is, unpolluted by my behavior or attitudes. Parasuicidality can lead to suicidality, either by accident or on purpose. It is important that I see every one of my patient’s parasuicidal acts as acutely dangerous, treating each as a medical emergency. Marginalizing Stance This person, who is clearly seeking a secondary gain from being a patient, is taking valuable time away from people who truly want help. Medical resources are not limitless. By going into the hospital so often, this person is sucking the system dry. Going into the hospital, she’s just looking for a vacation. He’s seeking attention again, without taking responsibility for his treatment. Objectifying or marginalizing—a clinical form of medusaization—clinicians are able to distance themselves from absurd situations and return, as if all is right with the world, to the comfort of their profession. My theory about the relationship between the absurdity of a patient career and the career crises of clinicians is admittedly based on conjecture. To argue

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that such a relationship exists depends both on a belief in patient careerism as putative fact and a presumption regarding the internal life of clinicians. This theory, however, holds considerable explanatory strength. First, it provides a path to understanding the hypermedicalization of parasuicidal individual, and especially the negative feelings directed by clinicians towards these individuals. Second, and related to this hypermedicalization, a theory regarding a doctor career crisis instigated by the threat of absurdity helps explain why clinicians resist legitimizing the common folk narrative they share regarding patient careerism. As I describe in the Introduction, a theory of patient careerism is not a new theory, but pervasively discussed among clinicians on an informal basis. Indeed, I would argue that it is as pervasive a theory regarding parasuicidality as any other, albeit an illegitimate one. Clinicians resist making it legitimate because doing so would mean recognizing the absurdity of what they do. Clinicians, in this light, are trapped in a dialectic of change, resistant to act on what they know because they are afraid of the existential consequences of this action.

CONCLUSION: THE SOCIAL ECOLOGY OF A PATIENT CAREER Invoking the metaphor often used by social ecologists (Kondrat, 2002), the problem of patient careerism can be seen as similar to a set of Chinese boxes, with each smaller box fitting inside the other (Figure 3.2). At the center is an individual suffering, a deep sense of ontological insecurity specifically rooted to issues of failure and, accordingly, with the struggle over change. Surrounding this individual are clinicians who conform to the medical norms and expectations of the medical institutions in which they work. These norms and expectations, which clinicians often dogmatically assume when faced with parasuicidal behavior, offer the patient careerist a means to endure her ontological insecurity. The ontologically insecure individual, the clinicians who treat the individual, and the medicalized institutions in which these two parties interact are contained within the hegemony of medical culture itself. This culture consistently fails dialectically (to appropriate a term from Linehan [1993a]), reifying human complaints into clusters of symptoms and interpreting human activity through a lens that rigidly divides the world into passive sufferers or watchful, mending interventionists. In Chapter 1, I explained that the medicalization of BPD is the outcome of medical culture’s attempt to commandeer the darker aspects of our humanity. I then described how parasuicidality, which is increasingly accepted in the therapeutic professions as the unique marker of BPD, is a behavior that is, in part, a socially iatrogenic phenomenon. This last analysis leaves unnoted one

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Mending vision Avoid change

Avoid change

Avoid change

Clinical gaze

Clinical gaze

Avoid change Avoid change Marginalization

P Avoid change

Objectivity

Client Avoid change

Marginalization

Clinician

Mending vision

Avoid change

Medicalized Institutions

Medical Culture

Figure 3.2

The Social ecology of patient careerism.

observation about the insidious relationship between medical institutions and individuals labeled as BPD—that the current trend aiming to “cure” parasuicidal borderlines of parasuicidal behavior is the outcome of medical culture’s attempt to label and treat symptoms it helped create. The medicalization of BPD, in other words, is the medicalization of iatrogenesis, the logical consequence of a dogmatic and totalizing medical culture—one only able to see the world through a medical lens. It is the snake eating its own tail. In the next section of the book, I show how “mutually authored” interactions are the antidote to the socially iatrogenic consequences of the medical model. I describe a particular cluster of strategies that enhance the possibility of more existentially honest encounters between patient careerists and all the professionals with whom they have contact, no matter the breadth or intensity of their relationship.

PA RT I I

The Practice of The Game

I remember one morning when I discovered a cocoon in the back of a tree just as a butterfly was making a hole in its case and preparing to come out. I waited awhile, but it was too long appearing and I was impatient. I bent over it and breathed on it to warm it. I warmed it as quickly as I could and the miracle began to happen before my eyes, faster than life. The case opened; the butterfly started slowly crawling out, and I shall never forget my horror when I saw how its wings were folded back and crumpled; the wretched butterfly tried with its whole trembling body to unfold them. Bending over it, I tried to help it with my breath, in vain. It needed to be hatched out patiently and the unfolding of the wings should be a gradual process in the sun. Now it was too late. My breath had forced the butterfly to appear all crumpled, before its time. It struggled desperately and, a few seconds later, died in the palm of my hand. That little body is, I do believe, the greatest weight I have on my conscience. For I realize today that it is a mortal sin to violate the great laws of nature. We should not hurry, we should not be impatient, but we should confidently obey the external rhythm. —Zorba the Greek (Kazantzakis, 1946, p. 121) If a patient careerist only sought passivity, she would lead a uniformly passive life. She would not risk reaching out to others to experience her own effectiveness (no matter the guise of ineffectiveness while doing so), nor seek continuous attention from these others (albeit with conditions that she be seen as passive), if she did not yearn for authentic interaction. The patient careerist 59

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covets what I call mutually authored encounters, interactions with others in which participants assume accountability for their actions and choices. Yet, she also simultaneously resists these kinds of encounters for fear of exposing her own agency and experiencing the agency of others. Indeed, the polar tension between the promise of fulfillment that comes with an authored existence and the annihilating threat of authenticity forms the walls of the patient careerist’s existential trap. Fear of authenticity is what keeps the patient careerist confined within the solipsistic struggle over issues of change and accountability. But this same authenticity entices her with a better life. In the following four chapters, I suggest a set of strategies that aim to enhance mutually authored encounters, while remaining sensitive to the existential needs of individuals trapped within the dialectics of failure. These strategies enable clinicians to reach through the thickly layered sediment of medicalized norms and relate to their clients authentically. Their goal is to facilitate a therapeutic space in which the patient careerist will risk exposing her own agency in the world. I call these strategies The Game. In the next chapter, I discuss both the liberating aspects of mutual authorship and the basic parameters of The Game.

CHA PTER 4

The Game: Treating the Problem of Treatment Seeking Authenticity: The Antidote for Patient Careerism

The Game Approach

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Authenticity, as I use the term throughout this book, implies authorship. When people act authentically, they assume accountability for their creative origination of their lives. To act authentically, people must also hold a genuine respect for the independence and accountability of others. Clearly, a person cannot act authentically with others she experiences as compliant, inanimate things. She is only able to act authentically when she can accept these others as independent and animated existential actors themselves. Authenticity, as I approach the term, is thus inherently a relational experience. When one approaches another authentically, one engages in a process of mutual, rather than singular, authorship. One takes accountability for one’s actions in the relationship, while accepting the independent agency of those with whom one interacts. This is why engaging authenticity with another is a most courageous act. A person is authentic when she can withstand two intricately entwined anxieties: that she is alone in her actions and that she is alone in relationship with others who act independently from her. A patient career offers a person the perfect counterpart to the twin anxieties engendered by authentic interactions. By defining a person as passive, a patient career guards his agency from the sight of others. Implicitly threatening others with liability, it guides these others to behave in a rigid, professional manner. However, while a patient career serves to protect an individual from the dangers of authenticity, the patient careerist also wants to engage in authentic relationships. The reason the patient careerist is trapped between an identity based on passivity and a craving for authenticity is because authenticity is more than an ontological destination he yearns for, it is also the single way to reach this destination.

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To break from the bonds of her career, the patient careerist needs the psychological goods that are only offered by mutually authored encounters. Such encounters occur in the here and now. They are based on the implicit recognition that each party in an encounter is fully engaged as the author of her experience in the very moment of that encounter. They contrast sharply with relationships driven by careerist themes, which are based on fixed ideas about the past and the future of the parties involved. The in-the-moment accountability of authentic interactions is an anxiety-ridden experience itself, but one that also offers an alternative form of safety to the rigid defensive structure of a patient career. A mutually authored encounter relieves the patient careerist of the nagging harassment of future expectations regarding change and the shameful fixation on how she contributed to past failures. In such an encounter, the patient careerist is offered the opportunity to experience herself as existing in the eyes of another without the need to defend against the other’s expectations. She is, in other words, offered the fertile ground from which she may risk change. For a person engaged in a patient career, the curative process of authentically relating to another is no different than that of others who enter psychotherapy due to an overwhelming ontological insecurity. Psychotherapy, however, requires a certain continuousness and devotion rarely maintained by someone entrenched in a patient career. Patient careerism is, in part, a problem of institutional, rather than individual, transference. It is rooted in a cathexis to medicalized institutions and a fixated desire to engage their cultural resources. This is why the patient careerist often seeks help from unfamiliar emergency personnel when his career is threatened; he seeks reengagement with medicalized institutions, not a connection with a familiar individual or a specific familiar group of individuals. The defensive structure of a patient career is contingent on these diffused engagements and thus dependent on numerous contacts with a scattering of clinicians. Because so much of a patient career is spent making these contacts, it is also characterized by inconsistent attendance to therapy (due partly to multiple hospitalizations) and thus, inevitably, a serial but interrupted record of forming and ending relationships with various therapists. Professionals typically approach the spasmodic nature of treatment associated with a patient career as a sign of deviance, for even though patient careerists identify themselves as ill, they deviate from a central component of the sick role: to conform their behavior to the advice of experts and follow through on prescribed treatment (Parsons, 1951). Patient careerists are thus often labeled by professionals as “treatment resistant,” “difficult to engage,” “noncompliant,” exhibiting “treatment interfering behavior,” or even “untreatable.” Taking this approach to patient careerists, clinicians assume that the treatments they

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provide are objectively appropriate and that their clients are simply not complying with the legitimate prescription for their ills. Accordingly, the choices for clinicians are reduced to cajoling or even forcing patient careerists into therapy, simply waiting until they are ready, or giving up entirely. In the current patient careerist-as-deviant approach to treatment, a large percentage of the clinical contacts made by patient careerists are devoid of the authentic encounters they need to change. In such an approach, tertiary treaters with whom patient careerists interact on multiple occasions—such as crisis evaluators, acute hospital staff, and case managers—are viewed as neutral elements within a system and responsible for assuring that their clients both comply with prescribed therapies and maintain their safety in the community. They are viewed, in other words, as part of a funneling system that leads to treatment, but not as the providers of treatment itself. Clearly, in this mode, tertiary treaters are not charged with the relational work associated with therapy. And hence, for someone engaged in a patient career, a vicious cycle is put into place: the patient careerist, who can only transcend the confines of her career in the safe arena of authentic relationships, makes multiple contacts with professionals who respond to her in an automated manner. By accessing tertiary treaters, the patient careerist’s wish for an existentially dishonest relationship is fulfilled, yet her opposite (and just as powerful) wish to enjoy the fulfillment of an existentially honest one is never met. The Game is a cluster of strategies specifically designed to enhance the possibility of more existentially honest encounters between patient careerists and their treaters, no matter the breadth or intensity of their relationship. These strategies do not always facilitate the depth of personal encounter associated with psychotherapy. They do, however, offer the patient careerist the rare chance to venture into the world of authorship and accountability when he meets with numerous tertiary providers as well as therapists. When these strategies are shared among professionals, they offer an alternative to the medicalized institutional response. Indeed, they are intentionally demedicalizing strategies, aimed at addressing institutional transference. When they are used consistently by a single therapist in the confines of a more traditional therapeutic encounter, they provide a means to protect this encounter from the impingements of medicalizing culture, offering the client a fertile and safe environment to which he may wish to return regularly.

THE GAME APPROACH The term game implies a process with specific demarcated goals that cannot be reached by any one given strategy. As game theorists describe them, games

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involve strategies that are developed without complete information on their effectiveness. They are constrained by the actions of other participants, the multiple possible consequences of choices each participant makes, and by rules accepted by these participants. The constraints, consequences, and rules of The Game are formed by the existential and interpersonal tensions inherent in authentic encounters. In The Game, issues related to the existential terror and psychic liberation associated with authenticity are always at play. Paradoxically, The Game is the game of authenticity. The goal of The Game is mutual authorship, a win-win interaction between clinician and client in which each is respected as the accountable author of her experience. By enhancing mutual authorship, the clinician offers a relational space that directly opposes medicalized interactions, providing the client the greatest opportunity to risk change. However, because a patient career is built on defensive responses to authenticity, each maneuver made by the clinician towards authenticity is likely to be answered by the client with an assertive countermaneuver aimed at retaining her patient career. Thus, in her quest for authentic interactions, a clinician in The Game consistently makes moves and countermoves. In this process, the clinician balances authenticity with ontological safety. She considers whether a particular act of self-authorship on her part might feel so damaging to the client that the client will severely restrict her own agency. Yet, the clinician also remains aware that her concerns for the client’s ontological safety may lead to actions that endorse the client’s patient career. Engaged in The Game, a clinician considers such issues as whether her expressed hopes for the client will be experienced by the client as overpowering expectations, whether the clinician’s own self-disclosure will cause the client to feel overwhelmed by the clinician’s agency, or whether comments regarding her client’s choices will feel, for the client, like shameful accusations. The clinician will also consider the effects on her client when the clinician does not express her own hopes, declines to disclose her own opinions, or resists commenting on the client’s choices. In this balancing act, the clinician strives to create an arena in which mutually authored relationships flourish—a relational site in which the client is engaged authentically. While the target of The Game is the win-win of mutual authorship, the goal of personal change is deliberately taken off the board. Thus, like so many themes associated with the dialectical trap of failure, The Game is paradoxical in regards to change. The topic of change is an unavoidable fact of clinical interactions and it is, in the end, their purpose. But the best chance to help someone who identifies himself as a failure is to avoid change as the axis of clinical interactions and focus instead on the goal of authentic encounters. Clinicians in The Game approach clients with attitudes similar to the Rogerian (1957) unconditional positive regard. They accept the client as he is in the moment, and they do so authentically, with the full recognition that the client is making rational decisions

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in the face of difficult circumstances. They accept that their clients may choose not to change, and that this choice, in itself, is an existentially valid one. While the clinician in The Game does not willfully seek change in her client, this does not mean that the clinician tailors her responses to the client’s every ontological need. To succeed at The Game, the clinician assertively infuses the therapeutic relationship with themes and expectations that often counter the defensive needs of her client. The clinician combats themes of passivity and automation by approaching the therapeutic relationship as one built on accountability and authorship. Optimally, the clinician is able to imbue the environment with her own agency without her client experiencing this agency as being overpowering. At the same time, the clinician is able to show the client that the clinician experiences the client as an agent herself without the client feeling her authentic gestures will be expropriated as evidence for the fodder of expectations. A clinician engaged in The Game resists the mending norms of medical culture described in Chapter 1 by taking a stand for good faith interactions, always seeking a means to relate with her client as one individual to another, both accountable for their choices. On the following pages I offer an example of The Game in process (Figure 4.1). I provide commentary on the example in two ways. First, I interpret the intentions of both the client and the clinician in the example as they maneuver around issues relating to authorship and accountability. In this part of the commentary, I also associate the clinician’s actions with particular interventions described in later chapters (the interventions are labeled within boxes). Second, I show the location of the relationship between the clinician and client within the context of The Game. Here, I attempt to portray the points in the example when mutual authorship is achieved and when it is disrupted or halted. As illustrated in the example below, The Game has no clear endgame or finish. Instead, it is a process of multiple events in which the clinician is seeking immediate periods of authenticity. This is why The Game can be “played” by both therapists and tertiary treaters. Almost every interaction with a person engaged in a patient career offers the opportunity for a clinician to intervene with the intention of mutual authorship. The more win-win encounters of mutual authorship are offered to the patient careerist and the less he is faced with automation of the medicalized response, the more likely the patient careerist is to risk the possibility of exposing his agency and, subsequently, attempting change. Within clinical settings, the ethos of mutual authorship is far from guaranteed. Indeed, the basic medical narrative operates as a counterforce to mutual authorship. Patient careerism is a means individuals use to engage medical culture in a defense against mutual authorship. This is why a clinician must take a strategic, game-like approach to mutual authorship. Yet, to truly enter The Game, one cannot expect to simply follow instructions for strategy.

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Automated interaction

Statement

Intention

Context in The Game

Client: I feel the urge to cut.

To present as passive while threatening liability in order to cause the clinician to respond in a mechanical, medicalized manner.

Client and clinician in automated roles.

Clinician: Oh. Well, let’s get you into the hospital.

To avoid an interaction in which the clinician engages with the client on issues of safety.

Roles disrupted, offering opportunity for mutually authored interaction.

Distracting relational intensity at points of liability

Client: But aren’t you going to check if I’m safe?

To urge clinician to enter automated roles.

Clinician: Well you’ve basically said you’re not.

To allow the client’s agency to flow by taking his or her statement about uncontrollable urges seriously, instead of intervening with the medicalized responses of risk plans, contracts, and so forth. Permit to agency

Client: I said I felt an urge, not that I was going to act on it.

Unsteady in his or her presentation of self as passive, to engage clinician with a subtle revelation regarding his or her agency.

Door to mutual authorship opened further.

Clinician: So you have some control over these urges.

To reciprocate this selfauthored attempt to engage.

Client’s authorship exposed.

Emphatically and empathically support language of change

Client: Well, my last therapist gave me some centering exercises to use. I would do them with her and that would help.

FIGURE 4.1 The Game in detail.

To bring the issue back to one of medicalized interaction in which the clinician prescribes the means for ameliorating the urges.

Return to automated roles.

The Game Clinician: It did? Client: Well, if she did them with me. She would either do them with me in the office, or call me and help me through them. That would help.

To again attempt to engage clinician in doctor/patient relationship.

Clinician: So you could manage these urges if she kept in contact with you after your session?

To resist the doctor role while remaining unthreatening to client by continuing to participate in the client’s selfdescription.

Issue of self-authorship reemerging.

Motivational interviewing

Client: Yes, that helped a lot. The urges went away when she checked in with me.

To persuade clinician to enter a monitoring relationship with him or her.

Clinician: Why? What about this checking in made you feel you didn’t need to harm yourself?

To return conversation to one based on the client’s agency rather than uncontrollable urges.

Door to mutual authorship opened further.

Motivational interviewing

Client: When I’m like this, I need a reminder to center myself.

To request the check ins without revealing his or her agency.

Clinician: Could you get an alarm clock to help you with that?

To take the client at his or her word, while provocatively questioning the client’s intentions.

Return to automated roles.

Taking client at his or her word

Client: No, because I may be on another side of my apartment when it goes off.

To continue to request check ins without revealing his or her agency.

Clinician: How about a watch with an alarm?

To continue to take client at his or her word while provocatively questioning the client’s intentions. Taking client at his or her word

Client: (Somewhat angry now) No! An alarm clock or a watch will not work. I need to just know someone cares when I’m like this.

FIGURE 4.1 (continued)

Cornered in his or her own logic, Door to mutual to reveal the more interpersonal authorship opened intention of the client’s request again. for check ins.

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Clinician: So the check ins aren’t just about reminders for you to center yourself, they’re reminders that someone cares, that you’re not alone.

To take the first step towards an interpretation based on the dialectics of failure. Metanarrative of change and the dialectics of change as source of interpretation

Client: (With some exasperation). Finally! Yes, my last therapist would help me by checking in and making me feel not so alone.

To engage clinician regarding his or her fear of aloneness.

Clinician: So this is about you feeling alone.

To take another small step towards an interpretation based on the dialectics of failure.

Metanarrative of change and the dialectics of change as source of interpretation

Client: Yes. Clinician: And hurting yourself, I take it, somehow makes you feel less alone.

To continue with interpretation based in dialectics of failure, while remaining somewhat unthreatening to client’s ontological security (i.e., the clinician does not say, “Cutting makes you feel less alone because you know that by cutting others will pay attention.”). Motivational interviewing

Client: Yes it does. Clinician: Did something in particular happen today that made you feel more alone?

To investigate the current threatening source to the client’s patient career. Metanarrative of change and the dialectics of change as source of interpretation

Client: Well, yes, I guess. I finally went out and got a job application yesterday, and everybody today was so excited. “You did it!” “Congratulations!” They were all so patronizing, patting me on the head like I was some sort of moron. I used to work a 40-hour week! Now I get a pat on the head for getting a job application?

FIGURE 4.1 (continued)

To seek an authentic, empathetic interaction with the clinician.

Entering the win-win achievement of The Game.

The Game Clinician: That must have been really disappointing. Here you do something small but important and you end up feeling bad about it. I can see how it made you feel really alone.

To provide an empathetic interpretation.

Client: No. It was small and unimportant. Why can’t anyone get that? You’re not getting it either.

Feeling threatened by the clinician’s authenticity (and thus his or her autonomous judgment), to flee the mutually authored interaction.

Clinician: I’m sorry you feel I’m not getting it. I think I understand how alone you feel, but my only way of understanding this is to reflect on what you’re telling me and what I know about you.

To regain the win-win of The Game by providing empathy while resisting a mode of interaction in which this empathy is offered as if it is something independent of the clinician’s own thoughts and observations. To be empathetic while simultaneously protecting the mutual authorship of The Game.

Emphatically and empathically support language of change

Win-win of The Game disrupted.

The apology

Client: Well, all I feel now is more alone and my urge to cut is only getting worse. I probably can’t stop it now.

To cause the clinician to feel liable for his or her safety and enter a medicalized mode of interaction. To regain the clinician’s empathy, but only under the condition that it is delivered without judgment or expectation.

Clinician: I’m very sorry to hear that. I really thought I was understanding something about the source of your awful sense of aloneness.

To regain an empathetic connection while protecting mutual authorship. Decenter expertise

Client: Well you weren’t, and now I’m just feeling like cutting.

FIGURE 4.1 (continued)

To continue to attempt to regain the clinician’s empathy under conditions.

Win-win interaction of The Game over.

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Clinician: Again, I’m sorry. The idea that others think you did something important by getting that job application is really upsetting for you. I wish you and I could get past that, but now the urges are so bad I think the main thing is just to be sure you’re safe. I need to think about what to do next as far as getting you evaluated for the hospital.

To show client that clinician’s empathy flows from his or her own personhood and is not something offered automatically. To show client that clinician’s attention is distracted when threatened with liability .

Door to mutual authorship opening.

Talk directly about the role of the clinician in the client’s current ambivalence Distracting relational intensity at points of liability

Client: Don’t you want to assess my safety further? It’s like you keep jumping to this hospital idea over and over again.

To regain automated interaction.

Clinician: You said you had an uncontrollable urge to cut and that it’s getting worse. I don’t think you could be clearer regarding your level of risk.

To keep interaction animated by responding to the client’s self-description rather than acting out the typical dramaturgy of assessing for risk.

Client: But I think we should talk further about what triggered the urges. I think that would help.

To regain automated interaction.

Clinician: I know, I think so too. But I’ve got to be honest with you. Once you raise issues related to your safety, I start thinking about all the things I need to do to keep you safe and I lose my ability to concentrate on the session itself. There’s nothing I would rather do right now than sit and talk with you about your present experiences, but my mind is caught up in thinking about such things as where I keep the number for the psychiatric evaluation team, which ambulance services I should use, and who I should call at the ER. I want my mind to be as clear and open for our sessions as it can be. Right now, however, it is cluttered with other issues.

To simultaneously show client that the clinician is eager to work with him or her and believes this work is important, while revealing that the clinician is unable to fully engage with client when threatened with liability.

Client: Well, I really want to keep out of the hospital. I think if I work hard enough I can control the urges. I guess I was kinda mad at you for saying that thing about the job application. I wanted to scare you so I said the urges were getting worse. They’re not worse. I think they’re manageable.

By revealing his or her own self-authorship (“I want to keep out of the hospital.” “I can control the urges.”), to maintain a connection with the therapist.

FIGURE 4.1 (continued)

Expression of eagerness Distracting relational intensity at points of liability

Entering the win-win of The Game.

The Game Clinician: Really? Great. Let me just figure out where that one phone number is and then maybe we can get back to business. (She looks through desk and finds number) So…

Aiming to secure this new achievement of selfauthorship, to dramatically portray both his or her eagerness to work with client and his or her distraction due to liability concerns. Distracting relational intensity at points of liability

Client: You know I used to be a nurse. I used to have a ful-time job!

To risk revealing his or her sense of failure.

Clinician: I know. And that must make this experience with the job application very difficult.

To emphatically show empathy regarding this revelation. Emphatically and empathically support language of change

Client: The application was for a job that pays about half what I made as a nurse. A cashier at a pharmacy, that’s all. Just a cashier. I know twice as much as most of the pharmacists there!

To further risk revealing his or her sense of failure.

Clinician: I can really see how that must have upset you.

To emphatically further show his or her empathy regarding this revelation. Emphatically and empathically support language of change

Client: It did. It made me have to look at where I am now, and I don’t like what I see. How could my life turn out this way?

Hoping that clinician can respond in a reassuring manner, to give an authentic interpretation of his or her current experience of distress.

Clinician: That’s an awful feeling, that sense that your life right now doesn’t match your expectations. It’s one of the most unbearable feelings.

To provide a comfort to client by reflecting on the universality of his or her experience. Discuss existential loneliness as a universal issue Metanarrative of change and the dialectics of change as source of interpretation

Client: It is. And you know what? I was doing OK with it. I was really ready to just swallow my pride, put my nose to the grindstone, and move on.

To give further and authentic interpretation of his or her current context.

Clinician: And what happened?

To further engage with client in mutually authored interaction.

FIGURE 4.1 (continued)

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Client: People started congratulating me on just getting the application in. I mean, if I didn’t feel bad enough already, here they were saying I was such a loser that simply submitting an application was some sort of big accomplishment. My God! Is that what people think about me? I deserve a pat on the head for a job application?

To risk revealing his or her context within the dialectics of failure.

Clinician: This is one of the most difficult binds for many people. To get back on your feet, you have to take these small steps, but to take small steps means facing where you are.

To provide an interpretation based on the dialectics of failure, while continuing to reflect on the universality of existential loneliness. Discuss existential loneliness as a universal issue Metanarrative of change and the dialectics of change as source of interpretation

Client: Well I don’t like where I am, and where my triggers to cut have gotten me. No one seems to understand how sick I am and how difficult things are for me to do.

Feeling vulnerable yet wanting the fruits of authentic interaction to achieve two conflicting experiences with the clinician: 1) Continue to discuss client’s context in the dialectics of failure and continue to engage in a mutually authored relationship. 2) Reintroduce themes of illness and automation in order to defend against client’s growing sense of failure and halt his or her emerging revelation of agency in the presence of the clinician.

Clinician: So the problem wasn’t just other people’s low expectations, it was also a problem of people having high expectations about you.

To offer another interpretation based on the dialectics of failure. Metanarrative of change and the dialectics of change as source of interpretation

Client: Yeah. Now that they think I’m so competent at getting the application in, the next step they think is

FIGURE 4.1 (continued)

Feeling ambivalent about the exposure of his or her agency

Client and clinician fully engaged in the win-win of The Game.

The Game for me to take a job. It’s like they forgot about how sick I am. I know what they’re thinking with that little pat on the head. It’s like, “OK, it looks like you’re now ready to move on. Hurray!”

and revelations regarding his or her experiences of failure, to both engage the clinician in a mutually authored relationship and to portray self as passive.

Clinician: Are you ready to move on?

To bring conversation back to issues of change and choice in the moment. Talk about change and choice in the moment

Client: No. Absolutely not.

To minimize the possibility that the clinician will hold high expectations regarding client’s ability to change.

Clinician: So you need to stay the same right now?

To engage the client in his or her self-description.

Client: Well, I’m definitely not taking that job if they offer it.

To further decrease the chance that the clinician and others will hold expectations regarding his or her ability to change.

Clinician: Considering all the ways in which change makes you feel bad about yourself, it makes sense to want to stay the same.

To again engage client in his or her self-description.

Paradoxical response

Win-win of The Game disrupted.

Motivational interviewing

Client: I didn’t say I wanted to stay the same. Clinician: But you don’t want to pursue the job any longer. You said you’re not ready to move on.

To steer conversation back to issues of passivity. To assertively reflect on the client’s own statements in order to allow the intention of these statement to have an effect on the conversation. Paradoxical response

Client: That’s because of the urges to cut. The extra stress of a job and all the things people say about a job makes the urges worse. I want to change right now, but it’s not safe. It’s too dangerous; I could end up really harming myself.

The discussion continues…

FIGURE 4.1 (continued)

To return conversation fully to themes of passivity and suffering.

Win-win of The Game ended.

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Clearly, a reliance on instructions betrays the central existential tenets of The Game. It also counters the basic intent of a game approach itself, which sees each participant as bringing her full aptitudes to an interaction that is constrained by the idiosyncratic actions of other participants. To enter The Game in good faith, a clinician comes with trust in her own skills and in her ability to understand and interpret what unfolds before her, rather than an adherence to the instruction of others. Instead of technique, the clinician offers her clients unique and creative actions guided by an understanding of the goals of The Game. In The Game, the clinician does not ask, “What is the best technique to use here?” but, “Considering this client’s debilitating experiences of failure and her consequent attraction to automated interactions, what can I do in this moment to facilitate a compassionate here-and-now authored interaction between the two of us?” Unlike recreational games, The Game does not come with an instruction manual. While it is always seductive to search for the clinical chalice of the perfect antidote, the notion of a state-of-the-art or best practice technique for a problem partially caused by the application of techniques is clearly contradictory. On the other hand, when one enters clinical interactions with an understanding of the goals of The Game, specific relational arenas for intervention do emerge. To engage in The Game, a clinician must simultaneously consider how to approach the actual relationship between herself and the client, how to assert herself as an actor in the relationship, and how to help motivate the client to engage in a mutually authored interaction. In the chapters that follow, I first offer three particular attitudes taken by clinicians that are intrinsic to effectively intervening in these arenas. These attitudes are eagerness, urgency, and unconditional positive regard. I then offer strategies for intervening in the three arenas: (a) Relationship, (b) Therapist Authorship, and (c) Change and Motivation. The attitudes and interventions I describe are interdependent. So, to appreciate them as they are actually deployed, I caution the reader to accept their division as useful for instruction, but somewhat artificial. In any given interaction, more than one relational arena is at play, and the clinician is never expressing a single attitude.

CHA PTER 5

The Attitudinal Conditions for The Game Attitude Number One: Eagerness 76 Empathy’s Limits 77 The Positive Effect of Eagerness 80 The Modulation of Agency 83 The Invigoration and Motivation of the Therapeutic Environment 84 Giving Weight to Choice and to Existential Precipitants 84 The Support for the Client’s Resilience 88 Attitude Number Two: Urgency 91 Describing the Therapeutic Frame 92 Framing a Specific Activity as Urgent 94 Replacing Emergency With Existential Urgency 94

Stating the Urgency of Life Goals 95 Addressing the Existential Roots of Urgency 97 The Clinician’s Reluctance to Be Urgent 99 Attitude Number Three: Unconditional Positive Regard 99 Unconditional Positive Regard and the Dialectics of Failure 100 Unconditional Positive Regard and Demedicalization 102 Unconditional Positive Regard, Eagerness, and Urgency 103

W

hen a clinical interaction works, when it helps facilitate change, the operant factor is often the interpersonal style of the clinician—his attitude and personal approach. Indeed, as Miller and Rollnick (1991) point out after reviewing the research on the impact of therapist style, “The way in which a therapist interacts with clients appears to be nearly as important—perhaps more important than—the specific approach or school of thought from which she or he operates” (p. 4). Style, in the lingo of theorists on therapeutic technique, is the nonspecific of treatment, the effective agent that exists across treatment modes. Like Miller, Rollnick, and other theorists (Luborsky, McLellan, Woody, O’Brien, & Auerbach, 1985; Truax & Carkhuff, 1967; Truax & Mitchell, 1971; Valle, 1981), I believe we can make specific the nonspecifics of treatment, bringing to light certain attitudes assumed by treaters that lay the fertile ground for change. I am also convinced that particular attitudes are specifically important in working with patient careerists. I name these attitudes in this chapter. Focusing on attitudes and style inevitably leads to a particular view of therapeutic interactions—that the therapist’s job is to create an environment for 75

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change, rather than to intervene actively on changing a person. Therapists, by assuming certain attitudes, provide a facilitative or holding environment (Winnicott, 1971), offering an atmosphere of change (Miller and Rollnick, 1991). They, as it is often described in popular literature, begin where their clients are, for they can’t change their clients, their clients have to want to change. This is a predominant view of therapy in most schools of thought. Whether one adheres to schools of therapy that see the facilitation of a therapeutic environment as the therapist’s primary goal (such as interpersonal, object relations, self-psychology, person-centered and humanistic approaches) or view this kind of environment as a nonspecific but important part of therapy (as in cognitive behavioral and narrative therapies), therapy is most commonly accepted by clinicians as resisting interventionist behaviors for the good of environmental and relational ones. In this vision of therapy, therapeutic interactions are metaphorically seen as being like gardening more than surgery or pharmacology; clinicians provide the right nutrients and elements for growth, but they don’t force change through their own actions. Focused on nurturing rather than mending or intervening, therapy holds a view that opposes a medicalized vision. Therapists, in other words, have the tools to combat medicalized norms. Indeed, while so far I have described parasuicidality as aided and abetted by clinical interaction, when therapists keep their sites on creating nurturing environments, they potentially offer the best environments from which a person can escape her patient career. The Game is really the means for clinicians to provide the right environment for someone who both resists and yearns for change (Figure 5.1). Because it is aimed to create mutually authored interactions for individuals who are particularly resistant to such interactions, The Game emphasizes specific therapeutic attitudes over others. Three particular attitudes are intrinsic to The Game. Two of these attitudes are rarely discussed in the literature as facilitative of change. These are eagerness and urgency. The third attitude of unconditional regard is the foundation of many therapies.

ATTITUDE NUMBER ONE: EAGERNESS “I am excited to work with you.” “Listening to your story invigorates me.” “I am interested in hearing your story every time I see you.” “You are someone I want to spend time with.” These are the expressions of an eager clinician, someone who is truly excited when meeting with his clients. Eagerness is a powerful opposing force to patient careers—often more powerful, in fact, than empathy—the mainstay of most therapies. To fully illuminate the power of eagerness, I first look at the limits of empathy and how empathy alone potentially supports rather than destabilizes patient careers.

The Attitudinal Conditions for The Game

Avoid change

Avoid change

Mending vision

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Clinical gaze

Clinical gaze Avoid change Avoid change Avoid change

Wish to change Avoid change

Client

Mutual Authorship

Marginalization

Marginalization The Game: Eagerness Urgency Unconditional positive regard

Clinician

objectivity

Mending vision

Avoid change Avoid change

Medical Culture Medicalized Institutions

FIGURE 5.1

The social ecology of patient careerism II.

Empathy’s Limits In most therapies, empathy is embraced as the central relational good offered by the therapist. Where interpretations, suggestions, and even prescriptions can be generated by a computer, true empathy is generated in the midst of a human-to-human relationship. Empathy is an important relational ingredient in The Game, as well, since the notion of unconditional positive regard is at base a form of empathy. When one accepts another as doing the best she can, one is simultaneously appreciating her struggle and making the cognitive leap of faith of walking in her shoes (“If I were in her shoes, I might do the same thing.”). Empathy alone, however, is only partially effective in work with patient careerists. An empathetic approach is typically therapeutically effective when offered within a traditional psychotherapeutic relationship that lasts for a marked amount of time. Here, the client tests and projects upon the therapist’s continuous source of empathy until he finally rests within the safety of the therapeutic environment and then begins to risk exposing more of himself and even making changes in his life. But because patient careerists typically seek multiple clinical interactions and are often only able to productively settle into longer term therapies once they have partially relinquished their careers, clinicians cannot provide them with a truly deep empathy. They cannot articulate

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a thorough understanding of their clients, nor can they build a history of trust or even a level of affection with them. Instead, feeling that empathy is their only choice, clinicians often provide a form of automated care, a superficial listening stance. They approximate the cartoon stereotype of the therapist: “I see.” “It sounds like you’re upset.” “Tell me more about the pain you’re in.” When clinicians take this pseudoempathetic stance, they tend to pervert the truly curative aspects of empathy into relationships formed by dynamics conspicuously similar to ones associated with the doctor-patient relationship. Empathy emerges from the clinician’s gaze, her ability to (somewhat omnipotently) clearly see the client’s pain. The clinician watches her client, keeping track of the client’s problems. When it is offered in an automated manner, these gazing and problem-focused aspects of empathy replace its more affectionate and compassionate features. A loving gaze becomes clinical surveillance, and compassionate consideration becomes a coconstructed problem-focused narrative. This is especially true in situations typically enacted by patient careerists, in which the clinician feels liable for the client’s safety and attempts to provide empathy while simultaneously attempting to gain information regarding the client’s risk for self-harm. The question, “How do you feel?” then emerges as much from the clinician’s mistrust of the client as it does from the clinician’s true and empathetic interest in the client’s emotional state. A pseudoempathetic approach not only parallels the gazing and problemfocused aspects of medicalized interactions, but also their enforcement of sterility. In therapeutic relationships based on empathy, the clinician acts as a mirror to the client’s struggle. And if the clinician shifts his position, showing something of himself independent of his ability to understand and feel for the client, the clinician risks shattering this mirror. The clinician will likely hold this stance with particular rigidity when he meets with a client who is repetitively parasuicidal. In the face of risk, the clinician will offer empathetic attention to the client, but only under strict conditions regarding exposing his own self. Tempering, monitoring, and restricting his agency, the clinician provides precisely the disinfected, mending-oriented approach intrinsic to the maintenance of the client’s patient career. In a pseudoempathetic approach, the clinician also enters a relationship with the client that mitigates the kinds of mutually authored interactions that are essential to The Game. As described on the following pages, the clinician in The Game uses multiple strategies in which the clinician asserts her own agency to coax the client into relating with her authentically. If the clinician views empathetic mirroring as the axis to her relationship with the client, the clinician will not be able to use these strategies. Empathically based relationships with patient careerists may be markedly restrictive for therapists, but they are intensely seductive to someone

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in the grips of overwhelming ontological insecurity. Such relationships give false hope to the promise of merger with another. Generally, for individuals overwhelmed by existential anxiety, symbiotic merger represents an intensely attractive alternative to the unbearable recognition of their aloneness in the world. People choose a wide array of behaviors in their pursuit of merger and their escape from existential aloneness—conformity, idolized love, the pursuit of power, addictive behaviors, religious and political fervor, consumerism. The person engaged in a patient career chooses empathetic interactions. For the patient careerist, the experience of someone walking in my shoes is not one of mirroring, but of something he takes almost literally—that someone will enter my world and join me in my walk. The clinician’s passivity is the central precondition for the symbiotic experience the patient careerist seeks, for one cannot merge in perfect harmony with someone who brings to the interaction his own individual wishes, interests, and decision making. The more one seeks a perfectly symbiotic relationship with another, the more one must defend against experiencing the other’s autonomy. Thus, parasuicidality, by engendering in clinicians a tendency to restrict their agency while providing empathy, creates an idealized arena for merger for the ontologically insecure individual. Idealized, however, is the key word here. While empathy devoid of agency may provide a superficial sense of safety for someone terrified of her own existential aloneness, in the end, it proves fleeting, brittle, and empty. Just as mature love is based on the precondition that each loving partner is secure in her own aloneness in the world (Fromm, 1956), empathy is curative and truly a source of enduring security when the person receiving the empathy accepts that the person delivering it is separate from her. Someone overwhelmed by ontological insecurity finds that acceptance difficult and actually covets empathy for the opposite reason—to deny her existential aloneness. Empathy for such an individual is truly a comfort, but it is a comfort she may never wish to relinquish. Metaphorically, individuals driven in their search for merger are attracted by forces similar to ones affecting gambling addicts. They are waiting for the big jackpot, which is, for them, the moment when their wish of a total win of unconditional, symbiotic empathy is attained. They are seduced to continue to seek this win by smaller, and only partially satisfying, sporadic wins (the care and empathy of others, friendships, kindness, etc.). Clinical environments are enticing for such individuals because they offer a taste of much grander, yet unattainable wish fulfillment. A client regularly receives empathetic responses in such environments. Some of these responses are only marginally reflective of the client’s experiences, while others are quite accurate. None of these responses, however, can satiate the client’s yearning to merge

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with another. These unsatisfying wins of empathy in clinical environments are mixed with multiple losses of empathy, in which staff ignore the client, punish the client, or treat the client in a rigid professional manner. Thus, through their sporadic, inaccurate, and uneven use of empathy, clinical environments provide the behavioralist’s tonic for the consolidation behavior: intermittent reinforcement. They provide this reinforcement within a larger promise of a wish fulfillment that can never be attained.

The Positive Effect of Eagerness While empathy-focused interactions have limited success in intervening on patient careers, I suggest that eagerness—a keen and energetic interest in the patient careerist’s life project—is a more curative force. In The Game, one must maintain a sustained stance of empathy and continuously show empathy for the client’s plight. Eagerness, however, is the overriding stance presented by the clinician. Dividing empathy and eagerness may seem like hair splitting, but these two attitudes are actually quite different. Eagerness, more than empathy, is spurred by one’s interest in the other as an agentic being. Typically, a person who is reasonably secure in his own agency does not eagerly want to spend time with someone he perceives as a static site of emotional pain. On the other hand, this same person will eagerly seek contact with the other if he perceives the other as actively grappling with this pain. This is the subtle distinction of eagerness—it is more about motivation, change, and choice than is empathy. When a person shows empathy, she focuses on the subjective experience of a person and attempts to reflect some accurate understanding of this experience back to this person. In empathy, one is, as we often say, there for the other in the other’s world, a mindful source of reflection. But when one shows eagerness, one portrays a general excitement about relating to the other because one assumes that this person is actively engaged in her life. Her eagerness is expressed as excitement regarding where the other is in her process of life authorship: “I am interested in where you are in the project that is your life.” Eagerness is part of a kind of solicitude that Heidegger (1962) called leaping ahead with another, rather than leaping in, to fully capture her predicament. For Heidegger, when one leaps in to help another directly, “The other can become dependent and dominated even if this domination is a tacit one and remains hidden from him” (p. 159). When, on the other hand, a person leaps ahead with another, she is engaged in “authentic care . . . help[ing] the other to become transparent to himself in his care and free for it” (p. 159). In this light, eagerness, an attitude that leaps ahead rather than in, is the most existentially honest means of helping another, for it does not betray the other’s

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agency. On the contrary, eagerness is generated from one’s appreciation of the other’s agentic powers. Eagerness is the most direct antidote to pessimism. If, as described, the patient careerist looks to enforce pessimism in his treaters as a means to defend against the treaters’ hope and contain their agency, then eagerness is the appropriate countermove to enforced pessimism. It is not necessarily a direct expression of optimism (“I am confident that you will be OK.”), experienced by the patient careerist as annihilating, but simply an expression of wanting to be with the client and feeling enthusiastic to learn about him. The eager clinician has not dimmed his own agency, nor dulled his appreciation for the client’s agentic powers due to the force of pessimism. Neither has the clinician expressed any judgment about the client’s current behavior or any thoughts about the client’s plans for the future. In the presence of an eager clinician, the client feels that “this is a person who really wants to work with me while I consider my life,” rather than “this is a person who expects me to change,” or, as in empathy, “this is a person who wants to join me by understanding my pain.” Below is an example comparing both empathetic and eager approaches. The scenario for this example is of a client who has just arrived at an acute psychiatric hospital unit following her call to the local police in which she stated that she was going to kill herself. She has a history of repetitively entering this unit under similar circumstances. She meets with a social worker on the unit with whom she has met on other numerous occasions. EMPATHY SOCIAL WORKER: You look so unhappy. What happened? CLIENT: I don’t want to talk about it. I wish they didn’t put me in here. Why couldn’t

they have just let me die? SOCIAL WORKER: You sound really upset. You seem like you’re in a lot of pain. CLIENT: (Angry) Well, yeah! How’d you guess? SOCIAL WORKER: You’re angry too. CLIENT: Yeah, I’m angry! My therapist just treats me like crap. I woke up late today

and came late for our session, and she wouldn’t give me much time with her. She triggered my suicidal urges. SOCIAL WORKER: That must have been really hard for you. You must have felt really

abandoned. CLIENT: I did, but that’s nothing new to me. Everyone leaves me. No one really

cares. Everyone is just doing their job when it comes to me.

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SOCIAL WORKER: That must be just awful for you. You seem to feel really hurt when

you think people are abandoning you. CLIENT: Look, you’re no different than the rest of them. You don’t care. (Mockingly)

“That must be awful for you.” “You get really hurt when you’re abandoned.” Give me a break. SOCIAL WORKER: I can see that you are very angry. CLIENT: (Sarcastically) Really? You see that? Wow! (She rolls over on her bed, fac-

ing away from the clinician.) SOCIAL WORKER: I can see you’re really upset right now and don’t want to talk. I’ll

have someone check on you later. CLIENT: Oh, now you’re leaving. Nobody cares. EAGERNESS SOCIAL WORKER: I saw your name on the board when I came in and asked if I could

be assigned your case again. I was really interested in what’s happened to you since we last saw you here. What brought you back? CLIENT: I became suicidal again. SOCIAL WORKER: Well, I guess you’re in the right place, then. CLIENT: I’d rather be home now. What good is this place? You’re just going to push

me right through that revolving door again. SOCIAL WORKER: Yeah, well, I can see how it feels that way. We don’t usually keep

you here very long. On the other hand, I’ve seen you regroup while you’re here. For me, that’s important work. I actually think you and I could do some of that work here. CLIENT: Great, so you’re just patching me up again. Doesn’t anybody listen here?

Isn’t anyone willing to spend the time to hear about all the crap I’ve been given lately? What “important work”? Give me a break. How about the important work of letting me die? SOCIAL

WORKER:

Well, clearly, I’m not going to help you with that. I guess I’ve always been impressed by your ability to pull yourself together in difficult situations and go back and try again. And that ability has always left me feeling invigorated and excited about working with you.

CLIENT: You’ve got no idea how bad off I am if you think I’ve got that ability. And

besides, this time’s different. I’ve got nothing to go back to. My therapist hates me now. I woke up late today and came late for our session, and she wouldn’t give me much time with her. She doesn’t get that I have abandonment issues. I was so hurt by what she said that it triggered my suicidal urges.

The Attitudinal Conditions for The Game SOCIAL

83

WORKER:

Telling me that gives us something to work on here. You’re back with another definable problem you might be able to take care of while you’re here. That, to me, is the best way to use these short hospitalizations. I really want to help you figure out this issue.

CLIENT: What do you mean? SOCIAL WORKER: I mean that you’re at a crossroads here, deciding what you want

to do about your therapy. That’s a real important place to be. You’re about to make decisions that could potentially change your life. I hope you don’t mind me saying so, but I’m excited knowing that we’ve got this sort of decision to discuss in the days to come. CLIENT: Yeah, well, I guess I’ll have to think about that. SOCIAL WORKER: Think about what? CLIENT: That we should talk about what I’m going to do about therapy. SOCIAL WORKER: Well, if I might say so, that is what got you in here, isn’t it? CLIENT: No! What got me in here is that I tried to kill myself. SOCIAL WORKER: Yes, yes, you’re right. But you’re also telling me that the reason you

acted that way is because of what happened with your therapist. CLIENT: That’s for sure. SOCIAL

WORKER: So what do you want to do? If you want me to go into patch-up mode, where I spend my time with you figuring out if you’re safe, we can do that. If you want to talk about the issue at hand, we can do that too. This is up to you. We can, as you said, push you through the revolving door, or we can get down to business.

CLIENT: Yeah, well, I’ll think about it. SOCIAL WORKER: The minute you figure it out, let me know.

In the examples above, the clinicians’ contributions of either empathy or eagerness set very different stages of interaction. The four most important differences involve (a) the modulation of agency, (b) the level of invigoration and motivation of the therapeutic environment, (c) the weight given to issues of choice and to existential rather than psychiatric precipitants, and (d) the level of support for the client’s resilience

The Modulation of Agency In regards to the modulation of agency, the difference in these two examples is one of emphasis. In the empathy example, the clinician’s emphasis is on the client as the sole agent in the room. The client in this relationship is like

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a character in a one-woman play and the clinician is the audience, watching the client, vicariously approximating an understanding of her experience, and spurring her on with empathetic support. In the eagerness example, the clinician asserts her own agency in the interaction. She, too, is a character, animated and sentient, taking part in the drama rather than observing it. Expressing her eagerness, she rehumanizes her own role in the interaction while offering a certain level of safety and positive regard for the client. The message is, “I am not made of stone, and that is a benefit to you, because I can only value you when I am allowed to be a person.” An eager approach resists the Medusa-like maneuvers of the client, while offering a positive interaction with the clinician in which the client’s humanity is valued. It imbues the therapeutic relationship with the therapist’s agency without attributing the clinician’s effectiveness to the powers of expertise (“I know what is best for you.”) but to the power of the relationship itself.

The Invigoration and Motivation of the Therapeutic Environment The eager approach is more oriented towards motivating the client (i.e., coaxing the client into motion) than it is towards deciphering and then reflecting the client’s feelings. This is the second characteristic of an eager approach. Such an approach is closer to a coaching stance in which the clinician is energized by both the client’s realized and potential strength and endurance, rather than a more parental stance in which the therapist seeks some approximate symbiosis with the client via empathy. Indeed, as opposed to symbiosis, an eager approach imbues the therapeutic relationship with the dissonance of leaping ahead. Here, the clinician’s connection to her client is based on the clinician’s excitement as an autonomous individual, generated by witnessing another autonomous individual’s life unfold.

Giving Weight to Choice and to Existential Precipitants When a clinician takes an eager approach to a client, discussions with the client typically lead to issues regarding choice. This is because the clinician is eagerly witnessing his client as an independent individual making a decision, rather than as a static site of emotional pain. The previous examples illustrate this point. The empathetic clinician focuses on the client’s emotional state, her stasis at present. The eager clinician, on the other hand, focuses on the client as embroiled in a difficult struggle over choices (whether she will decide to return to her outpatient therapist and, more subtly, whether she will relinquish her suicidality as the guiding topic in her conversations with her inpatient clinician). By energetically focusing on the client as a decision maker

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rather than a passive sufferer, the clinician minimizes discussions steered by themes of passivity and creates a set of norms for their interaction that engender discussion regarding the dialectics of change. Thus, not only does an eager approach more typically lead to discussions about choice in the moment, it also leads to interpretive discussions regarding the existential precipitants to a client’s crisis. To illustrate, I continue with the scenarios. The clinician has returned for a second meeting with the client: EMPATHY CLINICIAN: Are you doing any better? CLIENT: (In bed, facing the wall) No. CLINICIAN: You seem to be really upset. How can I help you? CLIENT: You can’t. CLINICIAN: Maybe if we just talk a bit. CLIENT: (Turning slowly over to face the clinician) It’s not going to help. The only

person who can help me is my therapist, and she doesn’t have time for me. CLINICIAN: I know it feels that way. CLIENT: It does. And she’s the person who knows me best. CLINICIAN: Would you like to try and reach her? CLIENT: I couldn’t take the rejection again. It would make me have the urge to cut. CLINICIAN: Would you like me to try and reach her? CLIENT: I guess. CLINICIAN: Why don’t I do that. CLIENT: Be my guest. CLINICIAN: I’ll try to reach her by the end of the day. I’ll check in with you later. CLIENT: OK. (The clinician begins to leave as the client turns over in her bed, facing

the wall again.) If she wants to work with me, we’re going to need a case conference. I’m sure I won’t be safe until we find a way to work things out. CLINICIAN: I’ll see what I can do.

EAGERNESS CLINICIAN: Hi. Did you decide what you wanted to do? CLIENT: (In bed, facing the wall) No. CLINICIAN: So you’re still thinking about what to do about your therapist?

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CLIENT: (Turning over) No. I didn’t say, “I’ve been thinking about it.” I said I hadn’t

decided. CLINICIAN: Sorry. So I take it a better word for your situation is undecided? CLIENT: Well, not undecided. What my therapist did just overwhelmed me and

made it so I can’t think straight. CLINICIAN: So you haven’t made up your mind. CLIENT: No, I haven’t made up my mind. I’m still very upset. CLINICIAN: And being upset gets in the way of you making a decision. CLIENT: Yes. CLINICIAN: So, how do you want to work this? Do you want me to wait until you’re

not so upset and then help you figure out what you want to do? I can … CLIENT: … She just thinks I’m stronger than I really am. CLINICIAN: Your therapist? CLIENT: Yeah. She doesn’t understand me if she thinks we can have that short a

session and I’ll be OK. CLINICIAN: It’s upsetting when someone’s expectations don’t match how you feel

about yourself. CLIENT: Yeah, it means she doesn’t understand how bad things are. She’s expecting

way too much from me. She thinks I can do everything on my own. CLINICIAN: That’s an awful feeling. CLIENT: What? CLINICIAN: That people expect you to be on your own when you want them to see

that you can’t do it. CLIENT: Yeah, she thinks, “Oh you’ll be OK with just a 15 minute session with me.” CLINICIAN: Her opinions regarding your abilities are really important to you. CLIENT: Sure they are. She’s my therapist. CLINICIAN: Well, I see your dilemma: you feel her expectations are unrealistic, yet

she’s important to you. CLIENT: That’s it. CLINICIAN: It seems to me that you’re really stuck, because if you go back to your

therapist, it’s really a message to her that you survived her expectations. She’ll see that, while you needed to go into the hospital, her behavior didn’t destroy you. But if you don’t go back to your therapist, you give up an important relationship. What do you want to do?

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CLIENT: God, there you go again, acting like I can make decisions right now. CLINICIAN: Sorry. Maybe you can’t right now. Maybe you need more time to figure

this out. CLIENT: You don’t understand me either. I’m not going to be able to make that deci-

sion ever. I’m too overwhelmed by my depression. CLINICIAN: Well, then I guess we’re both stuck. This isn’t the sort of decision some-

one can make for you. CLIENT: (Angry) OK, we’re both stuck. That’s great. CLINICIAN: What do you want to do about that? CLIENT: About what? CLINICIAN: About being stuck. CLIENT: Man! Would you stop it with all this talk about what I should do? CLINICIAN: I know it’s frustrating, but I don’t know what else I can do for you. I

really want to help you figure out how to get out of this dilemma. CLIENT: Could you call her? CLINICIAN: That’s a good idea. If you talk to her a bit you might be able to figure out

how to get out of the quagmire. Do you want to give her a call? CLIENT: Me? I thought you could do it. CLINICIAN: But it wasn’t my idea. CLIENT: I know, but its part of your job. CLINICIAN: What? Calling people? Yeah, I guess it is. But I would rather if you called

her. This is for you two to figure out. CLIENT: I don’t know. Maybe I could. I’ll have to think about it. CLINICIAN: Let me know what you decide. I’ll help you figure out what to do once

you know where you stand with your therapist. The clinician’s provision of empathy, in the first example, supports the client’s presentation of passivity. While presenting as passive, however, the client actually proves quite effective. Engaging with the clinician on themes related to the emotional injury caused by her therapist’s actions, she is able to influence the clinician into organizing a case conference with her therapist. She is thus able to regain the time and attention she felt was taken from her on her last session with her therapist, while maintaining her presumption of ineffectiveness. In contrast, the clinician in the eager example takes greater control of the interaction, while simultaneously focusing on the client as a

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decision-making being. She consistently shows interest in the client’s potential decisions rather than her emotional state. Approaching the client as an actor in the world, she leaves the decision for contacting the therapist in the hands of the client. Focused on decision and choice, the clinician fosters an environment that prevents against an overwhelming onslaught of themes of deep emotional injury. In such an environment, the decision to initiate a case conference appears as excessive, while the idea of the client calling her therapist appears as an appropriate first step. By emphasizing choice and decision, the clinician guides conversations regarding the precipitants to the client’s current crisis away from issues of emotional injury and towards issues related to the dialectics of change. For example, following the exchange in which the clinician repeatedly reflects on the client’s location in her decision-making process, the client states that her therapist expects “way too much from me. She thinks I can do everything on my own.” Here, the client provides insight about her experience in the face of a central threat to patient careers: that others witness her as autonomous. This insight allows for the clinician to respond analytically and even empathically to the client’s current existential dilemma (I will discuss this strategy of focusing on change and choice more fully in Chapter 8). That opportunity would less likely arise if the clinician entered the interaction focused on mirroring the client’s emotional state.

The Support for the Client’s Resilience Empathy and eagerness both require leaps of faith. The empathetic clinician takes the leap of faith that she can gain an approximate understanding of her client’s psychic and emotional world. The eager clinician, on the other hand, takes the leap of faith that within her client rests a remarkable source of resilience. An eager approach thus aims towards similar goals as solution-focused therapies. It resists the overwhelming invasion in therapy of problem-focused themes, and nurtures the growth of themes relating to the client’s resilience and strength. Unlike solution-focused therapies, however, its chief intervention is not narrative, but (like empathetic approaches) relational. Patient careerists exert a considerable amount of psychic energy concealing their achievements from others. Their social identities and defensive psychological structures are elementally comprised of narratives about themselves as problems only others can solve. Thus, for them, a thematic narrative switch, asserted by another, towards excavating the solutions they make in their daily lives threatens the very means they use to function in the world. An eager approach is less threatening. Instead of focusing on concrete solutions, clinicians taking this approach simply enunciate in the very act of relationship that they

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accept their clients as solution-making beings. Indeed, an eager clinician is excited to work with his clients precisely because he believes in their ability to endure as sentient and agentic persons, despite difficult odds. Such a clinician sees within his clients the remarkable gift of human agency. And he sees that gift in the moment of his encounters with them, because he believes his clients are making choices in their interactions with him and doing the best they can. I offer another two examples to elucidate the difference between empathy and eagerness in supporting the client’s resilience. In these examples, a therapist meets with her client at the beginning of a session: EMPATHY CLIENT: I want to go into the hospital. CLINICIAN: Why? What’s wrong? CLIENT: I don’t want to talk about it. I just feel unsafe. CLINICIAN: You seem upset. Do you want to tell me about it? CLIENT: No, I’m too upset. I’m too unsafe. CLINICIAN: I can see that you’re in unbearable pain. CLIENT: (Pulling legs up on to chair, hugging knees, and hiding face behind them) I

am. (Whispering now) I’m unsafe. I need to go to the hospital. CLINICIAN: You look like you’re in tremendous distress. CLIENT: Yes, I am. I can’t handle it either. CLINICIAN: It seems you are facing a great amount of despair. CLIENT: Yes, that’s how it feels. I’m so hopeless. I need to go into the hospital. EAGERNESS CLIENT: I want to go into the hospital. CLINICIAN: (Disappointed) Really? I was looking forward to seeing you for our ses-

sion today. CLIENT: Well, we could still meet. CLINICIAN: I gotta tell you, I don’t really think that makes sense once you’ve decided

to go into the hospital. The hospital sort of depletes what we do. I think you would agree that this isn’t just some average meeting you and I have. It’s very important and takes a lot of concentration from both of us. I think the session today really won’t have much meaning if you’re going into the hospital shortly after holding it.

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CLIENT: Well, I really feel unsafe. CLINICIAN: And the hospital’s the best place if you’re unsafe. So let’s get you in. I’ll

check in with you during the week to get the date of your discharge so we can get things going again as soon as possible once you get out. If you want, I’ll even try to make sure we meet the day of your discharge. That way we won’t lose any more time and we’ll get going right away. CLIENT: But I came all the way over here to meet with you today. CLINICIAN: I know, so did I. But you’re telling me that you’re not in the place right

now to really be able to do any work. You have all the right in the world to want to go into the hospital. But why postpone that just because we both like meeting with each other? I want to do the right thing here, and keep our work a bit separate from the hospital stuff. CLIENT: What if I just talked to you a bit about what got me upset. CLINICIAN: That would be great! CLIENT: Well, why don’t we give that a shot.

In the first example above, the therapist engages in the client’s decompensation. By offering only empathy, she simultaneously offers an endorsement that the client is truly unable to endure her emotions. In the second example, the therapist offers her client two important metamessages: (a) that the therapist supports the client’s choices as the gestures of someone doing the best they can (“You have all the right in the world to want to go into the hospital.”) and (b) that the therapist believes in the client’s ability to endure her current situation (“I’ll even try to make sure we meet the day of your discharge. That way we won’t lose any more time, and get going right away.”). The therapist delivers these messages through the medium of her eagerness. By energetically endorsing the client’s autonomy and resilience, she both resists an interaction with the client that is problem focused and offers an opportunity for the client to enter a discussion with her about the precipitants to the client’s behavior rather than one guided by the inevitability of the client’s parasuicidality. To be eager to be with a person is to have hope in this person. In one’s eagerness, one expresses this hope. Hope is not optimism. It is not the belief that life will get better. Indeed, hope, in its own subtle way, is the opposite of optimism. “Hope does not prevent us from expecting the worst,” writes Christopher Lasch (1991). “The worst is always what the hopeful are prepared for” (p. 81). Hope is the belief that one will endure no matter what one’s circumstances—not simply survive, but endure, and endure in one’s very beingness; one’s capacity to interact with the world, to make decisions, and accept experience. Hope, not optimism, is the antidote to pessimism. When it is

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expressed through a clinician’s eagerness, it is a message to the client that the clinician, herself, endures the client’s pessimism and the client’s behavioral assertions of automated interactions. An eager clinician takes the leap of faith that all her clients, while exhibiting behaviors to the contrary and legitimately fearful of hope, are simultaneously eager to believe in that message.

ATTITUDE NUMBER TWO: URGENCY Eagerness is a particularly powerful attitude that allows clinicians to facilitate a more existentially honest relationship with their clients. Eagerness, of course, is also an important means by which a clinician asserts his authorship. It is a statement that “I, as an experiencing person, am interested in you.” Urgency is a sister attitude to eagerness. If eagerness is an attitude in which the clinician leaps ahead with the client to look at the choices in the client’s path, a sense of urgency is the reason the clinician feels the client must get on that path in the first place. In this sense, urgency is more an attitude reflective of the therapist’s own perceptions and visions than eagerness; in the clinician’s urgency, the clinician is expressing his belief that a crisis is at hand. Urgency is the fodder for existential guilt. Existential guilt is rooted in one’s understanding that life is within one’s hands, that death is an unavoidable horizon, and that every moment wasted is irretrievable. The sense that there is truly no time to lose that is so intricately entwined with existential guilt typically causes a person to furiously avoid this feeling. Because the responsibility to make every moment count is so awesome and the path to meaning so incomprehensible, most individuals repeal to routine and knowable means of avoidance when faced with their existential guilt. A patient career is clearly such a means. For someone who feels she has wasted a disproportionate amount of her potential, it offers a mode of interacting with the world that defies the urgency of the moment, one of automation, mechanization, routine, and delay. Indeed, if enforcing pessimism in others is the patient careerist’s means of defending against the hope and eagerness of these others, then the routine of a patient career is her means of defending against the awful urgency of her existential guilt. Ironically, the patient careerist is often able to initiate relationships that are formed by routinized interactions by creating emergencies. Indeed, for parasuicidal individuals, the creation of emergencies is their key to the patient role. By harming themselves or threatening self-harm, parasuicidal individuals influence others to act in an urgent manner regarding their care. As we have seen, however, the behaviors of the professionals who respond to their emergencies are restricted by professionally encoded protocols and

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procedures. By enacting emergencies that inevitably lead to routine responses, patient careerists are able to defend themselves against the more chaotic, soulful, amorphous, and unsolvable experience of existential urgency. In this light, parasuicidality is the patient careerist’s attempt to fight fire with fire. The patient careerist ignites a series of acute clinical responses aimed to protect him from physical harm and designed to treat him as a passive sufferer, while avoiding the more intrapsychic inferno of his existential guilt. In order to initiate mutually authored interactions, clinicians must find a means to unsettle the routinization of both mundane and emergent medicalized interactions and infuse the therapeutic arena with a sense of existential urgency. This sense of urgency, however, will also inevitably raise the client’s sense of existential guilt. Thus, the clinician must find sensitive, companionate ways to infuse their relationship with urgency. Like most good therapeutic interactions, the goal of confronting a client with the exigency of the moment is not to rashly tear down the client’s defenses, but to find a means to reach the terror beneath them without becoming too destructive. Compared to the other three attitudes I recommend, urgency is the one that carries the greatest potential to disrupt therapeutic alliances. As with most individuals seeking therapeutic help, a person wrestling with the ravages of failure needs a sense of calm in the presence of individuals who accept her as she is in the moment. Urgency, on the other hand, is always invested with the question of “What is next?” It is an important sentiment, because it motivates people who otherwise seek the comfort of therapeutic interactions as a means to endorse staying the same. But it must be used sparingly and sensitively. Below I describe five means by which a clinician can communicate a sense of urgency. I describe these means in ascending order, from safe means of articulating urgency to means that are more challenging and thus potentially too threatening for some clients. The examples I give are simply examples. In contrast to other descriptions in the book, they are not meant as categories for suggested strategies. Urgency is an attitude, a feeling, and it is expressed in multiple ways by any given clinician. Good clinicians learn how to express it in a manner that is sensitive to the idiosyncratic needs of their clients.

Describing the Therapeutic Frame I find it helpful in my own work to formally frame as urgently important many of my interactions with clients who repeatedly approach clinical contacts as if they are a part of a routine. In such situations, I assert up front that these interactions are actually moments in the day that defy routine. Below is an example of how I begin a group on ambivalence and change in a day treatment program:

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Change and the ambivalence about change are extremely important in our lives. I’m assuming that you’re here today in this group because you agree with me. You’re here to work, to join together in figuring out the difficult problem of change. It may sound crazy, but my assumption is that you would almost rather be here than anywhere else you could be right now. If that’s not true, you shouldn’t feel bad, guilty, or as if you are going to be in trouble if you leave right now. My feelings won’t be hurt. There really is no magic here. While we do very important stuff, it is, in the end, just a group. It is only effective if you want it to be. I’m sure there are plenty of other things you could do during this hour that you might find more fulfilling. And that’s really the point of what I’m trying to tell you: I want you to leave if you’re not truly interested in this group. But I want you to leave and do something that is better than being here. Take a walk on this beautiful day, paint a picture, call someone you love, talk to a friend, plan a meal, eat a meal, write a story, listen to a story, go to the movies. Do anything, but do not waste this moment. That said, anyone who wants to leave, please do so and with our blessing. Now, I want to take just a few moments of silence to just get our minds ready for this most difficult and important topic. I’m not sure if that helps you. But I clearly need it. I can’t facilitate this group with all my concentration if I don’t just stop for a moment and remind myself of our task. In this example, I articulate three important messages, none of which directly address the tragedy of a misspent life, but all of which attempt to focus the members of the group on the urgency and importance of the moment. First, I directly state my belief that the group addresses issues of vital importance and implicitly promise that the upcoming session will seriously grapple with these issues. Second, I state my belief that members of the group are choosing to participate, and I clarify my expectation that the spirit of this choice is one of serious engagement, not of routine disengagement. Third, I place myself as the center and, in some ways, enforcer of the serious endeavor ahead, taking responsibility for my own intensity of concentration. By asserting my own beliefs and by using my own level of intense focus as a force in the session, I break from a central tenet of many therapeutic approaches: beginning where the client is. To allow the session to be guided only by the clients’ emotional states or relational desires would most likely mean participating in an automated vision of life, in which each unit of time is experienced as part of the structure of a day rather than a unique and irretrievable moment. Indeed, the purpose of imposing my own agentic energy and my own specific

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beliefs in this session is precisely to awaken the participants’ sense of urgency (whether they remain in the session or not). That awakening will likely not occur as rapidly without the introduction of someone who is approaching the situation as urgent.

Framing a Specific Activity as Urgent In the prior example, I blatantly state my approach to the group. In other instances, one can assert a sense of urgency by focusing on specific activities in a client’s daily life. For example, a case manager is picking up her client to go grocery shopping. The client, while quite skilled and able in other activities, historically presents to treaters as unable to grocery shop by herself. She has a long history in other programs of shopping with staff on a weekly basis. Over time, these shopping trips have become a matter of casual routine, in which the staff basically keeps the client company while she shops. To frame their encounter, the case manager states: Being able to feed yourself is such an important thing to do. When you think about it, it’s really an essential adult activity. I can’t think of anything more important. We have to find a way to get you to a point of independence on this. To me, this grocery shopping is the most important part of our work together. It’s the key to the better, more enjoyable life I so want for you. We need to figure this out. I’m going to work with you intensely to help assess what is wrong and fix it. In this example, the case manager attempts to raise the value of an activity that other clinicians and the client previously approached as simply a meaningless matter of routine. By doing so, she reinvigorates the activity as an important sight for change. She achieves this without blaming the client (for her lack of improved independency in shopping) or commenting on the client’s dependency needs (i.e., her wish to be accompanied while shopping even though she is likely able to do so herself ). The case manager is able to approach the situation in this demanding yet somewhat safe manner by framing it as urgent.

Replacing Emergency With Existential Urgency As described above, parasuicidality is a means a patient careerist uses to distract others from focusing on his urgent existential context. A therapist can avoid this intended consequence by focusing on a different danger: that risky

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behavior delays one’s engagement in a meaningful life. Doing so, a clinician replaces the force of clinical emergencies with a focus on existential urgency. For example, a therapist meets with her client following the client’s discharge from a hospital. The client has an extensive history of suicidal behavior. The most recent hospitalization was the result of such behavior. I’m glad you’re back. We’ve lost valuable time. We need to figure out how to get you out of this trap, and we need to do so immediately. There’s no time to lose. In this example, the clinician attempts to impose a frame on her interaction that is likely different from what the client expects. While the client expects to discuss her symptom of suicidality as a distinct and insurmountable phenomenon that she passively suffers, the clinician approaches it as a behavior that hinders the client’s ability to engage in a meaningful life. Both the client and the clinician in the example approach parasuicidality as urgent, but their urgency is rooted in very different concerns. For the client, her parasuicidality is a means to engender in others an urgent sense that they must take care of her. She thus uses urgency as an efficient means to remain the same. For the clinician, the client’s behavior raises issues of great urgency precisely because it is intended to maintain the status quo. In the three examples, the clinician takes control of the frame of the interaction, asserting that the moment at hand is urgent. Aware of the injurious affect of blatantly stating the existential reasons for this urgency (that life is finite and every moment counts), the clinician attempts to avoid raising her client’s existential guilt. In the next examples, the clinician directly articulates her own belief that certain life goals set by the client should be immediately attained.

Stating the Urgency of Life Goals As I’ve described earlier, a patient career is partly a person’s means of defending against both the expectation of others and the pressure from others to change. Thus, one important tenet of The Game is for the clinician to remove these sorts of expectations and pressures from the therapeutic arena. People engaged in patient careers, however, often also present life goals to others independent of how these others might feel about their progress. These life goals are typically described as in proximity, possible to achieve and yet somehow unattainable, as if they’re just around the corner yet not quite within the client’s grasp. The likely function of such goals is both to keep others at bay (“Don’t worry, change is at hand.”) and to provide the client with a sense of

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purpose (“I’m on my way to going back to school.”). When a client states, “I’m thinking of taking a night class,” or “I’m getting my energy ready before I start looking for work,” she is often using a delay tactic, guiding others towards her future instead of her present state, and providing herself with a sense of comfort that her life has goals. When a client states these sorts of goals, a clinician can infuse the interaction with a sense of urgency by taking the goals seriously and focusing on their attainment as vitally and immediately important. Below is an example of how a clinician responds urgently to the client’s statement of life goals. During a session with her therapist, a client states that she is interested in taking music lessons, stating, “I was better than anyone at playing the piano when I was a kid, and I’m thinking about studying again.” The client, however, feels she will need to postpone taking these lessons for another 6 months. The client has raised the issue of piano lessons repeatedly in her sessions with the therapist, and has regularly postponed this goal. THERAPIST: You clearly really want to take lessons again. What, exactly, is in the way? CLIENT: Well, first off, the money. It costs about 25 dollars an hour. THERAPIST: Do you have that much to spend? CLIENT: No. No way. THERAPIST: There has to be a way you can take those lessons. CLIENT: Well, I’ll just have to wait. I’ll just have to put them on hold, like I have to

put everything on hold in my life. THERAPIST: You can’t. You simply can’t. You can’t put something so important on

hold. CLIENT: Is this really the right thing to be talking about in therapy? I mean, aren’t

we supposed to talk about how I’m doing? THERAPIST: I think we are talking about how you’re doing. CLIENT: But you’re sort of telling me I have to take those lessons. You’re not sup-

posed to tell me what I should do. You know, I only just mentioned the piano lessons at the beginning of our sessions. They’re not, like, the most important thing in my life. THERAPIST: I don’t know. From what I can tell, I think they’re pretty important to

you. I’m sorry, but I just can’t stand the idea of you neglecting to do something you clearly love doing. We have to find a way for you to take those lessons. Could you take them every other week? CLIENT: I still couldn’t afford that. It’s really no use right now…

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THERAPIST: (Interrupting) What about cigarettes? How much are they costing you? CLIENT: About five dollars a pack. THERAPIST: And you smoke about a pack and half a day. Could you cut back? You

would save enough for the lessons every other week. CLIENT: Well, I guess I could. But, you know, it’s not just the money. I think all the

pressure of practicing and making sure I do well for the teacher may make me feel so bad I’ll want to cut myself. THERAPIST: Oh, I see. That’s another roadblock, and a difficult one too. It seems like

you’re up against a problem you often confront. CLIENT: You mean feeling like I’m going to fail? THERAPIST: Yes. CLIENT: And something really bad could happen if I get that feeling. I mean, I could

kill myself. THERAPIST: And that makes this situation really tragic when you think about it.

Here you are, wanting to do something that makes your life more livable, but you don’t want to do it because you’re afraid of how other people’s expectations might affect you. CLIENT: I think you’re being a little dramatic here. I don’t think it’s tragic. It’s just

something I need to postpone a bit more. It’s not that big a deal. THERAPIST: I’m sorry. We disagree a bit here. I truly think it’s tragic. You simply

deserve to do the things that you love. Not in 6 months, right now. In the above example, the therapist enhances two important themes by acting urgently about the client’s life goals. First, she clearly combats the client’s attempt to create a routinized interaction by asserting that the delaying of one’s life is tragic. By acting urgent about the client’s specific wishes to take piano lessons, she enforces her own general belief about the preciousness of living. Second, approaching the piano lessons as a necessity rather than a luxury, the clinician guides the conversation away from only material concerns (money) to also include more psychological ones (the client’s fear of failure).

Addressing the Existential Roots of Urgency When clinicians frame their interactions with clients as urgent, they do not necessarily address the more general existential issues at the root of routinized interactions. When they focus on life goals, they again avoid the larger issue of why the delaying of these goals is a problem. In the third and likely most

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threatening means of infusing a sense of urgency in the therapeutic arena, clinicians directly address why such aspirations as meaning, purpose, and fulfillment are matters of urgency. Pointing out the risk of being the same. Staying the same is risky. If we begin with the idea that life offers the promise of great depth, meaning, and purpose, and each individual is accountable for engaging in the spiritual abundance that life offers, then not engaging in life is extremely risky behavior. When appropriate, pointing this fact out to a client can help motivate him or her to change. Below is an example: CLIENT: I don’t know if I can take that job. I mean, I’ve been working at getting it,

but now that it’s mine, I’m scared I just can’t do it. It feels like such a risk. CLINICIAN: I see why it feels that way. This is such a big step. But you know what? I

think there’s a riskier choice you could make. CLIENT: What’s that? CLINICIAN: Not taking the job. Talk about risky. You describe your life to me as al-

most hellish, and you have dreamed about this job for months. Think about the risk you would be taking if you didn’t accept the job. It’s astronomical. Indeed, I would say that not taking the job is risky behavior. You’re risking more days of not doing anything and feeling bad about yourself. In this discussion, the clinician is clarifying a real truth, not simply being dramatic for the purpose of therapeutic effect. Pointing out the risk in staying the same, while assertive and potentially threatening to a client, is actually a form of empathy, for it exhibits to the client that the clinician is aware of how difficult life is presently and thus how important it is to change. The “five second suicide.” When appropriate, I will ask a client to sit with me silently for 5 seconds while I watch the clock. At the end of the 5 seconds, I explain that the client and I just experienced a 5 second suicide, stating that the moment we spent doing nothing is irretrievable, gone forever. I then state that the client and I are in the midst of a difficult dilemma: we can either spend more time avoiding life by regretting the lost 5 seconds, or we can give them value by learning from them. A life map. Yalom (1980) suggests drawing a line on a piece of paper and then asking a client to mark on this line where the client feels he is on the trajectory of his life. The clinician then asks the client what he or she wants to do to make the remaining period of his life as meaningful and fulfilling as possible. Looking back from the future. Some existential therapists ask their clients to write their own obituaries, attempting to guide their clients to examine what

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they are making of their lives. I believe that this form of historical review, in which a person will be noting her accomplishments (and often lack thereof ), is inordinately painful for people who define themselves as failures. On the other hand, I have also found that a different form of looking back from the future can be fruitful. When a client presents to me as trapped in a deep sense of remorse and shame related to the client’s vision of herself as a failure, I might request that the client think about her last remaining days, asking, “When you’re on your death bed and you look back, what will make you feel most satisfied and happy: that you were a person who spent her time taking account for all her mistakes and lost opportunities, or that you were someone who found a way to forgive herself, move on, and get engaged with the world around you?”

The Clinician’s Reluctance to Be Urgent The urgency communicated by a clinician is not merely a technique; it speaks clearly to the tragic truth of the moment. Thus, the infusion of urgency into the therapeutic arena is perhaps the most difficult task for a clinician. In all our lives, the house of potential fulfillment is truly burning, and no matter how much we wish to deny it, we are all trapped with the profound responsibility to make life meaningful. Being urgent with clients means looking at something we all try to avoid and seeing this problem in the very moment of our therapeutic encounters. It also requires that we resist the seductive aspects of routine and automation. Our clients often come to us with a serial description of their lives, in which each day is contained within a certain set of expected behaviors and experiences. We, in turn, tend to join with them in these descriptions, partly because such descriptions provide a defense against the realization that every day is pregnant with tremendous potential. Urgency, in this light, requires a level of courage on the clinician’s part. It means resisting the seduction of routine and focusing on the tragic fact of the finiteness and, thus, preciousness of every moment.

ATTITUDE NUMBER THREE: UNCONDITIONAL POSITIVE REGARD What’s the urgency? Why approach this day, this moment, as something that must be grasped, its potential experienced? An existential approach, so dark and pessimistic at times, gives the answer, especially when it takes on more theological tones. Our lives are finite, but they are not destined to be subsumed by anguish only. Indeed, when we engage authentically, we may ex-

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perience greater anxiety, but we also gain access to the fruit of a meaningful existence, one filled with awe, wonder, curiosity, play, creativity, intimacy, and the perpetual reflection of our own unique and spontaneous being. Life is an awesome gift we did not ask for nor deserve. To waste it is a sin. The word sin comes from an Arabic archery term, meaning to miss the mark, or even to shoot with the aim to miss. If our existential target is an authentically engaged life, then any act in which we aim to miss this target is truly sinful. In this view, a patient careerist lives in sin and parasuicidality is sinful behavior. It is sinful, unacceptable, but very understandable, for the tension between avoiding accountability and engaging authentically is at the core of human experience. To be human is to be sinful, and no one can rightly cast the first stone. The most authentic response to a person engaged in the sin of a patient career is what Carl Rogers (1957) called unconditional positive regard. Unconditional positive regard refers to the clinician’s attitude towards the client in which the clinician accepts the client as worthy, capable, and doing the best he can, even when the client engages in seemingly dysfunctional behavior. The patient careerist, so intensely engaged in the core tension of human experience, deserves such regard. No matter how mortally sinful the client’s actions are, he deserves this regard without conditions, for the dialectics of failure create an intensely intricate trap from which there is no easy escape. The patient careerist, in other words, is doing the best he can, considering his circumstance. Patient careerists do not only deserve unconditional positive regard, they need it. Rogers believed that the therapist’s provision of unconditional positive regard (along with empathy and genuineness) contributes to an environment in which individuals will most likely change to meet their potential. The unconditional in such an approach refers to the clinician’s willingness to suspend judgment, to see the client free from definitions of good and bad behavior. For multiple reasons, clinicians attempting to facilitate mutually authored interactions with individuals engaged in patient careers must take this unconditional stance. First, such a stance is the most liberating response for someone trapped in the dialectics of failure. Second, a nonjudgmental approach resists the medicalized alternatives of labeling individuals either sick or bad. Third, one cannot engage in the important attitudes of eagerness and urgency effectively without also approaching one’s clients with unconditional positive regard.

Unconditional Positive Regard and the Dialectics of Failure To risk change, a self-defined failed person must feel somewhat free from expectations and judgments. The dialectics of failure, the existential quagmires

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that trap an individual who has defined herself a failure, are often formed by the force of expectations. By changing, an individual exposes to others her ability to enact change and, hence, her agentic power. She thus raises the expectations of these others. A self-defined failed person fears this increase in expectations both because she does not want to be seen as an accountable agent, and because she is concerned that she will fall short of meeting the increased expectations of others, thus being seen by them as failing again. When a clinician places conditions on his positive regard, acting encouragingly about good behavior and discouraging about bad, the clinician contributes to an environment that feels inordinately risky for the client. From this parceling out of encouragement and regard, the client realistically understands that his positive achievements will raise the expectations of the clinician and that actions the client or the clinician see as negative will end in disappointment, or at least disapproval. Unconditional positive regard is the only means to avoid this risk. By offering positive regard without conditions, based on a genuine understanding of the client’s very human struggles, a clinician contributes to an environment in which the client can risk change without fear about dramatically changing expectations. The experience of unconditional regard is foreign to most individuals engaged in patient careers. Their general experience of clinicians or even friends or family is to be either stigmatized by these others (as sick, broken, failed by illness) or viewed as purposively deviant (cowardly, failing at self-sufficiency and adult responsibilities, and/or deviating from her responsibilities as a patient). Approaching a self-defined failed person as someone engaged in understandable behavior (which it is) and doing the best she can (which she is), a clinician contributes to a nurturing environment based on the existential reality of the moment. In an environment warmed by positive regard but quiet of expectations and judgment, a person engaged in a patient career is allowed a space in which to initiate the change she yearns to make. She wants the fruits of an authentic existence but needs a nonjudgmental environment to reach for these fruits. Focused on the client as a person capable of change rather than as a progenitor of liability-inducing behaviors, a clinician shifts his own gaze from parasuicidality to the human struggle regarding accountability. Doing so, the clinician provides an enduring attention to the client that is unconditional but safe. No longer is the client able to attain a sense of enduring attention through anxiety-provoking behavior. Instead, the client gains this attention by simply being a person. The movement from patient careerist to existential author is an act of salvation, for when we become authors of our own existence, we salvage our truer selves—the souls we are meant to be. To stay on this admittedly theological

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track, the forgiveness and grace of a nonjudgmental environment guide an individual toward salvation and away from the sin of a bad faith existence.

Unconditional Positive Regard and Demedicalization A stance of unconditional positive regard opposes a medical vision. Because it is truly nonjudgmental, such a stance resists the stigmatizing or marginalizing tendencies intrinsic to medicalization. A clinician approaching her client with unconditional positive regard views the client’s behavior as an understandable and normal response to existential tensions. The clinician does not, in other words, see this behavior as sick or bad. When a clinician assumes a stance of unconditional positive regard, he tends towards seeing the client as an active agent, someone who will take hold of his own life in the right relational arena. Unconditional positive regard is an attitude that contributes to the creation of a nurturing or facilitative environment described above. The British object relations theorist, D. W. Winnicott (1971) is instructive here. Winnicott coined the term facilitative environment. His work focuses on the interpersonal contributions that aid in the creation of an environment in which a person is willing to expose her true self. For Winnicott, a facilitative environment is durable, a place in which a person can move without great shifts in the attitude and response of the other. Such an environment offers a sense of being alone in the presence of other, something similar to what I have called enduring attention, yet without conditions. Lastly, a facilitative environment is nonimpinging. When a person acts in a facilitative environment, he does so with assurance that others will not appropriate his gestures, judge him, or employ these gestures to solve their own psychological needs. Clearly, a medical vision, in which the clinician assumes the role of someone who gazes and judges, and medical environments, in which clinicians often feel the need to protect themselves from liability, are antithetical to the kind of environment Winnicott (1971) described. The clinical gaze and the focus on mending are both ways of approaching a patient as a passive entity to be viewed, judged and acted upon. In a medicalized vision, each gesture made by the client is perceived as a sign of either health or illness, and the clinician is the judge of this binary attribution. This is an impossible situation for someone who is keenly sensitive to experiences in which her gestures are appropriated by another. An environment held within the gaze of a nonjudgmental and positive clinician, on the other hand, permits the client to risk gesturing towards change without her actions being appropriated. It is also a durable environment. Unconditional in judgment, the attitude of the clinician in such an environment does not change radically depending on the client’s behavior.

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Unconditional Positive Regard, Eagerness, and Urgency The attitudes of eagerness and urgency are only effective when clinicians regard their clients positively and without judgment. Both eagerness and urgency are attitudes that place clinicians as active agents within the therapeutic arena. A given clinician’s eagerness to work with a client and her sense of urgency come from that clinician’s authentic experience. Unlike empathy, which is also an authored response, eagerness and urgency are more assertive of the clinician’s attitude than receptive and reflective of the client’s experience. This is a somewhat novel place for a clinician in a field often constrained by the ethos of mending and a belief in maintaining a therapeutic arena sterile of the clinician’s agency. It is also obviously threatening to someone terrified of the free agency in others. Yet, the assertion of the clinician’s agency is an intrinsic element of a mutually authored relationship, and eagerness and urgency are specifically important attitudes in an environment facilitative of an escape from a patient career. Unconditional positive regard, by removing judgment and providing warmth and acceptance, mitigates the threat of eagerness and urgency. Without a foundation in unconditional positive regard, the attitudes of eagerness and urgency only endanger the potential for mutual authorship. If a clinician does not start from a belief that his client is doing the best he can, eagerness and urgency pervert to invasive, impinging attitudes. A clinician who is eager to work with her client but is also judgmental about that client’s behavior, believing his client can do better than she’s doing, is really eager to change the client and not excited to meet the client as he is in the present. The clinician is engaging with his client in a manner antithetical to the ethos of a mutually authored relationship or the facilitating of a nurturing environment. Even more dangerous, a clinician who expresses a sense of urgency about a client he sees as dysfunctional is the embodiment of everything a self-defined failed person fears. Here, urgency is married to judgment, for it is the bad behavior that needs to immediately change. Urgency only works therapeutically when it is introduced as a general attitude about making life meaningful. Even then, as I have written, it is dangerous. Unconditional positive regard is the glue of The Game; it holds together attitudes and interventions that would otherwise feel threatening to clients, while contributing to a demedicalized environment. Alone, it is not an attitude motivating enough to spur forward individuals engaged in patient careers. But it is a vital component to The Game. As I have mentioned, a clinician must attend to three specific relational arenas when engaging in The Game (Figure 5.2). The clinician must consider how to introduce her own agency into the relationship, how to support the

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Relationship

Unconditional Positive Regard

Urgency

Client

FIGURE 5.2

Eagerness

Clinician

The relational spheres of The Game.

client’s willingness to expose her own agency, and how to attend to her relationship with the client. The attitudes described above roughly fit with these arenas. Eagerness exposes the clinician’s agency, urgency is focused on the client’s predicament, and unconditional positive regard holds the relationship together. In the next three chapters, I describe strategies that also focus on these arenas. In Chapter 6, I describe interventions that occur within the relationship between clinician and client, in Chapter 7, I delineate a group of interventions in which the clinician’s agency is at force, and in Chapter 8, I describe strategies aimed at enhancing the client’s motivation to change.

CHA PTER 6

Relationship The Distraction of Relational Intensity at Points of Liability 105 The Expression of Interest in the Client’s Uniqueness, Attributes, and Normalizing Activities 110

Continuous Attention: Liability Condition 111 Continuous Attention: Client Attributes Condition 111

M

ost psychological theorists agree that the clinician/client relationship is elemental to effective therapy. The Game is not any different. Indeed, with its basis in here-and-now encounters, it is truly a relational model of intervention. The Game, like many depth psychotherapies, approaches the therapeutic relationship as an actual site of change. It is both the fertile ground from which a person feels safe to change his life, and an arena in which this person witnesses his actions in the relationship as representative of his current patterns of behavior with others. Similar to some behavioral therapists, a clinician in The Game also approaches the relationship as a resource to use for positive reinforcement. The clinician adjusts the intensity of his attention dependent on the content of his interaction with the client. One can obviously locate relational themes in all three relational arenas of The Game. Two particularly important interventions, however, are more purely relational maneuvers since the therapeutic relationship is their primary element of efficacy. These interventions are (a) the distraction of relational intensity at points of liability and (b) the expression of interest in the client’s uniqueness, attributes, and normalizing activities.

THE DISTRACTION OF RELATIONAL INTENSITY AT POINTS OF LIABILITY In the example of an empathetic approach in the previous chapter, the client’s threat of self-harm draws the clinician in, gaining the clinician’s intense focus and attention. The patient careerist uses threats of liability to attain effective ineffectualness, conditional continuous attention, and the medusaization of 105

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clinicians. Intrinsically entwined with medicine’s elemental processes of the clinical gaze and the focus on mending, the threat of liability is the key to accessing the social psychological parameters of a patient career. Thus, to succeed at The Game, clinicians need to dilute the power of liability threats. They do so while simultaneously buffering the threat of their clinical maneuvers on the ontological security of their clients. This is accomplished with a simple, but often neglected approach: telling the truth—being authentic about the effects of liability on the clinician’s agency. When faced with liability concerns, clinicians typically lose focus on their clients, becoming distracted by issues of self-preservation (from lawsuits, the judgments of colleagues, threats to licensure, etc.) and by thoughts about immediate tasks at hand and time limitations (committing the client to an institution, seeking a hospital bed, calling an ambulance service, and how long each of these tasks will take). While they are distracted, many clinicians attempt to maintain professional composure, continuing with the client as if liability concerns have not polluted the relationship. I suggest that, instead of ignoring the force of liability, clinicians directly address these concerns, articulating the fact that the issue of liability has caused them to lose focus, to become distracted. Below is an example: CLIENT: I feel an uncontrollable urge to cut. CLINICIAN: This is a really hellish place you’ve found yourself in again. It’s also a

real trap for us because it means it’s almost impossible for us to do any work right now. CLIENT: What do you mean? CLINICIAN: Well, you may not know this, but once you tell me you’re going to do some-

thing harmful to yourself, I can’t help but start thinking about all the things I need to do to keep you safe. And these things I’m thinking about aren’t the stuff of therapy, but mostly about the tasks I will need to accomplish so that when we’re done, I know you’ll be safe and I won’t have to worry about you hurting yourself. I’m trying to concentrate on you, but I’m also wondering about which on-call psychiatrist I should call in case you need to be committed, where I kept the numbers for the ambulance services, and what hospitals take your insurance. CLIENT: I don’t like that at all. I mean, here I am in the middle of some really bad

stuff, and all you’re doing is covering your butt! CLINICIAN: I don’t like it either, I … CLIENT: Look! I could care less if you don’t like it. What’s important is that I need

you to really listen to me, and you’re so worried about yourself you can’t! That’s just unprofessional!

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CLINICIAN: I don’t want to be that way with you. I want to be like I am usually—

right here, now, working with you on your life. But I can’t provide that kind of care when my mind is focused on keeping you safe. To me, ignoring the fact that you are feeling an urge to cause tissue damage and possibly even end your life is unprofessional. CLIENT: So you’re just going to ignore my feelings? CLINICIAN: You didn’t come in talking about feelings. You came in talking about a

behavior. CLIENT: I said I felt the urge to cut. CLINICIAN: I don’t want to get into the business of splitting hairs here, but to me that

sounds more like something that just hit you unexpectedly. You know, an urge. And I’ve got nothing to say about urges. I wouldn’t know how to talk about urges. When I hear “urges” I think “hospital” and how to get you in. CLIENT: What?! But aren’t you going to even evaluate me and my level of risk? CLINICIAN: You said you’re feeling an “uncontrollable urge to cut,” what more do I

need to get the ball rolling? CLIENT: You’re making me confused. CLINICIAN: That’s a feeling, and I understand it. You seem confused. And I under-

stand that completely. This is very confusing stuff. CLIENT: Maybe the word urge is the wrong one. I’m just feeling upset. My best

friend’s out of town with her new husband, and she was supposed to call me today from their hotel and … CLINICIAN: I’m sorry, I’m going to have to interrupt. This is such important stuff.

This is the stuff I really want to listen to. But I’m still thinking that you’re in possible danger. My mind’s going in two directions. I can’t fully listen to you until we figure out whether you’re still feeling like harming yourself. CLIENT: Well, I guess I’m not. Do you want me to sign some sort of contract for

safety? CLINICIAN: No, no, I trust you. CLIENT: OK. Well, I do think I really want you to hear this stuff about my day. I … CLINICIAN: OK, and sorry to interrupt again, but I need to remind you that our time is

almost up. We’ll get there, but we’re both going to really need to concentrate. Many psychological theories working with borderlines endorse the importance of clarifying for the borderline patient the treatment- and relationshipinterfering aspects of self-injurious behavior. I suggest a way of doing so,

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while respecting the rules of The Game. By openly addressing how the client’s behavior affects the clinician, the clinician potentially achieves multiple relational goals while avoiding her own participation in the coconstruction of a patient career. By being honest about the effects of liability threats on her own ability to participate in therapy, the clinician is able to address this issue without reverting to clinical language about the client’s failure to perform in the patient role. (This is in contrast to Linehan’s [1993a] suggestion that the clinician tell the client her behavior is treatment interfering.) Instead of taking a clinical stance, the clinician presents the dilemma at hand as a human one, in which two imperfect human beings are trapped in a difficult relational quagmire. The clinician is thus able to address the issue in a manner that clearly deviates from routinized, medicalized approaches. In The Game, when a client uses threats of liability, the clinician resists the temptation to enter the automated, medicalized modes of interaction of evaluating the client for safety and developing safety plans. Instead, the clinician exposes the client’s own agency without blatantly threatening the client’s role as a patient. Assuring that the clinician’s attentive energies are not steered towards the client by the client’s threats of liability, the clinician also initially resists using interventions typically formed by concerns about safety, such as level of risk and the client’s intent and means to self-harm. The clinician aims, instead, to articulate his interpretation of the relational results of this threat. The clinician articulates this interpretation by candidly discussing his experience as a consequence of the client’s liability threats (“I can’t help but start thinking about all the things I need to do to keep you safe ... these things I’m thinking about aren’t the stuff of therapy.”), rather than taking the role of a partial outsider to the relationship and offering an interpretation of the client’s intentions. By focusing on the consequence of the threat of liability instead of its intent, the clinician is able to articulate her interpretation without the client experiencing the clinician as unbearably judgmental. The clinician is also able to steer the interaction to the mutually authored here and now of her relationship with the client. The clinician thus dilutes the client’s attempt at effectual ineffectualness. Paradoxically, the clinician does so not by resisting the client’s gesture, but by naming its consequence. By naming how liability threats affect her, the clinician asserts her own agency while allowing the client’s agency to flow unhindered. Without expected clinical response, the client’s gesture at effectual ineffectualness loses its pressure and form. Neither capable of controlling the clinician’s agency nor able to present the client as passive, the client’s gesture is revealed as an act of self-authorship. Allowing the client’s agency to flow, the clinician facilitates an environment in which the client’s attempt at effectual ineffectualness becomes, simply,

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interpersonal effectiveness. With themes of interpersonal effectiveness at the forefront of their interaction, discussions about choice more easily emerge. When a client raises the threat of liability, he inevitably infuses the therapeutic environment with another issue: the level of care the client will need appropriate to his level of stated danger. When the client threatens to harm himself, he is thus on a precipice of a choice regarding institutional arrangement. He, in the end, has more control over this choice than the typical medical dramaturgy allows, for he can modulate his threat depending on his needs. In the typical medical dramaturgy, the client’s parasuicidality and the subsequent institutional arrangements are kept somewhat separate. The client, in this view, is isolated in his parasuicidality. His focus on harming himself is independent from how the threat of harming himself will likely lead to others mobilizing resources to keep him safe. Passive in his own illness, the client has little control over this mobilization. By being candid about the effects of this threat on the clinician, the clinician directly links the threat with the mobilization of resources (“If you’re saying you feel an urge to cut, the hospital is the best place to be. So, do you want to go into the hospital or not?”). Indeed, the clinician is focused more on the effect of the threat itself than on the client’s parasuicidal behavior. He thus subtly reveals the client as making choices in the parasuicidal act. By expressing how the client’s actions place the clinician in an automated position, the clinician fends again the client’s attempts at creating a mechanical interaction. The clinician not only responds to the client’s attempt at effectual ineffectualness, but also manipulates the provision of conditional enduring attention. The clinician does so without threatening the client’s assumption of patienthood. In the medical dramaturgy, the clinician’s message to the client at points of liability is, “I will focus all my energies on you to assure that you will be safe.” To assure the client’s safety, however, the clinician must avoid responses that reveal the client’s agency. The clinician’s message is thus partially disingenuous, for while she focuses on the client, she segregates the client’s own authorship from her vision. In contrast, when the clinician is candid about the effects of liability on her attention, she sends a message to the client that “you are an author in this relationship,” while simultaneously expressing to the client that “I can only be an author, and thus truly capture you within my gaze, if I avoid the conditions you have endorsed.” Illustrating for the client the vacuous nature of conditional relationships, the clinician thus turns one goal of liability threats on its head. Threatening liability, the client wants to be held in the mind of the clinician under the conditions of her own passivity and lack of accountability. The clinician’s candid response, however, articulates to the client that these conditions actually distract the clinician’s attention away from the client.

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If one approaches patient careerism behaviorally (an approach I only tentatively take), then the clinician’s eagerness to hold the client contiguously in his consciousness is a form of positive reinforcement. The clinician revokes this positive reinforcement when the client raises liability concerns. Clearly, however, the clinician cannot revoke something he has not already offered, so distracting relational intensity at points of liability is only as effective as the clinician’s overall provision of a sense of enduring attention to the client. In The Game, the clinician provides this enduring attention selectively. As discussed later (in Chapter 8, “Motivation and Change”), the clinician shows the client that he is invigorated by the client’s discussions regarding the client’s struggles over change, the client’s contemplation regarding issues of success and failure, and the client’s willingness to speak of his own existential angst. The clinician also shows the client that the client’s more human and productive attributes powerfully affect him, remaining in the clinician’s consciousness long after he is in the physical presence of the client. The clinician thus replaces liability threats with an appreciation for the client’s uniqueness, attributes, and normalizing activities as central means to gaining enduring attention from others.

THE EXPRESSION OF INTEREST IN THE CLIENT’S UNIQUENESS, ATTRIBUTES, AND NORMALIZING ACTIVITIES As we have seen, when a client makes a threat regarding liability, the client intends the effect of this threat to adhere to the clinician’s consciousness for a period of time. The client is not seeking simply a moment of attention, but something more lasting: a sense that this attention endures even when she is out of the sight of the clinician. When a clinician distracts relational intensity at points when the client is making such threats, the clinician is attempting to remove this attractive element from patient-like behavior. To help the client find other means to achieve a sense of enduring attention, the clinician offers her client a similar relational process, but does not provide this process in response to liability threats. Instead, she provides it in response to the client’s unique, unpatient-like attributes. In the place of a restricted yet acute gaze towards the client as a potential source of danger, the clinician reserves her most energetic attention for the client’s tastes and interests, the client’s likes and dislikes and talents. The following pages reveal two contrasting examples of how a clinician offers a sense of enduring attention to her client. In the first example, the clinician offers this sense in response to liability concerns. In the second, she offers

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it in response to normalizing activities. The scene takes place on an acute hospital ward. The clinician is meeting the client in the morning at the beginning of her shift. In the first scenario, the clinician is meeting with the client after the client made a suicide threat the previous evening. In the second scenario, the clinician is meeting with the client following a conversation the previous night regarding the client’s interest in furniture refinishing.

Continuous Attention: Liability Condition CLINICIAN: You contracted for safety with me last night, promising that you would

not make any suicide attempts for the next 14 hours, until I returned from shift. I checked in with the staff over the night to see if you were OK, and from what I can tell, you kept safe. I wanted to check in with you now to see if you are still thinking of harming yourself. CLIENT: I stick by my word and I promised you I wouldn’t do anything last night.

But nothing’s changed. I still plan on killing myself. I have to talk to you. CLINICIAN: OK. Can you hold yourself together a little longer, so I can just take care

of my morning duties? CLIENT: You don’t understand, I need to talk now. You don’t seem to understand

how serious this is. CLINICIAN: Alright, let me just let people know where I am, and we’ll talk. CLIENT: Good, because I think I’m going to need to contract with you again. I defi-

nitely need more safety checks than I did last night.

Continuous Attention: Client Attributes Condition CLINICIAN: I didn’t know much about furniture refinishing until you explained it to

me last night. It’s really a much more complex process than I had thought. I was at the library later in the evening, and was still thinking about our conversation. I went to the home improvement section and picked out a couple of books on the subject. I found one really great one and I brought it in with me, thinking you might want to look at it and explain a couple of things to me that I read. CLIENT: I could talk to you about it right now. CLINICIAN: Well, I just got on shift and … CLIENT: Sure, sure, I can wait … CLINICIAN: No, no, I was going to say that I just got on shift and I’d like to run over

to the nurses’ station for a second and see if I can put off a couple morning duties so we can meet now.

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In both examples, the clinician divulges to the client that the client’s gestures have resonated in the clinician’s consciousness long after she was out of the clinician’s site, and that the topic originally instigating this enduring attention was so gripping that the clinician offers her full attention once she returns and makes contact with the client. Relational rapprochement, initiated by particular gestures, forms the structure for each example. In the former example, this rapprochement is based on the clinician’s concerns about the client’s safety and her own anxiety regarding her responsibility to the client. She contracts with the client to provide a highly conditional form of attention, offering to check on the client regularly and regularly renegotiate their contract. In the latter example, this rapprochement is based on the client’s productive and creative capabilities, rather than her definition as a person suffering an illness. In this example, the clinician’s attentive energies are spent inquiring about the client’s more human and unique characteristics. The art of exchanging concerns about liability with an appreciation for the client’s capabilities is a subtle one. To coax the client into participating in a capability-based rapprochement, the clinician must be careful to approach these capabilities as objects of his own interest and curiosity and not as the first kindling for rising expectations. For example, in the second scenario above, the client would likely recoil from relating to the clinician in an authored manner if the client felt that her comments regarding furniture refinishing were the fodder for discussions about her immediate vocational future. If the clinician had responded to the client by stating, “I was thinking about our discussion last night, and looked into the want ads for furniture refinishing jobs,” she would disrupt her alliance with the client by appropriating information about the client’s creative capabilities for the purposes of a discussion about change. In a less dramatic way, the clinician would cause the same type of disruption if she spoke to the client about more simple, smaller steps towards employing her skills: “You like furniture refinishing so much. Is there somewhere you could go and just practice it again? I know of a vocational program that works with people on regaining their skills. I could look into that for you if you like.” Whether dramatic or more subtle, when a clinician appropriates a client’s revelations about her own aptitudes for the purpose of discussions about change, she is enacting the client’s greatest fear about such revelations: that when she ventures from the patient role, she automatically raises the expectations in others about her accountability for the future. Indeed, as described, her fear that others will appropriate her gestures into proof of her true competence is the very basis for the patient careerist’s attraction to effective ineffectualness and conditional enduring attention. When a client is willing to risk exposing her own unique attributes, the client is tentatively transcending the patient role and reaching out to the

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clinician for a more human, authored interaction. The clinician will squander this therapeutic opportunity if she approaches the revelations of aptitudes as signs of an automated role shift (from, for example, “patient” to “worker”), instead of gestures for human contact. Every human capability is both a sign of competence and a message about the person’s own unique tastes and interests. It is this latter message the clinician wants to receive and use as a means of reaching the client. The clinician thus offers the client a particular sense of enduring attention based on the clinician’s consideration of her personhood, rather than her potential problem as a patient, or her potential competence as an accountable human being. When a clinician approaches his client with a focus on unique attributes, the clinician views the client in the here and now. The clinician neither sees an illness with a previous etiology, nor a light towards a productive future. Valuing the client as an idiosyncratic personality, the clinician simultaneously raises the potential that his own agency will flow in his interaction with the client. The clinician is not introjecting the client into his consciousness because of anxiety over liability concerns, but because the clinician, as an autonomous and unique individual, is interested in the client’s autonomous and unique gestures. Thus, the clinician’s subtle assertion of the client’s agency is a conduit to in-the-moment, mutually authored interaction. In the next chapter, I suggest means to facilitate this type of interaction by subtly asserting the clinician’s agency. In the interventions I suggest, the clinician’s agency is the conduit to mutual authorship.

CHA PTER 7

Clinician’s Authorship Mirrored Threats of Agency Example 1: A Routinized Interaction Example 2: The Clinician Asserts Her Authorship Decentering Expertise

115 117 117 120

The Apology Strategic Self-Disclosure Addressing the Role of the Clinician in the Client’s Current Ambivalence

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In this chapter, I describe the means for clinicians to assert their agency in pursuit of mutual authorship. By asserting their own agency, clinicians show their clients that they are truly here in the moment, witnessing their clients as also present in the interaction. Doing so with a firm adherence to the tenets of The Game, they provide an opportunity for their clients to experience the fruits of relating to other people in an authentic manner.

MIRRORED THREATS OF AGENCY It is impossible to express one’s reception of another’s full personhood without fully being a person in relationship with her. This is a self-evident fact about mutually authored relationships. To reach out to another, and experience the other person as an authored, experiencing being, requires that one be open to experience. A robot or computer cannot appreciate the authorship of a person, only a sentient person can. The more robotically we act towards another the less we are able to experience her free agency. The converse of this dynamic is also true. The more we risk appreciating the authorship of another, the more we experience our own authorship in the world. To accept that the other is as equally sentient and agentic as ourselves, we drop our existential defenses and are thus most ourselves when we do so. Indeed, in Martin Buber’s (1970) terms, this I-thou (as opposed to I-it) approach to others carries a great existential risk. Receiving and appreciating the sentiency of another requires that one transcend a central existential threat: the potential that the person we experience as a sentient someone is free to see us as existentially accountable. This is why the ontologically inse115

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cure individual not only conceals her agency from others, but also attempts to limit her experience of their authorship. To experience a person as authored is itself an act of authorship, and it also leaves one vulnerable to the whims of an independent person. As we have seen, medical culture offers a sanctuary from the mirrored threats regarding the exposure of one’s agency and the risk of experiencing the agency of others. The psychotherapeutic tradition of the therapist as tabula rasa emerges from this medical worldview and pervades the basic norms of all mental health professions. Thus, for clinicians to expose their agency with clients requires that they both take the intrinsic risk of such exposure and break from powerful professional norms. It also requires that they do so with great sensitivity to how the exposure of their agency might feel threatening to their clients, causing these clients to retreat further from mutual authorship. While risky and difficult, the clinician’s assertion of his own agency is elemental to mutual authorship and thus essential to the type of relational space from which individuals might begin to relinquish their patient careers. By assertively infusing the therapeutic arena with their authorship, clinicians not only lay the groundwork for mutual authorship, but also achieve two other important goals. First, by enduring their clients’ attempts to treat them as things, clinicians compassionately reach out to their clients as people. They prove that aspects of their clients’ selves that the clients might experience as particularly toxic and despicable do not necessarily hold a complete power over others. By articulating through their actions that “your behavior does not make me into stone,” clinicians send a parallel message to their clients, “because you are not as hideous as you think.” Doing so, they lay the groundwork for an authentically secure and caring interaction. The second goal achieved when clinicians assert their agency is targeted in all the strategies of The Game—to steer the therapeutic encounter away from medicalized themes and towards more existentially honest ones. Strategically asserting their agency in the service of mutual authorship, clinicians send the entwined messages of, “I am here as a person,” and, “As a person, I come with certain idiosyncratic inclinations and expectations regarding our relationship.” For clinicians engaged in The Game, those inclinations and expectations are imbued with themes relating to existential accountability and the intrinsic existential challenge of change. To illustrate the way in which a clinician’s assertion of agency enhances the mutual authorship with her clients, I offer two examples on the following pages. In the examples, a clinician meets with a client at the point of intake into a day treatment program. In the first example, the clinician responds to the client in a somewhat automated manner. In the second example, the clinician asserts herself as an agent in the interaction.

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Example 1: A Routinized Interaction CLINICIAN: So, tell me why you’re seeking help from our program. CLIENT: I need day structure. CLINICIAN: So you’re looking for some place to go in order to help you organize your

day? CLIENT: It’s what my case manager feels I need. CLINICIAN: What, day structure? CLIENT: Yeah, I just don’t do anything during the day, and my case manager wants

me to do something. CLINICIAN: Do you have any goals you want to pursue here? CLIENT: I just said—to get some day structure. CLINICIAN: Yes, but what would you like to work on while you’re here? What are

your treatment goals? CLIENT: I don’t know. Right now I just need a place to go. You could ask my case

manager about treatment goals. CLINICIAN: I’ll give her a call later and see what she’s looking for. In the meantime,

do you want to go over your schedule for the day?

Example 2: The Clinician Asserts Her Authorship CLINICIAN: So, tell me why you’re seeking help from our program. CLIENT: I need day structure. CLINICIAN: I’ve heard people use that term before, but I’m never quite sure I know

what it means. CLIENT: Well, that’s what my case manager says I need: day structure. CLINICIAN: But what does it mean to you? CLIENT: I don’t know, I guess a place to go. CLINICIAN: Yeah, that’s what I think people mean when they say “day structure.” I

mean, it’s more than just structure, right? People can structure their day watching TV. When people say “day structure,” I think they mean a place for someone to go during the day where there are other people. Is that what you want? CLIENT: I don’t know. CLINICIAN: We really need to figure this out before we decide whether this is the right

place for you.

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CLIENT: What do you mean? Why can’t I just come? My case manager made the

referral. I’m all set to come. It took a lot for me to get here. CLINICIAN: Well, I do apologize for any miscommunication, but there really is a

problem here. You see, my colleagues and I, we see what we do as more than “structure” and more than a place to go. We’re all rather energetically interested in helping people change their lives. CLIENT: It sounds like the kind of place that might trigger my suicidal thoughts. CLINICIAN: It could. I can’t speak for you, personally, but we have many people

here who have histories of harming themselves. I think we have a good record of helping them. We take things slow. On the other hand, we’re also not just one treatment center among many. We’re unique. We are definitely not “structure” or just some place to go. CLIENT: I didn’t know that. CLINICIAN: To tell you the truth, I would quit if we were that kind of place. To be

“structure” would really mean that, in some ways, I was just sort of a nobody. A cog in a machine, if you know what I mean. I wouldn’t be able to stand that. That’s probably true about most of the staff here. CLIENT: This is weird. I’ve never heard a clinician say such things. It makes me

uncomfortable. CLINICIAN: I’m sorry for that. I don’t want to make you feel uncomfortable. I do

hear that from a lot from people when they first come into the program, however—that we make them somewhat uncomfortable. Why do you think? CLIENT: Well, I don’t know what this is going to be like. I don’t want people expect-

ing a lot from me. That triggers my suicidal thoughts. CLINICIAN: I guess if I were you, that would be the cost and benefit you have to weigh

regarding the program. CLIENT: What do you mean? CLINICIAN: Well, the cost is feeling uncomfortable and perhaps thinking about harm-

ing yourself. The benefit, on the other hand, is being in a place where people really want to help you rebuild your life. I don’t think you can rebuild a life with only structure. You need people around you who are really interested and energized to help you change. Structure is safe. Safety is good. Being around alert and interested people isn’t always safe. But it’s being around such people that usually motivates us to change. See what I mean? CLIENT: Sort of. I guess I’ll give it a try. CLINICIAN: That sounds fair enough. I’m glad to see you want to try us out.

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In the first of the two examples, the intake clinician approaches the client without exposing much of his own personhood. The clinician listens to the client, but does not articulate his own thoughts or inclinations. In this sense, the clinician’s behavior is similar to the behavior exhibited by such professionals as bank tellers, clerks, and cashiers (all professionals that are notably replaceable by automated equipment). This behavior corresponds to the client’s need for passivity. The client is seeking an anonymous, routinized daily structure, and the client pursues this structure while restricting exposing his agency, stating that he is only present at the intake due to the demands of the case manager. Acting conjunctively to the client’s approach, the clinician only tentatively inquires about the client’s wishes and focuses mainly on the case manager’s reason for referral. In the second example, the clinician assertively presents as a person with individual thoughts and inclinations, someone who is inquisitive about the client’s statements. The clinician acts disjunctively to the client’s wish for automation, witnessing the client as a fellow person with his own unique thoughts, inclinations, and inquisitiveness. Immediately, the case manager is out of the picture, and the issue of day structure is interrogated. Because the clinician is present in the interaction as a questioning, thoughtful agent, the conversation is lively—uncomfortable, perhaps, but vivid, meaningful. In the second example, the clinician does not state her views of the client with full candor. To tell the client, “I feel like you’re treating me as if I’m a thing,” or, “I think you’re afraid of taking accountability for your treatment,” would clearly be both insensitive and detrimental to the goal of mutual authorship. Instead of direct and candid statements, the clinician asserts herself in the interaction in a strategic and sensitive manner. To participate in The Game, a clinician must remain intensely considerate of how her autonomy might dampen the client’s willingness to authentically participate in the relationship. The patient careerist finds solace in medicalized interactions precisely because of the intrinsic “it-ification” of such interactions. The clinician denies her client’s wish for the defense of an I-it relationship when she asserts her agency. Indeed, in the moment of interaction, her agency poses a pivotal danger to her client’s sense of security. In pursuit of mutual authorship, a clinician’s behavior is thus constrained by the tension between the clinician’s self-authorship and her respect for how the imposition of this self-authorship might be experienced for the client in a way that causes the client to restrict exposing her own agency. In the act of asserting his agency, the clinician must consistently weigh the effects of this assertion on the client’s ontological security. Accordingly, while many of the clinician’s behaviors may break from the traditional rules

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of orthodox psychotherapies, these behaviors comply with a different rule set—one formed by the inherent tension that the clinician’s agency brings to the relationship. Below, I suggest four strategies for asserting the clinician’s agency that comply with these rules of The Game: (a) Decentering Expertise, (b) The Apology, (c) Strategic Self-Disclosure, and (d) Talking Directly About the Clinician’s Role in the Client’s Current Ambivalence.

DECENTERING EXPERTISE To fend against the threat of the clinician’s agency, a person engaged in a patient career will often either praise the clinician as a well-trained expert or degrade the clinician as ineffective. Both these means towards automated interaction hinge on the presumed expertise of the clinician. Either the clinician is an expert, knowing exactly what to do, or the clinician is failing as an expert, ignorant to the norms and ethics of her profession. To assert her agency, the clinician considers these polarities when she intervenes. The clinician works to decenter narratives of expertise in her encounter with her client, disrupting their force within the relationship. While the patient careerist may attempt to “expertize” or degrade the clinician as a means of petrifying the clinician, the expectation that clinicians in the psychotherapeutic and psychiatric professions hold certain expertise also helps clients of these professions feel some safety in the hands of another who is guided by particular historical and institutional norms and epistemologies. Thus, to combat it-ification, the clinician does not attempt to deny expertise, but to give it a sense of play and flexibility. To do so, the clinician both emphasizes and deemphasizes his expertise, asserting his wisdom and power to help the client change, at times, and acting naive and even incompetent at other times. In the example below, a client meets with her new therapist for their third session. Throughout the session, the therapist vacillates between presenting herself as either highly effective or markedly impotent in helping the client. CLIENT: Last night my suicidal thoughts took over. CLINICIAN: Oh, I’m really sorry to hear that. CLIENT: Those thoughts take over sometimes and I can’t stop them. CLINICIAN: That sounds awful. I’ve met a lot of people who have these kinds of

thoughts, but I don’t really know a lot about that problem. CLIENT: What do you mean? CLINICIAN: Well, I’m really highly trained in understanding what might lead to a

person making the choice to harm himself or herself, but not in the area of uncontrollable thoughts.

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CLIENT: But my last therapist talked to me all the time about that stuff. CLINICIAN: Yes, I know. From what I understand, it looks like much of your therapy

with her was focused on these uncontrollable thoughts. CLIENT: She made this plan with my residential program, my psychiatrist and the

crisis team that I signed. She put together a weekly case conference to make sure everybody was following it. That’s what kept me safe. CLINICIAN: Oh, I know. I saw it. It was very elaborate and thorough. It must have

taken a lot of thought and time to develop. I don’t know if I could ever write a safety plan that thorough. Well, to tell you the truth, I’ve never really written that kind of safety plan. CLIENT: What!? CLINICIAN: Yes, I’ve been doing this work for about 20 years, and I’ve never written

one. I definitely know what to do when a client is in danger. I use a basic formula for such situations, write up my own plans and communicate with other providers about those plans. But I’ve just never had the chance to write one of these elaborate safety plans. Many of them, like your own previous one, are really a marvel. They are so complex and thought out. It takes a certain kind of clinician and a certain kind of training to be able to write one of those. CLIENT: But you took me on as a client knowing that I had a problem with harming

myself. CLINICIAN: Oh, don’t get me wrong, I’m very experienced in issues of suicidality,

self-harm, and safety. If I may say so, my colleagues consider me quite proficient in these areas. Indeed, they often come to me for advice on their most difficult cases. CLIENT: But you just said you’re not well trained in that area. CLINICIAN: I’m sorry, no—I said I wasn’t trained in the area of uncontrollable sui-

cidal thoughts or the area of elaborate safety planning. That’s almost a specialty of its own, of which I do not have much expertise. I’m very well respected among my colleagues, however, for my work helping people rebuild their lives, and I’m very good at helping my clients think through how to have better lives, ones in which they no longer consider harming themselves. That’s what I’m trained in. I consider myself an expert in that area. CLIENT: But my suicidal thoughts take me over. CLINICIAN: I know. And if you want treatment for thoughts you can’t control, we really

should work together to find someone for you who has expertise in that area. CLIENT: Do you think I need that kind of treatment? CLINICIAN: That’s a good question. But, again, I don’t think I have the expertise to

figure that sort of thing out. What do you think?

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CLIENT: Well, I definitely don’t want to go looking for a therapist again. I guess I’ll

just have to stay with you. CLINICIAN: Really? This is your life we’re talking about. You really want to make

sure you’re making the right decision in who you see for therapy. To put it somewhat crassly, you don’t want to go to an ear, nose, and throat doctor with a heart problem. CLIENT: I guess I could give this a try. CLINICIAN: I strongly recommend you take some time to consider what you want

from therapy. Take the right road here. Don’t jump into something that doesn’t really meet your needs. This is serious business we’re embarking on. Make sure you’re taking the right path. The goals of interventions intended to decenter expectations regarding expertise are threefold. First, by either degrading her abilities to enact change or by dramatically upgrading these abilities to the status of individual talent, the clinician attempts to disrupt the client’s perception that her powers are netted to the common denominator of institutional expertise. She thus decouples the client’s expectations regarding her effectiveness from an automated vision of expertise in which the clinician is seen as the bearer of objective knowledge and steers these expectations to the clinician’s own agency, as a person who has integrated knowledge, training, and experience through her own personality and worldview. Second, the therapist attempts to steer the content of the interaction itself. Asserting that she is proficient in some areas of therapeutic practice while deficient in others, she subtly informs the client that the client will likely find their interaction dissatisfying if she seeks interactions with the clinician that do not match the clinician’s specialty (i.e., “You don’t want to go to an ear, nose and throat doctor with a heart problem.”). Her intention, however, is not to simply define her specialty, but to offer this specialty as a site of potential hope. This is the third goal of interventions aimed to decenter expectations regarding the clinician’s expertise. The assertion that, while the clinician does not judge the client’s behavior, she is—as an active agent herself—most eager to engage with the client on issues related to recovery rather than stagnation. No other defense deployed by the patient careerist is as intricately entwined with medical culture as is the expertization of the clinician. It is as much a means some ontologically insecure individuals use to petrify interactions, as it is an elemental narrative or thematic component of medical culture, and thus an influential element in most clinical interactions. Clinicians must decenter this expectation in order to reach a more interpersonal, hermeneutical, and flexible relationship with their clients.

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THE APOLOGY Typically, clinicians resist apologizing to their clients, except for obvious or grievous mistakes. Apologizing to a client breaks from the more routinizing norms of medical culture. It potentially shifts the clinician/client power relationship in favor of the client, turning the gaze of therapy towards the clinician. It also implies that the clinician is liable for a mistake, leaving the clinician vulnerable to both subtle and more dramatic blame from the client. Precisely for these reasons, apologies are a remarkably simple yet potent means for a clinician to infuse the therapeutic environment with her own agency. As long as it comes from a place of confidence and not guilt or insecurity, an apology from a clinician to a client sends the vitally important message that “we are only human.” It helps frame therapy as a coauthored process in which each actor is making imprecise attempts to reach each other. One means of apologizing is similar to the previous example regarding the decentering of expertise. The therapist, here, comments on her own expertise and naïveté in order to subtly articulate her expectations for treatment. To illustrate, in the example below, a client tells her therapist she is feeling the urge to cut. This is their sixth session, and the client has raised the issue of her suicidality in most of her previous sessions: CLINICIAN: You know, you’ve come to me a few times with this issue of cutting, and

you seem to really want to engage with me on this issue. I’m concerned that my responses to you have been a little unsatisfying. I’m just now realizing that I might not have fully articulated to you that I do a certain type of therapy. CLIENT: What do you mean? CLINICIAN: Remember when we met at your intake and we discussed all the ways

you wanted to change your life? CLIENT: Yeah, I remember. CLINICIAN: Well, the therapy I do is much more focused on all those goals than

on the symptoms you came in with—your uncontrollable thoughts to harm yourself. This is a therapy that is really based on focusing on how to make your life more fulfilling and meaningful. Much of the work in this kind of therapy is aimed towards those sorts of positive issues, not towards your behavior when you want to hurt yourself. I have to admit that I’ve been coming in here really eager and focused on working with you on these issues, not the urges. CLIENT: Yeah, I’ve noticed that. You don’t want to talk to me about how it feels when

the urges to cut take over.

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CLINICIAN: There are a lot of other therapists who do work focused on self-harm, so

I can see why you’ve come in here thinking that we should do the same. That kind of therapy, however, is not my specialty. If I haven’t articulated this to you fully, I’m truly sorry that we are now at a sort of crossroads in which you’re expecting a certain response from me while I’m approaching our meetings from a different direction. Using an apology to reframe the purpose of therapeutic interactions, a therapist must be careful not to empathically fail his client by censuring discussions regarding self-harm or by shaming the client regarding his failure to understand the nature of their particular therapy. On the other hand, if the apology is stated from a true sense of eagerness and excitement regarding issues of fulfillment and meaning, the clinician offers the chance for the client to experience the clinician as someone truly interested in helping the client escape from her painful existential context. Another form of apology more directly addresses this context by deciphering the client’s struggle over the paradoxes of change in the client’s actions. Here, the therapist apologizes for any action she has made that may have acutely threatened her client’s patient career. The following quote is an example of such an apology. CLINICIAN: You know, you’re here today saying you want to hurt yourself, but yester-

day you were so up and excited about all the changes you’re making. I got really excited yesterday, too. I sang your praises and even talked directly about future positive steps you could take, considering how well you’re doing. I’m now wondering if my focus on the future, and even my general enthusiasm and praise didn’t bother you. I got wrapped up in the whole excitement and neglected to recognize that you might have wanted to talk about these changes without immediately addressing more expectations. If I were in your shoes, I would have wanted to just rest on my laurels—and I mean really rest; just talk about your achievement without the pressure for more—rather than engage in a conversation about what’s next. Instead of allowing you to do so, I just pressed ahead. I’m sorry if my behavior caused you any anxiety. In this apology, the therapist is reaching out to her client, openly recognizing the way in which she failed to appreciate the client’s struggle regarding change. She is also using the apology as a gesture in service of interpretation about change. She is interpreting that the client’s current selfdestructive behavior is a response to the threats of higher expectations that come with change. The clinician thus steers the conversation away from behaviors the client is using to assert her patienthood towards a discussion

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about the dialectics of change. As delineated in more detail when I discuss the importance of addressing the role of the clinician in the client’s current ambivalence, the clinician places herself within this dialectic. By apologizing for how her high expectations may have felt disruptive to her client, she addresses the very dialectical tension of change in which her client finds herself trapped. As with most of the interventions I suggest, apologizing to a client is both an authentic gesture and a strategy (aimed towards a coauthored environment) that is deployed thoughtfully. Clearly, a clinician should not apologize whenever the clinician senses she has made a mistake. Instead, the clinician deploys apologies as a means to both disrupt automated processes in the relationship when she witnesses them emerging and to steer the relationship towards issues of change and recovery.

STRATEGIC SELF-DISCLOSURE Linehan (1993a) suggests that the self-disclosure of the clinician in the service of therapeutic strategy is effective in work with BPD. Self-disclosure also makes sense when we view these individuals as engaged in patient careers. By disclosing his own struggles, the clinician helps loosen the client’s fixation on the clinician as an expert and universalizes the client’s problems as human issues rather than solely matters of illness. Two rather obvious tenets apply to strategic self-disclosure. First, disclosures should address struggles, not successes. Clearly, a therapist telling a client, “I’ve tried this technique and it’s really worked for me,” sets the stage for comparison and envy. Second, a therapist should not identify too closely with the client’s problems. Telling a client that “I’ve been in your position before and I know exactly how you feel,” is empathically insensitive, diminishing the client’s pain and unrealistically placing the client and therapist in similar psychosocial contexts. Strategic self-disclosures should aim towards general comments about universal struggles, and they should come in the form of interpretation. For example: “I’ve wanted to change things in my own life, but found myself resisting doing so because I just keep disappointing myself in that area. I find this struggle over wanting to change yet not really wanting to be disappointed very frustrating.” Like decentering expertise or apologizing, self-disclosure should be used sparingly and purposely. While working with individuals engaged in patient careers, clinicians should use self-disclosure to specifically address issues related to struggles regarding change. The goal is to steer the interaction to such issues and away from issues of illness or damage.

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While a therapist may choose to self-disclose information about her own struggles in any number of situations relating to the dialectics of change, one particular opportunity for such disclosures repetitively arises in work with patient careerists. This is the opportunity to discuss the general topic of existential aloneness. Below is an example of a clinician disclosing information about herself as a means of endorsing existential aloneness as an inevitable fact of human experience. CLIENT: So I started work yesterday, but I’m not feeling any better. As a matter of

fact, in some ways, I feel worse. I can just tell that people aren’t treating me the same. They’re acting like I don’t have any problems anymore and they’re paying more attention to other people. I mean, it’s not like everything changed just because I got a job. CLINICIAN: You’re probably right about that. I can see how people might be treating

you as if you are more independent. CLIENT: So what’s the use, then? I mean, I finally get a job and then there’s no real

reward. I thought it was bad before with people never really understanding me. Now, forget it. Who’s going to get me now? Nobody’s noticing that I’m still sick. CLINICIAN: Isn’t that just the worst dilemma? CLIENT: What? CLINICIAN: That fact—the fact that you really want to make your life more complete,

but the more you aim for greater fulfillment, the more alone you become. CLIENT: I hate it. CLINICIAN: So do I. I see this in my own life. As I do better, I lose a bit of the chance

that people will witness my pain. On the other hand, if I don’t do better, well, I don’t do better. CLIENT: This is something you’ve had to deal with? CLINICIAN: You said “had to deal with.” It’s not something I only dealt with in the

past, it’s something I deal with now, in the present, and will likely deal with in the future. CLIENT: Well, how do you work around this problem, then? CLINICIAN: I don’t know if I’ve figured that out yet. What I am sure of is that the wish

to have people fully understand you is something that will never be achieved. It’s simply impossible. We’re all really separate and alone, and the more we improve our lives, the more we face that fact.

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ADDRESSING THE ROLE OF THE CLINICIAN IN THE CLIENT’S CURRENT AMBIVALENCE A person engaged in a patient career conducts many maneuvers aimed to modulate the expectations of others around him. Indeed, a patient career is sustained through this modulation, and when the consonance is severed between the careerist’s desire for a particular level of expectation from others and their actual (or perceived) expectations, the patient careerist experiences his career as threatened. A prime target for the careerist’s modulation of expectations, a clinician can use his own experiences as this target to interpret the client’s current predicament. Like the psychoanalytic concepts of projective identification and enactment generated from object relations theory, the client’s behavior towards the clinician, and the clinician’s own experience as an object of this behavior, are rich, informative material for interpretation. With an eye for the it-ification of the clinician, the client’s sensitivities towards shame and the stifling effects of the clinical gaze, I suggest that these interpretations are articulated through strategic self-disclosure rather than as the perceptions of an objective observer. Below is an example of such an interpretation: CLINICIAN: I can really see how my excitement yesterday about your achievements

affected you negatively. It makes a lot of sense. My problem is that I don’t know if I can hold myself back from getting excited about your positive changes. So, I’m honestly sort of trapped. On the one hand, I don’t want to scare you with my enthusiasm. On the other hand, I’m not sure I can restrain this enthusiasm when I see you acting in a way that improves your life. Hope, for anyone, is a terrifying thing. And for you, I can see how it is really terrifying. I don’t want to raise that terror, but I also don’t know how to do therapy without hope. This is a real dilemma, and I’m not sure I know the way out. I’m truly confused regarding what I should do. Like interpreting projective identifications or enactments in object relations approaching, clinicians working with individuals engaged in patient careers use their own context in the therapeutic relationship to understand the internal struggle of their clients. By addressing how the relationship affects them, they offer a potent portrait of this struggle. In this light, their enunciation of their experience with their client is a paraphrase of the client’s own experience. This is a particularly cinematic type of interpretation, in the sense that the client is able to best witness her own internally concealed struggle when it can be watched by her, projected in the light of externality.

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A person engaged in a patient career is not set within this career, facing the future with a linear vision of what lays ahead. To the contrary, the patient careerist is someone enwrapped in ambivalence, always modulating between his wish to be seen as an actual agent in the world, and his terror of being revealed as a failure. By describing how this ambivalence affects the patient careerist, a clinician helps the patient careerist begin to view his behavior as a series of choices informed by his ambivalent feelings about his authorship in the world. In the next chapter, I describe ambivalence as the central hindrance to personal change. I then delineate a series of interventions aimed to help individuals transcend the trap of ambivalence and attempt to change.

CHA PTER 8

Motivation and Change Focus on Metanarratives of Change and the Dialectics of Change as a Source of Interpretation 129 Emphatically and Empathetically Support Language of Change 132 A Motivational Interviewing Stance 136

Dealing With Resistance Simple Reflection Amplified Reflection Therapeutic Paradox

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In all the interventions described previously, the encompassing goal is to facilitate an environment in which present-time authored interactions flow. The theme of the content in these examples is also similar—that of change and the dialectical struggle over change. This particular content, resting within the process of authored interaction, is the cognitive or narrative goal in The Game. Whether the clinician is modulating her eagerness, apologizing for high expectations, showing interest in the client’s unique attributes, or disclosing information about herself, the clinician in The Game seeks discussions with the client in which the dialectics of change are always present, while simultaneously avoiding the polluting effect of high expectations on an authored environment. The clinician is not necessarily oriented towards discussing change in the future, but towards interpretations and insight regarding how the particular dialectics of change affect the client in the present. In this chapter, I describe specific strategies aimed at helping motivate the client towards change. First, I describe strategies based on a theory of patient careerism and the dialectics of failure and change. I then introduce interventions influenced by a form of treatment for substance abuse called motivational interviewing, that often work well with people engaged in patient careers.

FOCUS ON METANARRATIVES OF CHANGE AND THE DIALECTICS OF CHANGE AS A SOURCE OF INTERPRETATION No interpretive therapy is purely generic, as if the therapist offers insights simply on a whim without theoretical base. All such therapies originate from 129

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their specific mother culture of meaning. Thus, a therapist trained in trauma treatment and a therapist trained in work with BPD will likely interpret the behavior and words of the same client differently. These different interpretations influence the meaning of the therapy itself. Therapy is partially a process of coconstruction, and every therapist brings his own specific epistemological lens to this construction. In The Game, this lens is intentionally and assertively focused on the dialectics of change. Whether working with his client for a long duration or simply seeing the client briefly, through interpretation, the clinician attempts to steer the themes of his interactions with the client to the dialectics of change. Below are two examples of different interpretations of a client’s behavior. In the first example, the therapist’s epistemological lens is formed by training in DBT. Here, the therapist is seeking the biopsychosocial sites of distress affecting the client and the skills the client employs to tolerate this distress. In the second example, the therapist is seeking a discussion regarding the dialectics of change. DISTRESS TOLERANCE APPROACH CLIENT: I cut myself after group last night. CLINICIAN: You must have been in a very painful place. Did you try using your

distress tolerance skills? CLIENT: Yeah, but the urge to cut was just so strong. CLINICIAN: When was this group? CLIENT: At six. CLINICIAN: Did you eat before group? CLIENT: No, I forgot again. And I was hungry. CLINICIAN: As we have seen before, that’s often a trigger for your self-destructive

behavior. CLIENT: Yes, you’re right, and now that I think about it, I was just so irritable in the

group. And I couldn’t handle it. When I went home I felt more irritable than hungry and I forgot to eat again. CLINICIAN: I bet it was hard for you to concentrate on your skills. CLIENT: Yes it was. It was impossible. I couldn’t think straight. CLINICIAN: Can we come up with a plan to make sure you remember to eat before

group? CLIENT: I think that would be a good idea. CLINICIAN: Maybe we should also look at some other distress tolerance skills that

you might find more helpful. CLIENT: OK.

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CHANGE APPROACH CLIENT: I cut myself after group last night. CLINICIAN: Things must have been very difficult for you last night. Did something

happen in group? CLIENT: No. It was a good group. It was a very good group. I didn’t get upset in

group. The group was definitely not the problem. CLINICIAN: What did you talk about? CLIENT: Well, to tell you the truth, that’s what makes me feel so ashamed about my

cutting last night. The group talked a lot about how well I’ve been doing. One member even said I inspired her. Isn’t that crazy? Then the urge comes up to harm myself, and I sabotage everything. All that work to get better and I ruin it. Here are all these people supporting me, and I blow it. Now I’m back to square one. It’s useless to even try again. CLINICIAN: Maybe the group did have something to do with your behavior. CLIENT: What do you mean? CLINICIAN: Well, my guess is that while it feels good to get all this positive feedback,

it might not quite fit with how you feel about your progress. CLIENT: Yeah, that’s for sure. CLINICIAN: And so it feels both good to get it, but also feels like people aren’t getting

how bad you feel. CLIENT: Yes. That is how it felt last night. CLINICIAN: Also, support like that is a double-edged sword in another way, too. If

you feel like people are seeing you do well, then you also have to deal with the fact that they may expect you to do as well tomorrow, and the next day, and so on and so forth. You have to deal with the very real fact that the bar has been raised and that if you don’t do well, they’ll see you fall from that raised bar of expectations. CLIENT: I think that is what happened last night. And then I was so chicken about

their expectations, I went and blew it. CLINICIAN: Well, you could say you blew it or you could accept that you did a very

human thing. You got scared about expectations and you tried to lower those expectations in order to feel a little more safe. I know that in my own life I find myself struggling over raised expectations, and while I don’t harm myself to fend against the fear of these expectations, I do find myself tempted to do things that might lower them. Sometimes I just can’t stand it when people think of me as competent.

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CLIENT: Really? CLINICIAN: Yeah, really.

In the first example, the clinician focuses on the client as someone struggling with a unique symptom (distress intolerance) which she suffers due to her particular disease (BPD). Here, the clinician understands that the client is doing the best she can considering her immanent psychic defect. She coaches the client on skills to manage this defect. In the second example, the clinician accepts the client’s behavior precisely because she understands it as emerging from very normal human dilemmas regarding the modulation of the expectations of others (named in the 10 Reasons Not to Change as Destroying the Negatives and Raising the Expectations of Others). She interprets the client’s behavior as the outcome of a logical choice, considering particular challenges regarding expectations faced by someone who sees her life as defined by failure. Therapy for individuals engaged in patient careers should be a therapy about change. Change and the struggle over change, more than the menagerie of symptoms associated with BPD, is their defining dilemma. Thus, clinicians who wish to help such clients seek and nurture those moments when their clients address the dialectics of change. While they offer themselves as a source of authenticity and flexibility and remain a source of unconditional positive regard, their highest relational energies are somewhat contingent on the topic of change.

EMPHATICALLY AND EMPATHETICALLY SUPPORT LANGUAGE OF CHANGE The issue of tuning the clinician’s response to the particular topic of change has already been addressed. However, considering its importance in the goal of targeting change as the topic of treatment, it is worth further consideration. Again, this tuning is not necessarily an intended manipulation by the clinician, but the outcome of a particular vision guided by a specific epistemological lens that sees the issue of change where others might see something completely different. For a client who has endured an extensive history in the mental health system, the responses from a clinician attuned to change can present as startlingly unique. In the following example, a client presents to a psychiatric intake worker at a local ER. In the example, I offer commentary regarding the metamessage underlying the client’s words, the kind of responses she expects

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from experience, and the intended response of the clinician who is focusing on change. CLIENT: I feel unsafe. METAMESSAGE: I am at risk and want you to be concerned about my physical

safety. EXPECTED RESPONSE: Are you planning on harming yourself? CLINICIAN: I can’t think of anything worse than feeling like things are unsafe. INTENT OF RESPONSE: I think you are in a state of acute ontological insecurity. I am

not presently guided by liability concerns, but rather by my understanding of you as a person in turmoil about something in your life that doesn’t feel safe. CLIENT: I didn’t say, “Things are unsafe.” I said, “I feel unsafe.” I’m unsafe right

now. METAMESSAGE: I’m at risk. You need to do something. EXPECTED RESPONSE: Can you contract for safety? Can we check on you through

the night? CLINICIAN: I’m sorry. I think I’m missing something here. I hear you saying that you

are unsafe, and I feel quite touched by the fact that you’re in that awful state. I really want to find a way to help you out of it, but somehow my language isn’t conveying that. INTENT OF RESPONSE: Saying you’re unsafe instead of overtly stating that you’re

going to harm yourself, you want me to initiate a conversation geared by liability concerns and issues of suicidality. I am not going to take the bait. Doing so it-ifies both me and you. Instead of seeing you as a thing I need to mend, I hear in your statement a truly honest utterance of your current ontological state. CLIENT: That’s because there is no way “out of it.” You’re acting like this is just

something I should get over instead of truly being unsafe. METAMESSAGE: You need to put me in the hospital. EXPECTED RESPONSE: Maybe we should start working on getting you into the hos-

pital. CLINICIAN: I’m sorry if that’s what you heard. What I meant to express to you is how

I think I can understand your current anguish. Feeling that sense of unsafety about life is just terrifying. It’s horrible. OF RESPONSE: You want a way out of this awful cycle of bad faith, and when you talk about safety, there is a part of you that wants to have a

INTENT

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discussion about the anxiety over change. When they hear the word safety, clinicians typically don’t pick up that meaning and instead focus on liability concerns. I want to focus on the deeper meaning of safety and see if we can talk about your existential circumstances. CLIENT: What you’re not getting here is that I want to hurt myself. That’s what I

mean when I say I feel unsafe. METAMESSAGE: I’m not taking your bait either. EXPECTED RESPONSE: I’ll get you on to the unit. CLINICIAN: Oh. I’m sorry I missed that. That’s serious. I guess there’s no reason to

keep talking. I’ll see what I can do about getting you on the unit. OF RESPONSE: You, rather than I, have chosen to have a conversation steered by liability concerns. You have made a choice and taken a stand. The only way I can presently respond to such concerns is to take a conservative stance towards your safety and have you hospitalized. I hope, however, that in the future, we might be able to have a conversation steered by existential concerns.

INTENT

While in the example above, the final behavior of the clinician mirrors the expected response of the client (i.e., offering access to the hospital), the content of the conversation is markedly different than one based on liability concerns (or, for that matter, different therapeutic approaches). The clinician here attempts to assertively steer the frame of meaning of the interaction to one based on a conversation about change. Empathetically and emphatically focused on issues of change, she does not fully achieve this frame. However, by taking this stance and by taking it repetitively over time, she sets the stage for authored interactions. Convinced that there is a part of the client wanting this sort of interactions, she speaks to that part, coaxing it out, piquing its interest for the next time they meet. In the example above, the metamessages between client and clinician form a sort of meta-argument, filled with dissonant innuendos from two apposing camps. Many discussions, steered by the clinician’s empathy regarding the struggle of change, are much more harmonious. Often the client is ready to have such discussions but has never been offered the forum to engage in one. In the following example, a well-educated client, who once enjoyed a successful career but lost this career due to multiple hospitalizations, considers accepting an entry-level job. CLIENT: I worked so hard to get that job, but then at the final interview, it’s basically

some kid interviewing me. It was shameful. There’s no way I can take that job.

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CLINICIAN: That had to be just awful. CLIENT: It was. I couldn’t stand it. CLINICIAN: Now you’re stuck. CLIENT: Yep, and it’s hopeless. CLINICIAN: I can really see how it must feel that way. Here you are, willing to try again

and begin the first steps of reentering your career. You’re finally there, willing to go. But to reenter your career means to partly begin again, and to begin again means to face that regaining your career is going to take some incremental steps. CLIENT: That’s right, that’s the trap. But, more than simply taking those steps, yes-

terday felt like I was looking in the mirror and hating what I see. What happened to my life that I would be sitting there yesterday talking to some kid? My God, what the hell happened to my life? CLINICIAN: Oh, that really is awful, terrible. I see why it was so hard. And that makes

it seem even more like a trap. You’re stuck in the place in which any movement to regain your life is a reminder that you don’t like the way your life is now. CLIENT: Yes, I hate my life, and yesterday only made me hate it more. Yesterday felt

like I was sitting in the shit of my life. CLINICIAN: That is one of the worst feelings, that sense of disgust and shame in one’s

self. It’s unbearable. CLIENT: Yes. It is. CLINICIAN: And I know there is a part of you that desperately wants out from under

those feelings and wants a life that feels good. CLIENT: You know it. CLINICIAN: But there’s no way to get to that better life without changing this one. CLIENT: And to change this one might mean that I have to work for some pimpled

faced kid. Crap. That really is hard to do. I’m telling you, it just kills me. CLINICIAN: I know, I can really see how difficult this is. Like I said, it’s a trap. I

mean, it’s a trap you can definitely get out of, but to get out of it means bearing some awfully unbearable feelings. CLIENT: But avoiding these feelings is what keeps me here, isn’t it? CLINICIAN: Yeah, I think so. At least partly. What do you think? CLIENT: I’m telling you. After that interview, I’m sure it’s not partly, it’s the whole

thing. It’s what’s holding me back. The conversation above is subtly steered by the clinician’s focus on the dialectics of change. Seeing the client through an epistemological lens influenced

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by theories regarding patient careerism, she is able to help him understand his predicament as an existential one, guided by issues of choice, authorship, and the angst intrinsically entwined with existential accountability. By approaching the client as a choosing actor, trapped within his own understandable ambivalence, the clinician is able to genuinely offer unconditional positive regard to the client while motivating him to move forward. This balance between unconditional positive regard and motivation is currently captured artfully in motivational interviewing. Below I describe how a motivational interviewing approach can be used effectively with people engaged in patient careers.

A MOTIVATIONAL INTERVIEWING STANCE Individuals labeled as BPD are generally defined by clinicians as manipulative. Linehan (1993a, 1993b) resists this rather pejorative vision, describing such individuals as actually poor self advocates. In her interpretation, such individuals do not seek to manipulate others, but have not learned the appropriate skills to advocate for their needs. A theory of patient careerism, on the other hand, sees parasuicidal behavior as an act of efficient self-advocacy and unadulterated manipulation. Patient careerists are highly skilled self-advocates, who deftly manipulate large systems in order to meet their existential needs. Through their parasuicidality they effectively advocate for a life defined by bad faith narratives. Attaining this goal likely leads to a painfully false existence, filled with shame and the sense of totalizing failure. Yet, in regards to the patient careerist’s ability to advocate for a specific goal, the level of skilled manipulation required to attain this goal, and the quality of life this goal affords are independent of one another. They are as independent of one another as the highly developed social skills substance abusers use to attain illegal drugs and the negative, possibly life-threatening effects of these drugs. While at first glance subtle, the difference between Linehan’s vision and my own can easily be understood as existing in the often competing camps of behaviorism and psychoanalysis. Where Linehan sees a dysfunctional behavior, I see an existential tension beneath the behavior. For me, the specific tension parasuicidal individuals endure defies a pathogenic vision, for it is a tension inherent in the human condition: the tension between authorship and the wish to avoid the angst that authorship brings. If the better life is one filled with a sense of purpose, authorship, and meaning, then parasuicidality and patient careerism are truly dysfunctional. But, as I have discussed before, so are such normal dysfunctions as, for example, conformity, consumerism, and rapacious ambition.

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A motivational interviewing approach (Miller & Rollnick, 1991) provides a therapeutic context in which clinician and client can discuss the attractiveness of parasuicidality devoid of the impediments of shame and guilt. A counselor engaged in motivational interviewing views someone who misuses substances as experiencing varying degrees of ambivalence toward this use. For such an individual, there are pros (escaping from life problems, a social network, an identity, fun, recreation, etc.) and cons (possible loss of work, hangovers, other more serious physical problems, loss of intimate relationships, etc.) to misusing substances, just as there are pros (more stable life, greater physical health, better intimate relationships, etc.) and cons (facing psychological pain and anxiety, losing a social network of friends, less fun, less immediate possibility of recreational activities, etc.) to sobriety. A person misusing substances ambivalently looks out at her possible sobriety and struggles over these pros and cons. The concept of denial is an historical mainstay of most substance abuse treatment and theory. It is based on a belief that, because a substance abuser is doing something so clearly illogical, the abuser must be doing so because he denies he has a problem. Accepting the logic of use, motivational interviewers take a radically different approach. They believe that when a person is confronted by others as doing something deviant by using substances, the abuser will likely act defensively, knowing the things he likes about using, but unable to articulate these in an environment that likely rejects the positive attributes he associates with use as merely deviant. In such circumstances, an individual is likely to deny his misuse rather than enter a conversation that inherently defines his behavior as bad and the abuser’s actual attraction to such behavior as even worse. By denying he has a problem, the abuser inadvertently participates in the coconstruction of a tautology based on the disease model regarding his drinking, for the abuser has offered up the first evidence of the depths of his problem: the abuser, like all other substance abusers, is in denial. A motivational interviewing approach avoids this pitfall by accepting that the persons misusing substances are making choices, and that the choice to use is logical. When a counselor or clinician takes this approach, the clinician contributes to a therapeutic environment that allows a person who uses substances to discuss openly both the negative and positive attributes of using. Able to openly discuss his options without fear of reprimand, the person brings previously hidden attitudes regarding using substances into the light of shared, objective experiences, which is more organizing and feels more separate from the individual than the muck of subjective experience. When a person engages in motivation interviewing, all the cards are on the table, and the allure of substance misuse potentially loses some of its magic—once the attractive aspects of inebriation are brought fully into consciousness, they become merely choices situated among multiple other choices.

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Motivational interviewing is based on a few key beliefs similar to ones elemental to work with patient careerists. Just as I have emphasized the importance of particular attitudes and theoretical perspective over mere technique, Miller and Rollnick (1995), the originators of motivational interviewing, warn that “clinicians and trainers who become too focused on matters of technique can lose sight of the spirit and style that are central to the approach” (p. xx). Miller and Rollnick describe seven characteristics of the spirit of motivational interviewing. Six of these characteristics obviously parallel my point of view regarding The Game. They are: 1. “The therapeutic relationship is more like a partnership or companionship than expert/recipient roles” (p. 327). 2. “The therapist respects the client’s autonomy and freedom of choice (and consequences) regarding his or her own behaviour” (p. 327). 3. “Motivation to change is elicited from the client, and not imposed from without” (p. 327). 4. “Direct persuasion is not an effective method for resolving ambivalence” (p. 327). 5. “Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction” (p. 327). 6. “It is the client’s task, not the counsellor’s, to articulate and resolve his or her ambivalence” (p. 327). 7. “The counsellor is directive in helping the client to examine and resolve ambivalence” (p. 327). Clearly, motivational interviewing and The Game have much in common. Both approach the client as a choosing agent, who is making logical choices and doing the best she can. Both focus on ambivalence rather than deviant behavior. Accordingly, both theories also view the clinician as someone focused on ambivalence as a topic and on providing an environment in which the client may choose to change. This stance is opposed to ones in which the clinician intervenes on symptoms or directly confronts the client. One very important characteristic marks a difference between motivational interviewing and The Game. Believing strongly in the curative force of unconditional positive regard and the fit of such an attitude to their general view of substance misuse, Miller and Rollnick (1995) recommend that clinicians take a Rogerian approach to their clients. “The counselling style,” they write, “is generally a quiet and eliciting one” (p. 328). The Game involves a much more active and assertive style than a motivational interviewing one. In large part, this is because of the particularly difficult existential context of people engaged in patient careers.

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In regards to patient careerists, the task of facilitating the types of encounters associated with motivational interviewing are daunting. Parasuicidality is marked within the therapeutic professions as either an involuntary symptom of a disease or as a sinful self-centered attempt at gaining attention that misuses valuable and limited social resources. Well entrenched in psychiatric institutions, the patient careerist resists discussing how he finds such behavior attractive because the patient careerist accurately believes that his utterances will be interpreted by others as either the sign that he is deviating from his role as someone suffering an illness (as Parsons [1951] describes, medical patients are obliged to define their sickness as undesirable) or, more likely, that the patient careerist, like a repentant welfare cheat or con artist, has revealed that his behavior, all along, was merely a scam. For a patient careerist operating in traditional clinical milieus, admitting that he deploys parasuicidal behavior for the purpose of gaining social goods simultaneously means relinquishing these behaviors, for once the patient careerist deviates from the illness role and admits the intent of his behavior, the patient careerist feels as if the jig is up. He is starkly revealed to others as an authored, intentional social actor, one who could be interpreted by others as making irresponsible and selfish choices. Accordingly, for patient careerists, a frank and open conversation about both the costs and benefits of their career-generating behavior is difficult to attain. To enter a motivational interviewing stance with individuals engaged in patient careers, the clinician must be able to find the means to openly discuss the intent of parasuicidality, often introducing this intent herself. While the risk of such a discussion is that the client will feel judged for her behavior, this risk is not diminished by avoiding the topic. Indeed, as a theory of motivational interviewing clarifies, when individuals are left to conceal the true reasons for their behavior, they only feel more ashamed about this behavior and less likely to consider changing it. Like many secrets, their hidden attraction to behaviors that others judge as deviant festers within their consciousness and infects other actions. To avoid colluding in this secret, clinicians must first be willing to assert their own opinion regarding its function within a patient career, and second, approach the behavior as logical considering the client’s struggles regarding issues of failure. In other words, like so much else within The Game, clinicians must be more assertive with their clients than in other circumstances. To facilitate The Game, clinicians must simultaneously assert their own agency, raise the issue of patient careerism, respect the fact that the client is ambivalent, and view the client as in charge of his own choices regarding change. Depending on the level of the client’s own contemplation regarding

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his parasuicidality and the depth of his relationship with the clinician, such discussions are held in varying degrees of frankness. Below are two examples of such discussions. In the first example, the client meets with the intake clinician of a hospital. She has met with this clinician on only two other occasions. She typically addresses her suicidality as the result of uncontrollable urges. In the second example, a client meets with her therapist, with whom she has been meeting for over six months. She has held discussions with her therapist regarding the link between her suicidality and her fears regarding change. EXAMPLE #1 CLIENT: I feel the urge to cut. CLINICIAN: It sounds like you’re looking for some time on the unit. CLIENT: No, I just feel that urge. CLINICIAN: But you’re here now, at the hospital. Why did you come here? CLIENT: Because I need help stopping the urge to cut. CLINICIAN: And how can we help you with that? I’m not sure I know of anyone on

shift right now who really knows how to stop those kind of things. CLIENT: But on the unit, you can keep me away from sharp stuff. CLINICIAN: So you’re looking to be monitored closely on the unit. CLIENT: No! God you are frustrating. I just need some time to get myself back to-

gether. I don’t feel the urge as much when I’m on the unit, OK? CLINICIAN: So, if I understand you right, you’re looking for a bit of a break from

things. Something about the unit makes you feel more calm and collected. You get away from everything, and that helps you out. CLIENT: Now you’re making it sound like I’m going on vacation! Just forget it, al-

right! Forget I ever came in. I’ll just go home and cut myself, how’s that? CLINICIAN: Well, that’s always something you can do, but I’m not sure if I under-

stand why I’m upsetting you. Going on the unit is hardly Club Med, so I really didn’t mean to imply that you were looking for some sort of vacation. What I hear from you right now is that something’s going on for you that’s quite distressing, and I’m thinking that using the hospital is one thing you do to find a way to escape this unbearable distress. That makes sense to me. It’s not like you’re doing something wrong by going into the hospital. You’re doing the best you can to hold yourself together. CLIENT: Damn right I am. I’m trying my best, and everyone acts like I’m some sort

of jerk because I want to be hospitalized.

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CLINICIAN: Well, I hope I’m not part of that “everyone.” I’m getting the picture that

what you want and feel you need is some time on the unit. It’s part of your way of functioning. I’m just trying to figure out how we can help you. Do you need monitoring for your cutting? Or are you looking for a bit of a rest from a difficult life? These are two very different things we can offer here, and I’m trying to do my best to get you the right type of service. CLIENT: Well, I definitely don’t need monitoring. I can promise you I won’t cut when

I’m on the unit. CLINICIAN: So you’re looking for some well-deserved break time. CLIENT: Yes, I guess you could say that. Just a break, a time to get my act back

together. CLINICIAN: A time to get away from pressures of expectations? CLIENT: Yes! I can’t stand everybody’s attitude and how they want me to do all this

stuff! CLINICIAN: And the hospital helps you get away from these expectations? CLIENT: Yes, that’s what I need sometimes.

In this example, the clinician actively but subtly manipulates the conversation to focus on struggles regarding expectations, while simultaneously avoiding a conversation steered by mechanical themes (urges outside the client’s control) and liability concerns. She is able to introduce this sensitive topic by approaching the client’s behavior as making sense and acceptable considering her life circumstances. Doing so, she offers the client an opportunity to discuss, briefly, the existential reasons she seeks hospitalizations. Over time, as the client continues to present at the hospital and continues to enter discussion like the one above, she might begin to accept, without the painful hindrance of guilt, that her hospital-seeking behavior is a matter of choice. Once she is able to see this behavior as a choice, she is primed to decide whether she wants to continue with it. EXAMPLE #2 CLIENT: I’m probably going to hurt myself tonight. CLINICIAN: Are you looking to get into the hospital? CLIENT: Yes. I think I need it. CLINICIAN: Why? CLIENT: Because I’m unsafe.

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CLINICIAN: Why do you think? What’s making you feel unsafe? CLIENT: I don’t know, I guess it’s just that it doesn’t seem like anyone’s getting how

bad I feel. CLINICIAN: And that’s making you feel unsafe? CLIENT: Yeah, it’s like, why even try anymore? Nobody gets it anyway. CLINICIAN: That’s an awful feeling. CLIENT: What? CLINICIAN: That sense that people just don’t get how bad you feel. It’s like the worst

kind of loneliness. CLIENT: Yeah, it is. I feel so alone, ’cause nobody seems to see how much pain I’m in. CLINICIAN: People aren’t getting it. CLIENT: That’s right, they aren’t, and I can’t stand that. Everybody’s expecting stuff

from me, as if I can just get up and be fine, put on my smiley face, and just get out there. Well, I can’t. CLINICIAN: Again, I think I’m getting how you feel. Just so alone, because no one is

fully seeing you. CLIENT: That’s right! No one is seeing me. I’m invisible. That’s how it feels. CLINICIAN: Well, hurting yourself, or even just threatening to hurt yourself, is one

way to take care of this feeling, isn’t it? CLIENT: What do you mean? CLINICIAN: I mean, people really respond when you get suicidal. You cut yourself

or threaten to cut yourself and everybody will be talking about you for a bit, thinking about you more, and trying, somewhat, to figure out why you’re in so much pain. CLIENT: Are you saying I cut to get attention, ’cause that really pisses me off! People

have said that before you know, and that really hurts! CLINICIAN: Said what? That your suicidal behavior is just a way to get attention? CLIENT: Yeah. CLINICIAN: Oh, what a truly mean thing to say to you. I’m not saying that, exactly.

What I am saying is that this feeling that people don’t get how much pain you’re in is just awful. Personally, I think it is one of the most unbearable feelings. It’s not something a person can just sit with for a long period of time. And one way to soothe that feeling a bit is to tell people you’re going to hurt yourself, or to even go ahead and hurt yourself. CLIENT: But why? Why does telling people I’m going to hurt myself get rid of the

feeling?

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CLINICIAN: Well, you’re definitely not alone once you do it, right? I mean, saying

you’re going to hurt yourself sets a whole system of responses in motion. People are talking about you, working to figure out what to do, trying to gain more information from you. Then, they’re putting you in the hospital, checking on you to see how you’re feeling, and so forth. That’s just a fact about how this mental health system works. CLIENT: Yeah, well, I guess I can see that. CLINICIAN: Do you know that I meet once a week with my colleagues here at the

agency? And do you know who we talk about? We talk about those cases that seem risky. We’ve tried again and again to make sure we talk about clients who are doing well, but we always end up talking about the problem cases. It drives me crazy, but we can’t seem to stop doing that. And do you know who I’m going to bring up tomorrow at that meeting? You. So, not only did your threat to harm yourself gain my attention today, but it will still echo tomorrow as others discuss your case. CLIENT: So you are saying that my behavior is all about attention? CLINICIAN: Yeah, well, I guess you’re right. I guess I am saying that. But I also feel

that people need attention and that they especially need attention at those times when they feel they are acutely alone in their pain. CLIENT: You’re confusing me. CLINICIAN: I’m sorry. CLIENT: I can’t tell what your opinion is. I can’t tell if you think I should go into the

hospital or not. CLINICIAN: Well maybe I’m confusing you because I’m a bit confused myself. This

isn’t easy stuff to figure out. Between going to the hospital and staying out, both decisions make their own sense. They’re both valid. Staying out might have longer term and subtle, positive effects on how you feel about yourself. It might be a step towards making your life more fulfilling. But I gotta tell you, I don’t know anyone, including myself, who makes only decisions that they think will produce some vague positive change in the future. Really, if anyone could actually make decisions that always postpone immediate needs in order to reach some positive goal, they’d be like the ultimate Boy Scout. Can you think of anyone more boring? CLIENT: (Laughing) Well, I guess not. CLINICIAN: We all, sometimes, just feel we need to take care of immediate concerns.

And the concerns you’re addressing today are not only immediate, but powerfully painful. On the other hand, you are at a crossroads today. You have a chance here to learn how to sit a bit with your pain, to give yourself the attention you need. You know, we all want that sense that people just understand us

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completely. But that’s really an impossible thing to attain. So, learning how to get that sense in approximates, and to also continue on with life when we can’t get it at all, can help to make your life more livable. In contrast to the client depicted in the first example, the client in the latter example is more engaged in treatment and more contemplative regarding change. Still defended and sensitive to certain observations regarding her behavior, she is able to tolerate a frank discussion in which her behavior is approached as intentional and even socially manipulative. Her therapist, keenly aware of her level of contemplation, risks introducing highly combustible issues to this frank discussion. The clinician guards against this risk by facilitating a nonjudgmental environment through the assertion that the client’s ambivalence makes sense.

Dealing With Resistance We label clients resistant when they argue with a clinician, consistently interrupt him or her, deny a problem, ignore the clinician through inattention, sidetrack the conversation, or simply not answer questions (Chamberlain, Patterson, Reid, Kavanagh, & Forgatch, 1984). Resistance is a central consideration in most therapies. Indeed, if resistance is the pushing back of clinician feedback, then without resistance, therapy would require a simple and rather linear conversation in which the clinician explains to the client the client’s problem and the client reflects on this feedback and changes. Miller and Rollnick (1991) give a rather unique description of resistance. For them, “Client resistance is a therapist problem” (p. 100, italics theirs). They point out that research on the subject of resistance indicates the therapist style is an intrinsic indicator of how much a given client resists engaging in treatment. For them, resistance is behavior that “signals [to] the therapist that the client is not keeping up” (p. 100). For Miller and Rollnick, clients become resistant when “the therapist is using strategies that are inappropriate at the client’s present stage of change. In a way it is the client’s way of saying, ‘wait a minute. I’m not with you’” (p. 100). In this view, resistance, like denial, is partly a treatment created behavior rather than simply resistance to change. This view of resistance obviously fits well with a theory of patient careerism. Indeed, patient careerism is, in many ways, an act of both seeking treatment and resisting much of the feedback of treatment providers. Miller and Rollnick’s suggestions for dealing with resistance are instructive in working with individuals engaged in patient careers. On the following pages, I review three types of responses to resistance that they suggest, each incrementally requiring greater assertiveness on the clinician’s part.

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SIMPLE REFLECTION “One good general strategy is to respond to resistance with nonresistance,” write Miller and Rollnick (1991, p. 102). By simply reflecting on the client’s statements in a nonjudgmental manner, a therapist potentially highlight conflicts and contradiction (the client’s ambivalence, in other words) in these statements. By subtly shifting emphasis, the clinician in a reflective stance is also able to guide the conversation to a focus on ambivalence. Below is an example of simple reflection with a person engaged in a patient career. CLIENT: I can’t go to my sister’s wedding because of my danger to myself. I told my

sister this, and now my family thinks I’m doing it for attention. All of them are mad at me, calling me all the time. CLINICIAN: It sounds like you’re in an awful position here. You have this debilitating

problem that keeps you from engaging in important occasions, and, from what you’re telling me, this problem is also affecting your sister’s wedding. CLIENT: Wait a minute here, why are you laying that on me. I’m not affecting her

wedding. They’re all fine. No one’s affected by whether I come or not. Jesus! CLINICIAN: I’m sorry, I guess I’m confused. You said that all of them are angry with

you and constantly calling you about the wedding. CLIENT: Oh my God! You’re acting like they’re the important ones here! Why are

we talking about how my problems are affecting them? Why don’t you get them in here for a session? CLINICIAN: You seem very angry about attention being placed on them right now. CLIENT: I am. And I’m angry about all the bad attention I’m getting, too. I hate this.

This is going to make me suicidal. CLINICIAN: You’re really stuck in the middle. CLIENT: Yes, and it’s driving me crazy. I can’t stay in the middle of this forever. CLINICIAN: You want to get out of this middle ground and do something. CLIENT: Yes.

AMPLIFIED REFLECTION In the example above, the clinician is able to help the client contemplate her own ambivalence about her sister’s wedding and how her parasuicidal behavior both provides a means to advocate for herself and hinders her relationship with her family. The clinician does so by simply reflecting on

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the client’s statements, attempting to match her reflections evenly with the different emphases given by the client. In some circumstance, Miller and Rollnick suggest that the clinician amplify their reflections to the client, exaggerating what the client has said. I offer an example of amplified reflection below. CLIENT: My brother thinks I can just go and get myself my own apartment. I can’t

do that. I’m too at risk. CLINICIAN: You’re very clear that it’s dangerous for you to live on your own.

From what you’re telling me, your brother’s just wrong—dangerously so, actually. CLIENT: He’s just looking out for my best interest. CLINICIAN: I think you’re telling me that he’s concerned with you, but he has poor

judgment regarding your needs. He wants what’s right for you, but he’s suggesting something that could put you at risk. CLIENT: Well, it’s true that I can’t live on my own. Last time I tried that I almost

killed myself. I think if I lived on my own again I would try to kill myself again. CLINICIAN: You’re clear that you can’t live on your own, that you may end your

life if you do so. In a sense, you’re telling me that living on your own is risky behavior. You’re brother’s pointing you in the wrong direction here. Not that he’s aware of it, but he’s pointing you toward suicide. CLIENT: Well, I don’t know if he’s “pointing me toward suicide.” He’s just expecting

too much of me. CLINICIAN: So much so that you may kill yourself. CLIENT: Yes, well, living on my own does feel very risky. CLINICIAN: From what you’re telling me, you can’t live on your own. CLIENT: You’re making it sound like I will never be able to live on my own. If I have

to keep living in the residential program I’ll just hate my life. CLINICIAN: You are really stuck, aren’t you? You can stay here and be miserable, or

live on your own and possibly end your life. CLIENT: Well, I don’t know if it’s really that extreme. It’s just a real struggle. CLINICIAN: Yes, it sounds like it is, like you’re really betwixt and between on living

on your own. CLIENT: Yes, and I can’t stand being in the middle. I wish my brother never said

anything.

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THERAPEUTIC PARADOX From Victor Frankel’s logotherapy (1984) to Jay Haley’s work (1963), paradoxical interventions are well known within therapeutic arenas as often radical but also effective means for working with clients who present as stuck and resistant to change. In a paradoxical intervention, the clinician prescribes that the client continue with the very behavior the client resists changing. Miller and Rollnick (1991) suggest that therapeutic paradoxes are effective in a motivational interviewing stance. This makes immediate sense, for when a clinician prescribes a behavior that is otherwise perceived by the client and others as deviant, the clinician addresses a part of the client’s ambivalence rarely approached by people in her life. Taking an unconditional stance, the clinician simultaneously reflects on the logic of the client’s behavior while providing an environment in which the client may want to reflect on the benefit of this behavior. Below is an example of a paradoxical response to a parasuicidal client. CLIENT: Why are we talking again about me making choices about my suicidal

thoughts? Don’t you get it? I can’t control these thoughts. That’s what I mean by being triggered, that’s what my other therapists in the past meant when they called it being triggered, and that’s what my psychiatrist means when he talks about me having an impulse problem. You just don’t get it. This is a problem of impulses, not choices. I’m diagnosed as having problems with my impulses. CLINICIAN: I’m sorry if I’m not getting this. Maybe I’ve been going in the wrong

direction. I think you’re telling me that this is a behavior that you’re going to have to live with, right? I’m wondering what it would be like to work around the behavior instead of trying to change it. What if, instead of changing it, we come up with ways to lessen its effect on you and your life. What do you think? CLIENT: I think you’re crazy. CLINICIAN: What do you mean? CLIENT: Well, we’ve got to change this. It could kill me. CLINICIAN: Yes, I understand that. But maybe we could find a way to make it less

dangerous. If it’s not changeable, then the best we can do is find a way to make you as comfortable with it as possible. CLIENT: This isn’t cancer. It’s a behavioral problem. CLINICIAN: Yes, but it’s not something you can change.

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CLIENT: Well, it may take time, but that doesn’t mean it’s terminal.

In The Game, the clinician approaches his client as doing the best the client can and sees seemingly dysfunctional behavior as making sense. Paradoxical interventions specifically articulate this stance in the service of mirroring for clients their behavior and the possible intentions of this behavior. They are an effective way to help people reflect on whether they wish to change this behavior. Like all the interventions that I suggest, the interventions that focus on change, choice, and motivation aim to provide the right psychosocial ingredients that will help a person contemplate change. But unlike most of the interventions suggested in this book, the interventions described in this chapter aim at setting a person in motion, rather than only creating a durable facilitating environment in which a given person may become motivated. They are thus very important interventions in a Game approach. Where most of the other intervention are nutritional in the sense that they offer the nutrients for change, interventions aimed at motivation and change are inciting in that they attempt to spur a person towards change. In Heidegger’s (1962) words described earlier, motivational interventions are a kind of care that leaps ahead. They are the encouraging, stimulating, and even irritating aspects of The Game.

PA RT I I I

Organizational Considerations

No institution can possibly survive if it needs geniuses or supermen to manage it. It must be organized in such a way as to be able to get along under a leadership composed of average human beings. —Peter Drucker (1956) Most clinical interactions with individuals engaged in patient careers occur within institutions. Whether presenting to crisis teams or emergency rooms, residing for periods of time on hospital units, living in residential programs, attending organized day treatments, or meeting with therapists or psychiatrists at community mental health centers, the careers of patient careerists are formed by institutional life. Patient careerists willfully engage with institutions. Their experience of institutional life is thus somewhat different from individuals social scientists would call institutionalized, who have been thrust into institutions against their will. Nonetheless, the behaviors that comprise a patient career are institutionalized behaviors. These behaviors simply would not exist without the influence of medical institutions. Patient careerists exhibit institutionalized behaviors, but so do the clinicians who treat them. And, in many ways, this book is my attempt to help clinicians in the process of their own deinstitutionalization. The intended audience for this book is clinicians, not clients. As I’ve stated, my aim is to change the outlook and behavior of the former group of individuals in service of the latter. In this pursuit, I have offered a demedicalized theory of patient careerism and suggested attitudes and strategies influenced by this theory. The next logical step is to investigate the means to influence the institutions in which clinicians and their clients build their careers. I do so in the next chapter. 149

CHA PTER 9

Deinstitutionalizing Institutions Organizational Responses to Liability 153 Liability Rules 154 Foreseeability and Surveillance 154 Documentation and Supervision 157 Risk Plan 160 Decision Making: The Hourglass 163 Initiation of the Meeting 169 Step One: Data Collection (10 Minutes) 170 Step Two: Brainstorming and Analysis (15 Minutes) 170

Step Three: Multivoting the Meaning of the Behavior (15 Minutes) 171 Step Four: Inventing the Intervention (15 Minutes) 172 Step Five: Multivoting the Intervention (10 Minutes) 173 Keeping It Positive 175 Step One: Data Collection 176 Step Two: Brainstorming and Analysis on the Meaning of the Behavior 177 Step Three: Inventing the Intervention 177

The tragedy of an individual trapped in the dialectics of failure is that the answers to her problems are both right at hand and seemingly impossible to grasp. Of course, in differing degrees, that tragedy strikes everyone. The things we want for ourselves psychologically can appear so simple, yet we are blocked from attaining them by our psychology. This is a tension no one escapes. Indeed, the study of this tension is at the origins of the field of psychology, for why investigate the subjective lives of individuals if not for the fact that people are often obstinately and even bizarrely resistant in the face of obvious solutions? This same tension is elemental to literature and drama. Imagine a novel or a play in which characters acted only on the most appropriate decisions and always followed logical paths to fulfillment. Certainly, the humanity would be stripped from such endeavors, for being human inevitably means struggling with the psychological barriers to reasonable, commonsense goals. Humans are clearly imperfect in their quest towards meaning, fulfillment, and happiness. Organizations are nothing more than structured human activity. It is therefore no surprise that organizations invariably find themselves caught in the tension between the straight and narrow of setting seemingly simple goals and the circuitous and congested path to actually attaining them. That tension comes part and parcel with organizational life. Indeed, 151

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like clinical psychology, there would be little need for applied sociology or for social, organizational, and industrial psychology if not for the fact that people, when organized, often stumble towards or never even achieve their goals. Like the individuals who inhabit them, institutions often require a large amount of energy and attention to achieve a small amount of change. But this seemingly disproportionate amount of effort is often worth it, for (like with individuals) small changes in institutions can have profound effects. In this chapter I suggest such changes, focusing on two particular aspects of psychiatric institutional life that obstruct the ability for clinicians to engage with their clients in a mutually authored manner. These changes are oriented towards influencing (a) the way in which organization respond to liability concerns and (b) the decision-making processes within mental health institutions. In these changes, I seek actionable solutions that organizations can implement presently, rather than revolutionary institutional change. Indeed, if much of this book has focused on creative and often playful ways of approaching clinical interactions, this chapter focuses on much more conservative and structured solutions. Strong enduring structure is not antithetical to play. On the contrary, play and creativity are intrinsically entwined with structure. “You don’t play whatever you feel,” writes jazz musician Branford Marsalis (in Keogh, 1993, p. 38); “[t]he only freedom is in structure.” Describing the elemental interplay between structure and improvisation, which is at the very foundation of jazz music, Marsalis simultaneously articulates the intrinsic tension of play and creativity. Original acts come from enduring, durable environments. As Winnicott wrote (1967), “It is not possible to be original except on the basis of tradition” (p. 99). To support clinicians in the process of helping individuals escape patient careers, institutions must find the means to provide structure from which clinicians can engage in serious play. The Game is a creative, spontaneous process, and clinicians will resist engaging in it if they feel they are risking their own authenticity in unsubstantial environments. The threat to creativity is not simply flimsiness, however. Indeed, whether in family life or in larger organizational endeavors, an enduring sense of limits, structure, and cohesiveness protect individuals from another threat that directly annihilates the potential for creativity—the threat of what Winnicott (1971) described as impingements. This threat is a feature of most psychiatric and mental health institutions. An impingement occurs when an individual’s authentic gesture is appropriated by others or experienced by others in a manner that is not emotionally reflective of its intent. Psychiatric and mental health institutions are typically

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impinging institutions because of the threat of liability. In such institutions, a clinician is always operating under the threat that his or her work will be questioned in a harsh investigative light. Clinical work, on the other hand, is always guesswork, requires on-the-spot decisions, and is not an endeavor easily described or documented. It is not, in other words, easily defendable. This polarity between an organizational culture in which clinicians feel their actions can be impinged upon and a profession based on the nonspecifics of human encounter works against originality.

ORGANIZATIONAL RESPONSES TO LIABILITY The minute a client kills herself is the minute the organizational gaze reserved for patients turns to the clinician. Clinicians know this as they work with their parasuicidal and suicidal clients. As I briefly describe earlier, the clinical gaze, while an epistemological lens assumed by individual clinicians, is also something experienced by people as more anonymous, unidentifiable; it is a medicalized version of a more general sense of surveillance of deviant behavior that courses through modern society. When one is held within such a gaze, especially when one is being looked at for doing something wrong, one feels herself penetrated, exposed, and helpless, as if her social and psychological being is being dissected and studied. The fear of liability is partly the fear of this type of psychological nakedness. Fearful of both the psychological and material results of being exposed and investigated, clinicians working in psychiatric institutions typically operate as if their maneuvers will potentially lead to liability creating incidences. They thus comply therapeutically with the safest seeming norms within these institutions, even when these norms may have little therapeutic viability. To resist an impinging culture, psychiatric and mental health organizations must operate within clear norms regarding liability concerns and offer their employees a shared vision regarding issues of risk. Below, I describe how they can do so. My suggestions, while aimed to provide environments that nurture originality, emerge from traditional research and theory regarding suicidality and liability. The literature and research on suicidality and liability is rich with insights and suggestions that can help free, rather than constrain, clinicians to act creatively with their clients. Indeed, the problem with many psychiatric and mental health institutions is not that they conservatively adhere to the research and theories regarding suicidality and real liability for suicidal clients, but that they do not communicate a strong message about much of this research and theory.

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Liability Rules Clinicians need to be well trained, and well protected, regarding issues related to suicidality in order to work in an ameliorative manner regarding parasuicidality. Participating in The Game does not make clinicians more liable for their clients’ behaviors than when they use other techniques. Liability concerns, however, do have a negative effect on a clinician’s ability to participate in The Game. As stated, when faced with the threat of liability, clinicians tend to turn to the automated functions of the medical model. Thus, clinicians must operate within clear guidelines regarding issues of liability. Such guidelines provide them a sense of structure and safety as they intervene with their clients in a nonmedicalized manner. The most immediately identifiable threat to clinicians working with suicidal clients is the possibility of a malpractice lawsuit aimed at specific clinicians or the institution in which they work. While the probability of such a suit is actually rather low (Bonger et al., 1998; Jobes & Berman, 1993) and decreases significantly in outpatient treatment, I will venture that most clinicians feel the danger of a malpractice suit is the most frightening and tangible threat—this as compared with such threats as news coverage of the incident, loss of licensure, or workplace disciplinary actions. I will also venture that while the possibility that an actual lawsuit might destroy a given clinician’s career is terrifying for most clinicians, the fear of liability is as much a fear of occupational ostracization as it is a fear of the actual material devastation such a suit could bring. The study of the reasoning behind malpractice litigation regarding suicides is a study in the concrete implications of the clinical gaze. Indeed, a naive person from a distant culture, unaware of the purpose of modern medicine, would likely make only one conclusion following a survey of literature on risk management and malpractice issues in psychiatry: that the psychiatric and mental health professions are fields in which surveillance is the guiding purpose. As I describe below, malpractice lawsuits hinge on four issues directly related to the act of gazing. The first two are the reasons a suit is first brought. They involve an investigation into the clinician’s sight. These are (a) foreseeability (to see the future) and (b) control through surveillance (to oversee or watch). The second two reasons are the ones that influence the potential success of a lawsuit. These involve the means a clinician uses to report what he or she saw: (c) documentation (writing what one has seen for others to see) and (d) clinical supervision (literally to be seen from above).

Foreseeability and Surveillance Malpractice lawsuits typically rest on issues of reasonable standard of care. Black’s Law Dictionary (1979) defines standard of care as “that degree of care

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which a reasonably prudent person or professional should exercise in same or similar circumstances” (p. 1260). In mental health situations, malpractice occurs when a clinician is negligent in meeting a reasonable standard of care and this negligence harms a client. An act of negligence can either be an act of commission, in which the clinician does something he or she should not have done, or an act of omission, in which he or she did not do enough. Sexual abuse of a client, which is the highest ranking cause for successful litigation against mental health practitioners, is an act of commission. Suicide, on the other hand, is most often considered the result of an act of omission. Furthermore, this negligence of omission is defined as a problem of either foreseeability or approximate cause, often called causation. Typically, a clinician is sued when he or she neglects to take the right measures to foresee the suicide and/or neglects to respond in the appropriate manner to something he or she did or did not foresee (causation). Foreseeability means the ability to assess the risk for suicide, not predict such an act. Because of the dearth of evidence on the exact causes of suicide, courts rely on the latter issue of proper assessment to define reasonable foreseeability. Probable cause describes the neglect of a clinician to act in a manner to protect the client. In most cases, however, probable cause involves issues related to control and surveillance of the client. Later, I will describe how probable cause can relate to actual treatment. For now, however, I will discuss it as failure to provide the appropriate surveillance. Below are the most common complaints in malpractice suits (Robertson, 1988). I show how each relates to foreseeability, surveillance, and other forms of causation. 1. Failure to predict or diagnose the suicide (foreseeability) 2. Failure to control, supervise, or restrain (surveillance) 3. Failure to take proper tests and evaluations of the patient to establish suicidal intent (foreseeability) 4. Failure to medicate properly (causation) 5. Failure to observe the patient continuously (24 hours) or on a frequent enough basis (e.g., every 15 minutes) (surveillance) 6. Failure to take an adequate history (foreseeability) 7. Inadequate supervision and failure to remove belt or other dangerous objects (surveillance) 8. Failure to place the patient in a secure room (surveillance) Lawsuits following suicides increase in parallel to the level of supervision a clinician or institution is expected to provide. As Packman and Harris write (in Bonger et al., 1998, p. 154), “The more control a clinician or facility has, the more likely a court is to find the clinician or facility responsible

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for” a suicide. In large part, the control these authors refer to is the control to observe clients. Typically, lawsuits involving suicide can be placed in one of three categories (VandeCreek, Knapp, & Herzog, 1987), all involving different level of surveillance: (a) when a client kills himself on a hospital unit and the unit is blamed for not providing the appropriate care of supervision; (b) when a client commits suicide after discharge from the hospital and the hospital is blamed for releasing him or her too early or without the proper level of care in the community; and (c) when an outpatient client kills himself and the outpatient providers are blamed for not providing the right care; the negligent act most often being a failure to commit the individual to an institution. Clearly, clinicians must conform to the basic professional norms relating levels of surveillance when working with parasuicidal and suicidal clients. At first glance, this compliance may seem counterproductive for a clinician who sees parasuicidal patients as using their suicidal gestures as a means to attain resources in order to maintain a patient career. They may want to take calculated risks with their clients. However, clinicians engaging in a theory of patient careerism should resist taking such risks. Indeed, honoring the basic tenets of The Game, clinicians should not be forcing lower levels of supervision on clients who state they are suicidal. There are three reasons why they should not take risks regarding their client’s behavior. All three of the reasons comply with the tenets of The Game and are not directly influenced by liability concerns. First of all, when a clinician does not comply to his or her client’s (either direct or indirect) requests for particular levels of safety, the clinician is taking a dominant stance towards the client in which the clinician is revoking something the client wants in service of the client’s best interest. This is a stance of leaping in rather than leaping ahead; it is not a stance based on a pursuit of mutual authorship. Second, when a clinician takes such a stance, a client will likely respond with more provocative behaviors, and thus clinician and client will inevitably enter a struggle in which the client will feel herself effective while presenting herself as ineffective. The clinician, in other words, will have contributed to an interaction in which the client’s attempt at effective ineffectualness reigns. Third, often when clinicians revoke a certain level of control and supervision, they do so after making a bargain with the client. The bargains come in many different forms: the outpatient clinician promises to check in by phone with a client whom the clinician has resisted committing to a hospital; an overnight hospital staff member invites an inpatient client to watch television with him late at night instead of performing regular checks on the client; a psychiatrist discharges a client early, following the creation of an elaborate safety plan, in which the client is able to contact her treaters immediately following distressful situations. When a clinician makes such bargains

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with a client, he or she not only supports the client’s wish to be effective while appearing ineffectual, but the clinician offers a more specialized form of conditional enduring attention, specifically contoured to the client’s needs. The goal for individuals working with patient careerists is to help these individuals live lives without the need for conditional enduring attention. Forcing a lower level of supervision on such clients, however, is counterproductive in this quest. For, inevitably, the level of supervision remains the same, or increases, once a clinician has attempted to refuse to provide the supervision the client wants. Simply put, one does not win at The Game by keeping someone out of the hospital or discharging him early. Thus, common guidelines regarding the commitment of clients to psychiatric hospitals, the supervision of clients in such institutions, and reasons for discharge from hospital settings can and should be followed by clinicians interested in helping individuals escape patient careers. Other important standard guidelines must also be followed, not only to protect from actual lawsuits, but to protect clinicians from a sense of overriding anxiety about liability concerns (see Bonger et al., 1998; Maris, Berman, Maltsberger, & Yufit, 1992). These include regular clinical supervision, full training on risk assessments and documentation of risk assessments, a system for collecting past chart information, and clear documentation of safety and treatment plans. Institutions that aim to provide cohesive and enduring environments need to implement the full spectrum of these guidelines and to meet regularly regarding their implementation. For the purpose of the current topic, however, two important aspects of standard liability protection require further explication. These are documentation and supervision.

Documentation and Supervision To avoid a lawsuit, clinicians must prove, typically through documentation, that they used an appropriate means of assessing for suicide, and that they developed an appropriate treatment plan in regards to the level of threat they assessed. Their assessment may not have predicted a successful suicide, and their treatment plan may not have stopped this suicide, but the assessment and plan must reflect a reasonable standard of care. Thus, to some degree, as long as therapists are acting in a responsible manner towards their clients and documenting the reasoning behind their treatment planning, they are free to use a variety of techniques and have some choice over what they address in the client’s life in order to diminish the client’s potential for suicide. Clearly, a given therapist will be vulnerable to a lawsuit if he or she invents his or her own technique or targets issues with little proven relevance to suicidality. Nonetheless, within the realm of reasonable treatments, therapists can

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make some choices regarding how they treat their clients. The techniques and theories in this book can be used as one such choice, as long as their use is documented right and conducted under supervision with someone trained in these theories. Techniques for helping individuals escape patient careers are also techniques for minimizing suicidality. Edwin Schneidman (in Maltsberger & Goldblatt, 1996), the father of suicidology, describes one factor as the sole cause of suicide: psychache. For Schneidman, “Psychache refers to the hurt, anguish, soreness, aching, psychological pain in the psyche, the mind. It is intrinsically psychological—the pain of excessively felt shame, or guilt, or humiliation, or loneliness, or fear or angst or dread of growing old or dying badly, or whatever” (p. 633). For Schneidman, psychache is the elemental component of suicide. For him, without psychache, a person may be suffering any number of social and psychological stresses, but he or she will not commit suicide. For Schneidman, “All person who commit suicide—100% of them—are perturbed, but they are not necessarily clinically depressed (or schizophrenic, or alcoholic or addicted or psychiatrically ill). A suicide crisis is best treated on its own terms. It is a deadly serious (temporary and treatable) psychache” (p. 637, italics his). So sure is Schneidman about the preeminence of psychache as the cause of suicide, that he takes a rather radical stand regarding all the commonly accepted indicators for suicide: All our past efforts to relate or to correlate suicide with simplistic nonpsychological variables, such as sex, age, race, socioeconomic level, case history items (no matter how dire), psychiatric categories (including depression), etc., were (and are) doomed to miss the mark precisely because they ignore the one variable that centrally relates to suicide, namely, intolerable psychological pain; in a word, psychache. (p. 634) Again, for Schneidman, all these variables may lead a person to experience psychache, but people are suicidal only when these variables do so. If psychache is the central component in every suicide, then treating psychache should be the focus of clinical interaction with individuals presenting as parasuicidal and as suicidal. The Game is a way of treating psychache or the potential for psychache. By attempting to help individuals leave their patient careers and engage in an agentic approach to life, a clinician is attempting to help individuals fill their lives with experiences that are the antithesis to deep psychological pain. Indeed, at base, The Game is a means to help a person relinquish one of the most painful of psychological experience: that of totalizing personal failure.

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Schneidman believes that psychache is caused by “the blockage, thwarting, or frustration of certain psychological needs” (p. 635). He offers a list of these needs (explicated in Joiner, 2005), which include “abasement, achievement, aggression, autonomy, counteraction, defendance, deference, dominance, exhibition, harm avoidance, inviolacy, nurturance, order, play, rejection, sentience, shame-avoidance, succorance, and understanding” (p. 37). For the patient careerist, many of these needs can only be met when he or she is able to break from a patient career and experience his or her own agency in an enduring manner. Indeed, while Schneidman’s list is a rather generalized description of the causes of psychache, psychologist Thomas Joiner (2005) suggests that psychache is the cause of only two combined ingredients: “perceived burdensomeness combined with failed belongingness” (p. 37). This is an accurate description of the existential turmoil of individuals who define themselves as failures: they feel unbearable guilt about their burdensomeness and they yearn for, but also resist, belonging, because belongingness also signifies their agency. To truly belong to a social group other than one defined by illness, one must contribute to this group. As I have described, however, by contributing, one exposes his or her agency in the world. Thus, for someone overwhelmed by a sense of personal failure, membership to groups based on illness is one means to feel some sense of belonging. This belongingness is based, however, on remaining in a state of failure. The Game is an attempt to help individuals escape this difficult quagmire. Using The Game, or employing the basic tenets of The Game, combined with high sensitivity to and direct implementation of the guidelines regarding liability protection, clinicians can work assuredly with clients who are potentially suicidal. To do so, however, supervisors must agree with the use of The Game and antisuicidal elements of The Game should be emphasized in the documentation of supervision, treatment planning, and notes. Clearly, a clinician cannot feel free to engage in The Game as a means to lower the potential of suicidality in her clients if the clinician’s supervisors do not agree with this approach. Without the safety from liability that supervision brings, it will thus be very difficult for the clinician to engage in the risk of mutual authorship intrinsic to The Game. Working with a supervisor who believes in The Game, on the other hand, can provide a clinician with a tremendous amount of support in attempting to help individuals disengage from their patient careers. Documenting their agreement enhances this sense of support. On the following pages, I offer an example of such documentation. The document relates to a group supervision meeting at a residential program with the medical director of a community mental health agency. The client has a long history of parasuicidal behavior, and is seeking greater independence

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from the program. She is working actively with a therapist who uses The Game as her approach.

RISK PLAN Client: Client T Date: 7/10/02 This plan is informed both by previous notes and consultations in the client’s chart, and serves as a case conference note regarding a meeting between myself; Mary Allen, the client’s therapist; John Smith, assistant director; Nancy Young, associate director; Dr. Stan Jones, Medical Director. Dr. Jones provided considerable consultation regarding this case. GENERAL PROGRAM RESPONSE TO CLIENT

In regards to Client T, Dr. Jones concurs that program staff should (a) respect her wishes for greater freedom and autonomy, (b) work to develop trusting relationships with her, and, accordingly, (c) create an atmosphere in which the client can be honest and open about her suicidality. He continues that the best steps treaters can take are ones that, within reason, respect her desperate need to be the boss. The program staff should make her feel that she is now the captain of her own team. Dr. Jones believes that the best way to help Client T with her risky behavior is to do everything possible to keep communication open and to remain empathetically in touch with her. Dr. Jones believes that the program might actually raise the client’s risk of suicidality if we become too willful regarding her behavior, especially behavior that is independent, normal, and responsible. He suggests that the best means for ameliorating Client T’s tendency towards suicide is to maintain an authentic relationship with her and support her autonomy. We want to convene a sense of support for Client T’s hopes and dreams. We should, of course, intervene when she shows blatantly poor judgment regarding risks. However, behavior that evidences a true wish to connect with friends and family members, to seek work or educational goals, and to independently seek out treatment should be fully supported. While we want to show a united front in regards to our respect for her autonomy, we should also request reciprocation of this respect from Client T, asking that she let us know her whereabouts and keep in contact with us when she is away from the program. We should

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let her know that this kind of mutually trusting relationship is the best means for her to attain greater independence from treaters. Suggestions From Consultation 1. Client T should be reminded that she does not have to make suicide attempts when she feels desperate, but should ask for help. She needs to know that the team will not respond in a knee-jerk manner, immediately evaluating her for hospitalization, when they are confronted with her desperation. Instead, the staff will attempt to help her find the precipitants to her current psychological pain. Ms. Allen states that Client T’s previous parasuicidal behavior is typically based on interactions with her family in which they pressure her to leave the mental health system. Staff should be especially sensitive to these issues when discussing Client T’s behavior. Again, this kind of open communication is contingent on a nonwillful and supportive relationship with staff. If Client T is unable to engage in such a conversation and exhibits continued suicidal statements, staff should work vigorously to make sure she is hospitalized (see #2). 2. Program staff should behave in an eager and engaged manner when Client T raises issues regarding her independence and autonomy. They should, as much as possible, take extra time to talk to her about such issues. Indeed, as much as possible, staff should put down what they are doing and spend time with the client when she raises these issues. On the other hand, when she discusses her suicidality and is unable to focus on the reasons for her current feelings, staff should provide a more automated response, oriented towards decisions regarding level of care. 3. Emergency hospital arrangements will be worked out in advance. When Client T presents as suicidal, we should work closely with the crisis team, facilitating immediate hospitalization rather than engaging in lengthy evals and attempts at diversion. We have notified the Crisis Team of this plan, and they have left a note in the chart. 4. Ms. Allen has introduced to the client the idea that the client’s past engagement in the mental health system was actually risky, in the sense that by remaining outside of normal social activities, the client risks losing the chance of fulfillment and purpose. Client T has responded energetically to this analysis. Dr. Jones suggests that, since the client appears to be contemplating change and

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seeing the risk in change, this balancing of risk should continue in treatment, with the client reminded regularly of the extreme risk of staying the same. 5. With regard to our wish to support the client in her attempts at autonomy and independence, we need to also ensure that she respects our program, contacting us at regular intervals when she is away from the program site. She has currently resisted such suggestions. We need to attempt to speak to her again about this, stating that her openness with us allows us to trust her behavior in the community. Once we have spoken to her about this, we will set a clear plan with her in which any missed scheduled calls to the program are responded to as an emergency. In this risk plan, basic techniques of The Game are recommended. The plan recommends that clinicians point out the risk of being the same; use urgency and eagerness; express interest in the client’s uniqueness, attributes, and normalizing activities; and distract relational intensity at point of liability. In service of maintaining an open relationship with the client and supporting her autonomy, these techniques are described as a means of protecting her from becoming suicidal. The document also recommends that clinicians only engage with the client on conversations about her suicidality when she approaches the issue intending to discuss the roots to her suicidal feelings. Doing so, the clinicians seek to find a means to ameliorate the client’s psychic pain, while avoiding interactions controlled by liability concerns. Because the latter types of interactions interfere with the clinician/client relationship, the clinicians decrease their relational intensity at these points of liability and focus instead on committing the client to a psychiatric hospital. The plan above offers a viable means to help a client relinquish her patient career. It is also a good plan for preventing suicide. The plan offers long- and short-term protective solutions. In the long term, it aims to nurture in the client the sense of meaning and purpose that autonomous adult experience brings. It operates, in other words, to prevent the inevitable psychache that comes with an overriding sense of burdensomeness, failure, and isolation. In the short term, the risk plan suggests a way to immediately place the client in a psychiatric facility when the need arises. In documentation regarding interaction with individuals engaged in patient careers, clinicians should describe their efforts as aimed at the same types of long-term goals addressed in the risk plan above: autonomy, a life free of a sense of failure, a full experience of belongingness. Combined with these

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long-term goals, clinicians should document both how they are assessing the client’s level of risk and their plans for attending to a client when this risk is so great that the client will need to be placed in a restrictive environment. By addressing their long-term therapeutic goals while proving that they are assessing the client’s level of safety, clinicians document a reasonable, if not exceptional, effort to foresee a suicide and to protect the client from such an act, both in the future and immediately.

DECISION MAKING: THE HOURGLASS Over the last two decades, I have worked intermittently as an organizational consultant to large corporations. The experience of working with business people has influenced one particular opinion of mine regarding the functioning of mental health and psychiatric institutions: that social workers, psychologists, psychiatrists, and other clinicians are not good at running meetings. Indeed, in such institutions, the most basic rules for conducting a meeting are often completely disregarded. Too often, meetings in mental health institutions are run without agendas, without a strong sense of time constraints, and without a strong identified leader who monitors and structures the process of the meeting and charges the meeting with a sense of purpose. The outcome of this untimed, agendaless, leaderless, and purposeless approach to meetings is quite predictable for anyone trained in the basics of group process: a struggle over issues of cohesion and authority. Quite simply put, a group without structure becomes a group about the group. In such a group, the meaning of present interactions between group members holds prominence over decision and strategy. In meetings regarding treatment planning, the effects of such a group are prominent in two types of interactions: (a) a free-flowing and ever-shifting conversation in which decisions are either never made or made without a spirit of seriousness and (b) scapegoating of the client. Indeed, these two types of interaction are often central to the ebb and flow of such a group. The group experiences the diversity, independence, and autonomy of its members through tangential conversations in which no one person’s decisions hold prominence over the others’, and they feel a great sense of group cohesion and togetherness when they discuss how the client has similarly affected them in a negative manner. On the next page, I offer an example of such a treatment planning group. The group is meeting about Sam, who repetitively calls the on-call clinician for an assertive community treatment program stating that he is anxious. The on-call responsibility is rotated weekly among team members. I exaggerate the process for the sake of economy.

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GROUP LEADER: Well, who do you guys want to talk about today? CLINICIAN 1: How about Sam? CLINICIAN 2: (Sarcastically) Yes, Sam! CLINICIAN 3: God, not Sam. Please, not Sam again!

(Everyone laughs) GROUP LEADER: OK guys, should we talk a bit about Sam? CLINICIAN 2: I’d rather talk about Son of Sam!

(Again, everyone laughs) CLINICIAN 4: OK, yes we really should talk about him. Let’s figure out what we’re

going to do. CLINICIAN 1: God, you are such a party pooper.

(Laughter) GROUP

LEADER: OK, OK, clearly we’re all just blowing off steam. But maybe we should talk a bit about Sam.

CLINICIAN 4: Well, I think it would make sense to talk about his calls to the on-call

in the evenings. We should come up with some different way to interact with him that may decrease the calls. CLINICIAN 5: I agree. We really should address this. CLINICIAN 3: Yes, that and the problem with his Social Security. We really have got

to settle what’s going on with that. He can’t move on in life if his Social Security benefits aren’t settled. We need to work as a team on this, not just leave it to one person to settle it. CLINICIAN 1: You know, you’re right. Where do we keep the paperwork on that? I

would be glad to help out. CLINICIAN 3: Speaking of paperwork, I couldn’t find the staff phone list last week.

Anyone know where that is? CLINICIAN 5: Oh, I saw it. It’s in the drawer under the computer. You know, we re-

ally need a central place for that stuff. Can we come up with a central place for that? GROUP LEADER: Sure, where would you like it to go? CLINICIAN 5: How about next to where we keep the files? CLINICIAN 3: I’m not sure about that. It’s so hard to get to the files already. It’s just

very cluttered in the file storage room. How about by the door? CLINICIAN 5: I would just be worried that a client could reach in and get our phone

numbers easily if it’s there.

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CLINICIAN 3: I hadn’t thought of that. Maybe you’re right. Is there somewhere else

we could put it? GROUP LEADER: Wow, this keeps coming up. We should really do something about

it. Let’s see. . . . CLINICIAN 4: I’m sorry to interrupt, but weren’t we going to talk about Sam? GROUP LEADER: Yes, Sam. Sorry. I wonder why I was avoiding that topic!

(Everyone laughs) CLINICIAN 2: Could we have snacks for these meetings? I get so hungry by this

time. CLINICIAN 3: That would be great. Maybe we could rotate who brings the snacks. CLINICIAN 1: That’s great! I’ll go first. I’ll bring something next week. CLINICIAN 2: Could you make sure it’s healthy? CLINICIAN 3: Here he goes again! Mr. Health Nut!

(Laughter) GROUP LEADER: OK everyone. Let’s get back to Sam.

(Clinician 6 enters the room) CLINICIAN 6: Sorry I’m late. What did I miss? GROUP LEADER: Guess who we’re talking about? CLINICIAN 6: Not Sam again!

(Laughter) GROUP LEADER: Well, yes. That’s who we’re discussing. CLINICIAN 6: What have you covered so far? GROUP LEADER: Well, we started to discuss his calls to the on-call. CLINICIAN 3: And his problem with the Social Security. GROUP LEADER: Yes, that too. CLINICIAN 6: And have you come up with anything? GROUP LEADER: We were just getting to that when you walked in. CLINICIAN 4: I just think we’ve got to find a way to deal with him differently in the

evenings. CLINICIAN 1: Oh God, I couldn’t agree more. He is so disruptive. I was trying to put

my son to bed the other night and he paged me! It ruined my evening. CLINICIAN 2: You know it. It’s just constant. I missed almost an entire movie because

of him.

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CLINICIAN 5: He’s just so persistent with those calls. It can drive you crazy. CLINICIAN 3: The other night, he called me six times throughout the night. I finally

just gave up, moved down to the couch, and put on the TV because I knew he would be calling all night. CLINICIAN 4: What should we do about it? CLINICIAN 5: I don’t know, but I’ve had the experience too. Just sitting there all night

taking his calls. I can barely work the next day because of those calls. CLINICIAN 2: That’s really a good point. I mean, his calls can actually affect our

performance with our other clients. I can’t tell you how many nights I’ve lost sleep because of him. CLINICIAN 1: It’s true, it’s true. I can barely function after doing on-call because of

him. CLINICIAN 4: Maybe if we came up with some sort of consistent plan, in which we are

all more clear with him about the use of on-call, he wouldn’t call so much. CLINICIAN 1: Can we take a bathroom break? GROUP LEADER: Is that OK with everyone? GROUP IN UNISON: Yes!

(Laughter) GROUP LEADER: But really, you guys, just a short break. Last week you were gone for

about 20 minutes … (20 minutes later. Everyone is returning to the room and seating themselves except clinician 2 [Jason].) GROUP LEADER: OK. So, let’s get going. Where’s Jason? CLINICIAN 6: He made a call to a case manager during the break and he’s still on the

line with him. He said he’ll just be a few more minutes. GROUP

LEADER: Well, I think we were talking about coming up with some sort of plan regarding Sam and the on-call.

CLINICIAN 3: Could he use DBT diary cards? What if we had him fill those out, and

we could walk him through specific techniques in the evenings? CLINICIAN 5: We tried that before and it didn’t work. He just kept calling more. CLINICIAN 4: What if we just really clarified for him that the on-call is an emergency

line, and that we only take emergencies. We could make it clear to him that we’re only going to evaluate him for the hospital when he calls in an emergency. (Clinician 2 enters the room.)

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CLINICIAN 2: What did I miss? GROUP LEADER: We were talking about Sam. CLINICIAN 2: Oh, yeah. How fun!

(Everyone laughs) GROUP LEADER: Do you have any ideas? CLINICIAN 2: Other than hanging myself?

(Group laughs again) GROUP LEADER: Yes, other than that.

(Laughter) CLINICIAN 2: Well, maybe we should introduce him to some of the DBT techniques. CLINICIAN 3: We just discussed that and it seems that didn’t work before. CLINICIAN 2: Well, maybe we just didn’t work with him on them right. CLINICIAN 1: Excuse me, but I’ve got to get to a case conference at the hospital. I’m

going to need to leave soon. GROUP LEADER: Do you have anything to add before you go? CLINICIAN 1: Not really. Only that we need to figure out that Social Security stuff. CLINICIAN 3: Yes! We really need to figure that out. Thank you. CLINICIAN 5: I need to go in about 5 minutes to pick up a client. GROUP LEADER: Can we come up with something about how we’re going to respond

to the on-call calls from Sam before we break up? CLINICIAN 4: Well, I was saying that maybe we should clarify that the on-call is only

for emergencies and be very strict about that and very consistent regarding how much we talk to him when he calls. GROUP LEADER: Well, what do the rest of you think? CLINICIAN 3: I’m all for that, but I really think we should also talk about the Social

Security. GROUP LEADER: How about next week? CLINICIAN 1: I need to go now. GROUP LEADER: OK everybody. What do you think about the idea of telling Sam

that it’s an emergency line, and so forth? (Clinician 1 and clinician 5 are leaving the room.) CLINICIAN 1: I’m fine with it. CLINICIAN 5: Me too.

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CLINICIAN 2: That sounds good. CLINICIAN 4: Let’s do it. CLINICIAN 3: I hate to say this, but I’ve got some problems with it. I’m not sure if it’s

the right way to go. Could we talk it over a bit? GROUP

LEADER: Well, I’m sorry to say so, but looks like things are breaking up. Maybe we could review this again next week, hear you out, and come up with a decision.

At least three dysfunctional processes take hold of this meeting, all typical of clinical group meetings without structure or leadership. First, the conversation is more like a melange of comments and observations than a disciplined process of brainstorming. Second, the group only comes to-gether as a cohesive unit when they are participating in a conversation that is derogatory towards the client. Third, a sense of time is disregarded, with no one in the group paying attention to time constraints and the need to make decisions on time. No good treatment can come from such a meeting. In such a meeting, good ideas are either ignored or applied only superficially following the meeting. Without a real sense of mission regarding the formation of treatment, treatment ideas simply do not adhere as real plans. I have developed and used a strategy for protecting group treatment planning from these dysfunctional processes that is specifically aimed at developing nonmedicalized solutions. Called The Hourglass, this strategy offers highly structured and concrete controls on group decision making. The Hourglass is a means to always end an hour and 15 minute meeting with a treatment decision. This is a tall order, considering the facts that the effects of clinical decisions are always difficult to measure or predict, and that many mental health professionals are not trained on the basics of efficient meeting participation and facilitation. The Hourglass transcends these challenges by providing a time-structured, rule based, yet playful and creative, means of meeting facilitation. It aims to provide an enduring organizational structure in the service of creativity. I use the term hourglass, not only because it signifies that the meeting is timed, and that the participants are working under time constraints, but because it captures, in “shape,” the basic structure of the meeting (Figure 9.1). In this structure, particular content are segmented by time. In an Hourglass meeting, the participants begin with unrefined and loose data and attempt to refine this data into a more constricted discussion of its meaning. They then use the information from this discussion to engage in the more flexible and open process of brainstorming and, finally, agreement on an intervention.

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Initiation of meeting

Data collection: 10 min

Brainstorming analysis of data: 15 min

Multivoting on the meaning of the behavior: 15 min

Inventing the intervention: 15 min

Multivoting the intervention: 10 min

Intervening

FIGURE 9.1

The Hourglass.

INITIATION OF THE MEETING I have two rules that I believe should apply to all meetings with both clinicians and clients. These rules are also intrinsic to The Hourglass. First, meetings should begin exactly on time, no matter how many people are in the room. Second, there should be no roundup of participants. In other words, the leader of the meeting should not search out other participants, reminding them that the meeting will begin.

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This mode of beginning a meeting is clearly influenced by the fundamentals of the therapeutic hour. Therapy is most effective when it is held within the constraints of time; that it begins and ends at specific times. Without this sense of time constraints, it loses its potency as a moment that endures independent of the subjective life of the client. The Hourglass aims to provide this same kind of enduring and durable structure to clinical meetings. If that structure does not prove its integrity at the very beginning of the meeting, the group process is already threatened. Lastly, in regards to the initiation of The Hourglass, the precious time of the meeting should not be spent deciding on which client is to be discussed. Instead, the topic for clinical discussion should be decided by the group before the meeting. This can be done at prior clinical meetings or other forms of staff meetings.

STEP ONE: DATA COLLECTION (10 MINUTES) For this stage of the meeting, participants talk directly about the issue or problem regarding the client they want to address. If possible, the participants develop a chain analysis regarding the behavior, studying when it began and/ or when it appears to increase or decrease, and how possible environmental or social stimuli might be related to changes in this behavior. If only one member of the group works with the client, he or she spends the time discussing the issue with the group. This step in the process is aimed only at data collection, and participants avoid analysis of the meaning of this data. By the end of the meeting, the participants join in an agreement on how to describe this problem, and a sentence is written on a white board describing the problem. In the example regarding Sam, a team of individuals working within the confines of The Hourglass, might write something like: Sam calls the person on call repetitively. It appears that his use of an on-call service has increased since coming to the program. Sam used to call a local crisis team when he felt anxious, but he did so minimally.

STEP TWO: BRAINSTORMING AND ANALYSIS (15 MINUTES) For the second stage of the meeting, staff work together to interpret the problem. Using a theory of patient careerism and considering the particular actions

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of someone trapped in the dialectics of failure, they analyze the meaning of the client’s behavior. Here, their eyes are set on such issues as the way in which the behavior operates to medusaize others or hide the client’s agency, how it might be a means to avoid accountability or experience a sense of effectiveness while remaining seemingly ineffective. During the meeting, one participant writes all the interpretations on a board. In the case of Sam, these interpretations might look something like this: 1. Unconsciously, Sam knows he is irritating us, and by doing so, he feels less alone because he knows he has affected someone. 2. Sam calls lots of people during the night. We are just part of his call list when he’s anxious. 3. This has more to do with us than with Sam. We have never told him the real nature of the on-call process, so he feels free to call whenever he feels lonely or in need of contact. 4. Sam’s engaged in see me/don’t see me behavior. By calling, he makes contact, but never really resolves anything. 5. Sam has crises all day involving threats to his patient career. By calling us and saying he’s anxious and suicidal, he can regain that career.

STEP THREE: MULTIVOTING THE MEANING OF THE BEHAVIOR (15 MINUTES) In the third step of The Hourglass, the participants multivote on the meaning of the behavior. Multivoting is a voting technique used in organizations that aims towards consensus. It provides a rank-ordered list showing the relative importance to the group of items on the list. To multivote on the meaning of a particular client’s behavior, each participant in the meeting is given 10 votes. He or she is allowed to use these votes to select the description of the meaning of the client’s behavior written on the board. The meeting participant can use his or her votes in any manner he or she chooses. If, for example, he or she believes that only one description is correct, he or she would give that description 10 votes. Most often, however, meeting participants tend to spread their votes, selecting two or three statements and giving different weights to each. Meeting participants are given Post-it notes or dry erase markers, and each comes up to the board and places his or her votes. In Sam’s case, the board might look something like this: 1. Unconsciously, Sam knows he is irritating us, and by doing so, he feels less alone because he knows he has affected someone. Votes: 2 1 3 1 3 = 10

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2. Sam calls lots of people during the night. We are just part of his call list when he’s anxious. Votes: 1 1 1 1 2 = 6 3. This has more to do with us than with Sam. We have never told him the real nature of the on-call process, so he feels free to call whenever he feels lonely or in need of contact. Votes: 3 3 3 2 2 = 13 4. Sam’s engaged in see me/don’t see me behavior. By calling, he makes contact, but never really resolves anything. Votes: 3 2 2 2 3 = 12 5. Sam had crises all day involving threats to his patient career. By calling us and saying he’s anxious and suicidal, he can regain that career. Votes: 2 2 1 1 3 = 9 Once the voting is calculated, participants discuss whether there are similarities between the highest ranked descriptions. If there are, these are combined and written up on the board as a two or three sentence description. If not, then the description receiving the most votes is written on the board. In the case of Sam, the description could be written as follows, synthesizing interpretations 1, 3, and 4: Sam has learned over the years that one way of calming his anxieties about his aloneness is to call treatment providers. Doing so, he achieves a sense that he is recognized without raising anyone’s expectations. By calling treaters repetitively, Sam likely irritated them (as he does us at times), and they then responded in an increasingly distant manner. Without telling Sam that our on-call service is only for life-threatening emergencies and by talking at length with Sam often when he calls the on-call, we have participated in supporting his behavior, showing him that we will recognize him, while at the same time acting towards him with little of our authenticity.

STEP FOUR: INVENTING THE INTERVENTION (15 MINUTES) In step four, the team takes 15 minutes to discuss a possible intervention to use with the client that matches the final interpretation written on the board. Again, one participant writes possible interventions on the board. For Sam, the suggested interventions might look like this:

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1. We apologize to Sam for not informing him of how we use the on-call. We tell him that this was a serious mistake, because we gave him the impression that it was OK to call if the problem was not life threatening. 2. We work on a plan with Sam regarding parasuicidal behavior or his anxiety, and we review that plan when he calls. 3. We start answering the phone by saying, “Emergency line, please state the nature of your emergency.” 4. When Sam calls, the on-call clinician acts urgently, instead of distantly, regarding the content of Sam’s complaint.

STEP FIVE: MULTIVOTING THE INTERVENTION (10 MINUTES) For the final 10 minutes, the participants again multivote, this time focused on an intervention. The multivoting for Sam might look something like this: 1. We apologize to Sam for not informing him of how we use the on-call. We tell him that this was a serious mistake, because we gave him the impression that it was OK to call if the problem was not life threatening. Vote: 3 4 4 4 3 = 18 2. We work on a plan with Sam regarding parasuicidal behavior or his anxiety, and we review that plan when he calls. Vote: 2 2 1 01=6 3. We start answering the phone by saying, “Emergency line, please state the nature of your emergency.” Vote: 3 4 3 3 2 = 15 4. When Sam calls, the on-call clinician acts urgently, instead of distantly, regarding the content of Sam’s complaint. Vote: 3 3 3 1 1 = 11 If a few highly ranked interventions appear similar or can be synthesized into a comprehensible plan, they are joined together. The intervention is written on the board. A combination of interventions 1 and 3 in the plan for Sam might look something like this: We apologize to Sam for neglecting to inform him of how to use the on-call. We tell him that this was a serious mistake, because we gave him the impression that it was OK to call if the problem was not life threatening. By doing so, we set him up for disappointment, for now we are changing the way we take the calls. We learned from

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our mistakes, and from now on, we are answering the phone with a short sentence: “Emergency line, please state the nature of your emergency.” Once the intervention is set, the team decides on a date to review its effectiveness. The meeting is then adjourned. The Hourglass is developed on the belief that psychological and psychosocial interventions are always acts of faith. No interpretation of human behavior can be proved to be accurate. Indeed, no single interpretation of human behavior is accurate, for human beings behave in particular ways for infinite reasons. Because clinicians can never be sure that their interpretations are accurate, they can also never be guaranteed that their interventions are effective. They cannot predict the future effect of an intervention, nor can they look back in hindsight and assuredly review this effect. If a given clinician implements an intervention regarding a behavior exhibited by his or her client and this behavior dissipates, the change in behavior is not an inarguable proof of the effectiveness of the intervention. People change for multiple reasons, and it is accordingly impossible to prove that any one element is what caused the change. Conversely, if a clinician implements an intervention targeting a specific behavior in the client and this behavior stays the same, this is not a sure sign of the intervention’s ineffectiveness. Interventions take time and change could be just around the corner. Because of the nebulousness of the effects of psychological and psychosocial interventions, the tendency in group treatment planning is to argue and talk for long periods of time, as if, at some point, the perfect solution will emerge. The Hourglass resists this tendency, forcing a group to decide on such interventions and then try them. The Hourglass balances the spirit of “trying anything is better than doing nothing” with a refined means of brainstorming. It is a quick way to help a group act in an energized and cohesive manner. Interventions that emerge from The Hourglass must be reviewed continuously to be effective. Thus, groups must set regular scheduled times to check up on the possible effects of their interventions and possibly refine them. I suggest 6 to 8 week timetables, and that the dates for the reviews of the interventions are always set at the end of an Hourglass session. One last note regarding the basic use of The Hourglass. With some modification, this brainstorming process can be used in individual supervision. Clearly, in such a use of The Hourglass, the multivoting is no longer applicable. However, without multivoting, a supervisor and supervisee can easily walk through all the other processes of The Hourglass, developing a shared understanding of the behavior on which they are focused, a shared interpretation of its meaning, and a creative investigation of an intervention.

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Keeping It Positive The Hourglass imposes structure on clinical planning meetings, with the aim of reaching meaningful and realistic goals specifically focused on the relationship between clinicians and their clients. While it is effective in helping clinicians reach decisions, the basic structure of The Hourglass does not affect the kinds of decisions they make. Clearly, the decisions a particular treatment group makes is directly influenced by how the content of their decisionmaking process is framed. This is why it is important during the interpretive stage (Stage two) of The Hourglass that the discussion is framed within a theory of patient careerism. “How,” the group should be asking, “is this behavior operating to sustain the client’s career as a patient?” Within the process of The Hourglass, participants can work together within a theoretical frame to intervene on patient careerist behavior. However, when The Hourglass is only used for the purpose of investigating behavioral problems, it already preconditions a way of looking at people that can pervert an attempt to help these people engage in an autonomous life. To work effectively, The Hourglass must be used as a means to support a given client’s attempts at change, as well as a way to intervene on behavior associated with a patient career. The belief that each client engaged in a patient career is ambivalently trapped between resisting and wanting to change is central to the basic theory of patient careerism. Thus, it makes immediate sense that treatment planning regarding patient careerists should focus as much on the resistance to change as on the yearning for change. Two forces, however, work against the latter form of treatment planning. First, organizations, in general, tend to work towards solving problems rather than looking at strengths (Cooperrider & Whitney, 2005). In service of efficiency and excellence, people typically will focus together on how to diminish deficits, because in this way of thinking, as long as deficits are extracted, the problem no longer exists. Second, most clinicians, trained in the medical model are taught in problem-focused ways of viewing clients. Clearly, the medical model is a deficit-oriented model, in which diagnoses and disease reign as the fundamental lens for viewing behavior. The Hourglass should be imposed by leaders on treatment planning groups as a means of deciphering and highlighting client strengths. Indeed, I suggest that group leaders enforce one particular rule regarding The Hourglass: that 50% of the time it is used, clinicians employ it to study and support noticeable change in clients. The reason I recommend this imposition of a solutionfocused treatment planning is threefold. First, as I’ve stated, within theory of patient careerism, it makes sense to focus on the client’s attempts at change.

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Second, and more specific to a theory of patient careerism, many of the reasons a person maintains a patient career is based on her concerns about how others perceive successes she makes. Thus, treatment should be modeled in a manner that supports these successes while remaining sensitive to the dialectics of failure and the basic parameters of The Game. Third, by imposing a strict rule regarding the investigation, interpretation, and support of client strength and growth is potentially initiating an important, even radical, cultural shift in usual treatment. It sends a message about the vision and mission of the group and even the organization in which that group occurs—that the organization resists purely deficit approaches and seeks to understand and support the strengths in the individuals it serves. Below, I give a description of a supervisor and her supervisee using The Hourglass to support a client’s marked abstinence from parasuicidal behavior. I begin this description on Step One, “Data Collection,” for there is no need to review the generic topic of how to begin the meeting. I will call the client Mary.

STEP ONE: DATA COLLECTION The supervisor and supervisee review Mary’s chart, searching for the point in Mary’s treatment when she stopped presenting as parasuicidal. They find that Mary has not been parasuicidal for 4 months. This is a marked change from her behavior over the previous 3 years, in which she presented to treaters as suicidal at least twice a month. Prior to this 3 year period of parasuicidal behavior, Mary had worked as a nurse’s assistant in a small private doctor’s office. The supervisor and supervisee discuss possible changes in Mary’s life. Reviewing her work with Mary, the supervisee realizes that Mary has made one more significant change in her life; in the last 5 months, Mary has befriended her roommate in her residential program. Mary talks often in therapy about how she has helped this roommate with her suicidal behavior, boasting at times that she is “better at this than the counselors at the program.” At the end of this data collection period, the supervisee writes something like this on the board: Mary’s parasuicidal behavior has markedly decreased in the last few months. She has recently done better in this area than she has in the last three years. In the meantime, Mary has become friends with someone in her residential program. She often talks about how she helps this person with her suicidal behavior. Mary once worked as a nurse’s assistant. She often says this was the “best time in my life.”

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STEP TWO: BRAINSTORMING AND ANALYSIS ON THE MEANING OF THE BEHAVIOR Supervisor and supervisee analyze the data on the previous page. They develop an interpretation regarding Mary’s new positive behavior: By helping her new friend, Mary has tapped into “helping behavior”; behavior she has found fulfilling and meaningful in the past. This has not only given her a sense of pride in her own skills, but has given her a reason to remain out of the hospital. If she is hospitalized, she will not have the opportunity to help her friend, and will thus lose the chance to feel herself as effective and important in a person’s life.

STEP THREE: INVENTING THE INTERVENTION Because success is one of the paramount threats to a patient career, clinicians must be very thoughtful about how to intervene in successful behavior of their clients. In the case of Mary, it would likely be detrimental to her success if her therapist congratulated her or even noted the fact that she has remained out of the hospital. Instead, the therapist should focus on the roots of her positive behavior. But even here, direct praise can backfire, making the client feel as if her treaters have caught her in the act that exposes her agency and accountability. Aware of these parameters to interventions, Mary’s therapist and her therapist’s supervisor engage in a brainstorming process aimed at supporting Mary’s behavior without threatening her with the risk that others have viewed her as an independent individual. Their aim, specifically, is to support Mary in helping behavior, while minimizing the threat that this support may indicate. They develop a plan as follows: Suzanne [the supervisee] asks Mary if she would be willing to sit down with Sarah [the supervisor] to discuss how she’s helping her friend. Suzanne tells Mary that her agency wants to learn more about how to help individuals decrease their suicidality, and that Sarah is interested in any ideas on how to do better at this. Sarah meets with Mary monthly to review any new suggestions on working with suicidal clients. Following their supervision, the supervisor sets a date to meet with Mary. The supervisor and her supervisee discuss the outcome of this meeting and

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subsequent meetings between the supervisor and Mary in the following months, shifting the interventions and using The Hourglass to develop new ones. What does it mean for a client engaged in a patient career to give up parasuicidal behavior if she operates within a deficit-oriented organization? For such an individual, how many of her fears will be actuated? If the patient careerist’s treaters are focused acutely on problems and not solutions, will she not lose a sense of being held continuously within their consciousness? Will the patient careerist be wrong to feel the growing threat of abandonment through discharge? What about the patient careerist’s day-to-day sense of importance in group activities and treatments? How will it feel for her when clients who exhibit parasuicidal behavior gain the greatest attention, while clients presenting with stories of growth are neglected? Indeed, as long as treatment organizations focus on problems, every threat within the dialectics of failure comes to fruition at the point in which a person begins the process of escaping her patient career. Clearly, The Game is crippled if clinicians do not engage in this process with an eye on the complicated vicissitudes of success, hope, and change. By imposing a solution-focused use of The Hourglass on treatment meetings and on individual supervision, the leaders of treatment organizations ensure that treatment focuses on supporting positive change and that the organizational culture of the programs or institutions they run is imbued with an ethos aimed towards solutions rather than problems only.

CHA PTER 1 0

Conclusion: Alienation, Dehumanization, Conformity, and Their Influence on Parasuicidal Behavior A Ghost of a Warning

182

The opposite of courage in our society is not cowardice, it is conformity. —Rollo May (1953) Man’s main task in life is to give birth to himself, to become what he potentially is. The most important product of his effort is his own personality. —Erich Fromm (1955)

I

n this book, I have described patient careerism as the result of a confluence of individual psychological, existential, and spiritual needs and social and institutional forces that temporarily and superficially soothe these needs. The individual needs emerge from the pain of personal failure. As I’ve described it, the patient careerist is a person who experiences herself as an error of a being. To escape this overriding sense of personal failure, she seeks situations in which her agency is dulled in the eyes of others. Medicalized institutions provide such situations, because they are steered by a way of gazing that sees individuals as things more than as agentic beings. In Chapter 3, I describe this confluence of personal needs and social/ institutional forces as like a set of Chinese boxes. In this view, patient careerism and parasuicidality are understood as partly influenced by individual interactions between clients and clinicians. These interactions are themselves influenced by the cultural norms of the institutions in which they occur. Individual medical institutions, however, do not exist in isolation; their norms are influenced by medicalized culture. In this concluding chapter, I briefly describe one more influence on the social ecology of patient careerism. This is 179

FIGURE 10.1

Avoid change

Client

Dehumanizing Culture

Medical Culture

Medicalized Institutions

Marginalization

Mutual Authorship

The Game: Eagerness Urgency Unconditional positive regard

Mending vision

Clinician

Clinical gaze

Avoid change

Avoid change

Avoid change

Avoid change

Wish to change

The social ecology of patient careerism III.

Avoid change

Avoid change

Avoid change

Mending vision

Objectivity

Marginalization

Clinical gaze

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the largest, most socially ubiquitous of the so-called Chinese boxes—it applies to the culture at large (see Figure 10.1). I work daily with individuals who, in a medicalized vision, are typically defined as suffering from severe and persistent mental illness: schizophrenics, mood disorders, and yes, people often described as suffering from personality disorders. On any given day, I meet with individuals who are frequently very disturbed and desperate, fraught with differing intensities of psychache. It is on my commute home, however, when I often feel as if I am witnessing real insanity. I pass whole neighborhoods in which each house resembles the other. In the driveways are men and women coming home from work, all dressed the same. They greet children, who are also dressed the same. Along the roadside, replacing fruit stands and the occasional general store, are mini-marts, gas stations, and donut shops. Remarkably, I commute home through the land of Emerson and Thoreau, the great thinkers on originality and individuality (my halfway mark is Walden Pond). As I look out the window of my car, however, I see a landscape that is increasingly resistant to truly original impulses and crushing of individual gestures. Sameness—homogeneity—is a driving norm in twenty-first century America. And it perverts our humanity. As I have described in previous chapters, each of us is born with a potential for deep meaning and purpose. This meaning and purpose is netted into our ability to experience our agency in the world as unique individuals. Accordingly, when we base our existence on conforming, we engage in a form of psychological suicide, for our potential to fully be selves (sui) is killed (cide). Conformity is a social disease intrinsically entwined with two other maladies: dehumanization and alienation. Dehumanization occurs when we approach and treat each other as things instead of unique beings. In a dehumanizing culture—in which people are consistently bombarded as consumers of goods, or as replaceable workers, or, more fitting, as the embodiments of diagnostic categories—people lose the capacity to control and own the most intimate parts of their selves. Their homes, the very domestic bases for unique and creative endeavors, are no longer places of unique habitations, for these homes are filled with premade things and match the designs from magazines and experts. The food they eat and the clothes they wear are manufactured to meet general, rather than unique, tastes, and their social lives often revolve around a steady stream of sameness—the next movie, the next sale at the local mall, the new restaurant chain, the next soccer game. Most important for the themes of this book, the very inner lives of individuals in a dehumanizing culture—each of their feelings, each of their gestures—are defined and categorized by experts.

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When dehumanization is pervasive in culture, as it is right now, people lose control over what Jurgen Habermas (1989) accurately calls the grammar of forms of life. This loss of control is alienation. When we no longer approach the world as unique and contributing agents, and instead experience ourselves as acted upon by forces outside our control, we become alienated from our humanity and the humanity in others. Medical culture is elementally a culture aimed towards conformity (baseline health), and tends to view people through a dehumanizing lens (as diagnoses or the hosts for illness). It thus, inevitably, alienates people, not only from the control of their health, but, when it invades on issues of behavioral health, their very self-definition. Medical culture thus influences and is influenced by the dehumanizing and alienating trends in modern society. It wasn’t long ago when we were warned persistently about these trends.

A GHOST OF A WARNING In the 1956 horror film Invasion of the Body Snatchers (in Dirks, 1997), a town is slowly overcome by an alien invasion that, one by one, strips the unique humanity from the town residents. The protagonist in the film narrates his observation of this seeping conformity: I’ve seen how people have allowed their humanity to drain away. Only it happened slowly instead of all at once. They didn’t seem to mind. . . . All of us—a little bit—we harden our hearts, grow callous. Only when we have to fight to stay human do we realize how precious it is to us, how dear. (par. xxx) Body Snatchers gave dramatic form to a growing concern in modern America. From the late 1940s to the late 1970s, academics and philosophers in the fields of psychology, sociology, and theology all gave clarion warning about the invasion of conformity, alienation, and dehumanization in American culture. Like the protagonist in Body Snatchers, their efforts have been subsumed by the very threat they warned about. Indeed, where we now find books describing all manner of human behavior as symptoms of disease in the psychology and self-help sections of our bookstores, we once found books written for both academics and the general public celebrating the self and warning about conformity and alienation: Paul Tillich (1952), Erich Fromm, (1955), Rollo May (1980), R. D. Laing (1969), Herbert Marcuse (1991), Ivan Illich (1982), Victor Frankel (1984), Martin Buber (1970), David Riesman (1950)—the list goes on and on. Their thoughts where not entirely academic,

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for, at the center of one of the greatest social movements in twentieth-century American history, were basic concerns about dehumanization, alienation, and the destruction of the individual. “Segregation,” wrote Martin Luther King, Jr. (in Washington, 1986, p. 119): stands diametrically opposed to the principle of the sacredness of human personality. It debases the personality…. The tragedy of segregation is that it treats men as means rather than ends, and thereby reduces them to things rather than persons. To use the words of Martin Buber, segregation substitutes an “I-it” relationship for the “I-thou” relationship… But man is not a thing. He must be dealt with, not as an “animated tool,” but as a person sacred in himself. To do otherwise is to depersonalize the potential person and desecrate what he is. (p. 19) Warning against the threats of dehumanization, alienation, and debasement of personality, the academic and popular zeitgeist from which King emerged is but a whisper today. The threats themselves, however, are very much with us. And, to understand patient careerism, practitioners must simultaneously understand these threats. People engaged in patient careers are fleeing a sense of failure. This sense of failure is the result of comparing themselves to how they conform to others. It is exacerbated by a culture in which social feedback is typically reserved for what you do and how you present yourself rather than who you are as a unique individual. Struggling with a deep sense of failure and “outsiderness,” individuals engaged in patient careers find a role to conform to: the patient role. Dehumanizing as it is, it protects them from the terror of not fitting in. In this book, my theories mostly hearken back to the time when psychology was about the fight to stay human, rather than the study and control of deviance and illness. I aimed to provide a model that snatches back a group of individuals who are increasingly being defined by, and define themselves through, the medical model. Just like the conformist, the possibility of escaping the struggle over existential accountability through socially legitimized means is intensely seductive for patient careerists. But, and again, like the conformist, when these individuals succumb to the comfort of passivity, automation, and homogeneity, they allow a part of “their humanity to drain away.”

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text rev.). Washington, DC: Author. Augoustinos, M. (1986). Psychiatric inpatients’ attitudes toward mental disorder and the tendency to adopt the sick-role. Psychological Reports, 58, 495–498. Bettelheim, B. (1984). Freud and man’s soul. New York: Random House. Black, H. C. (1979). Black’s law dictionary. St. Paul, MN: West Publishing. Bonger, B., Berman, A., Maris, R., Silverman, M., Harris, E., & Packman, L. (Eds.). (1998). Risk management with suicidal patients. New York: Guilford. Buber, M. (1970). I and thou. New York: Touchtone. Burston, D. (1998). Laing & Heidegger on alienation. Journal of Humanistic Psychology, 38, 80–93. Camus, A. (1955). The myth of Sisyphus ( Justin O’Brien, Trans.). New York: Knopf. Camus, A. (1988). The stranger. New York: Alfred A. Knopf. Chamberlain, P., Patterson, G., Reid, J., Kavanagh, K., & Forgatch, M. (1984). Observation of client resistance. Behavior Therapy, 15, 144–155. Conrad, P., & Schneider, J. (1992). Deviance and medicalization: From badness to sickness. Philadelphia: Temple University Press. Cooper, M. (2003). Existential therapies. London: Sage Publications. Cooperrider, D., & Whitney, D. (2005). Appreciative inquiry: A positive revolution in change. San Francisco: Barrett-Koehler Publishers. Dirks, T. (1997). Invasion of the body snatchers. Greatest Films. Retrieved April 3, 2007, from http://www.filmsite.org/inva.html Dostoevsky, F. (1992). Notes from underground. New York: Bantam Books. Drucker, P. (1956). The practice of management. New York: Harper & Row. Esslin, M. (1986). The theatre of the absurd. London: Penguin Books. Farber, L. (2000). The ways of the will (Exp. ed.). New York: Basic Books. Fleener, P. E., comp. (n.d.). Borderline personality disorder: “The Journal of the California Alliance for the Mentally Ill” excerpts about borderline personality disorder. Retrieved December, 2006, from http://www.borderlinepersonalitytoday.com/main/ jourexcerpts.htm Foucault, M. (1975). The birth of the clinic: An archaeology of medical perception. New York: Vintage Books. Frankel, V. (1984). Man’s search for meaning. New York: Washington Square Press. Fromm, E. (1955). The sane society. New York: The Henry Holt Company. Fromm, E. (1956). The art of loving. New York: Harper & Row.

185

186

REFERENCES

Giddens, A. (1986). The constitution of society. Berkeley: The University of California Press. Goffman, E. (1959). The presentation of the self in everyday life. New York: Doubleday. Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. New York: Doubleday. Goffman, E. (1963). Stigma: Notes on the management of a spoiled identity. New York: Prentice-Hall. Goleman, D. (1985). Vital lies, simple truths: The psychology of self deception. New York: Bloomsbury Publishing. Gunderson, J. (1984). Borderline personality disorder. Washington, DC: American Psychiatric Press. Gunderson, J., & Phillips, (1991). A current view of the interface between borderline personality disorder and depression. American Journal of Psychiatry, 148, 967–975. Habermas, J. (1989). In S. Seidman (Ed.), Jurgen Habermas on society and politics: A reader. Boston: Beacon Press. Haley, J. (1963). Strategies of psychotherapy. New York: Crune & Stratton. Hegel, F. (1896). Lectures on the history of philosophy. London: Kagen Paul, Trench, Trubner & Co. Heidegger, M. (1962). Being and time. London: SCM Press. Heller, L. (1999). Dr. Leland M. Heller discusses borderline personality disorder. Retrieved July, 2007, from http://www.healthyplace.com/communities/personality— disorders/biounhappiness/bpd/21a.htm Heller, L. (1999). Biological unhappiness. Okeechopee, FL: Dyslimbia Press. Horowitz, A. (2002). Creating mental illness. Chicago: University of Chicago Press. Hudziak, J., Boffeli, T., Kriesman, J., Battaglia, M., Stanger, C., & Guze, S. (1996). Clinical study of the relation of borderline personality disorder to Briquet’s syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorder. American Journal of Psychiatry, 153, 1598–1605. Illich, I. (1982). Medical nemesis: The expropriation of health. New York: Knoft. Jacobson, G. F. (1980). Crisis theory. In G. F. Jacobson (Ed.), Crisis intervention in the 1980s (pp. 1–11). San Francisco: Jossey-Bass. Jobes, D. A., & Berman, A. S. (1993). Suicide and malpractice liability: Assessing and revising policies, procedures, and practice in outpatient settings. Professional Psychology: Research and Practice, 24, 91–99. Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press. Kazantzakis, N. (1946). Zorba the Greek. New York: Simon and Schuster. Keough, P. (1993, March 17). Becoming Colette, Branford Marsalis. Boston Phoenix, p. xx. Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15, 641–685. Kierkegaard, S. (1944). The concept of dread. Princeton: Princeton University Press. Kierkegaard, S. (2005). Fear and trembling. New York: Penguin Books. Kirk S., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry (social problems and social issues). New York: Aldine de Gruyter.

References

187

Kleisman, J., & Straus, H. (1989). I hate you, don’t leave me: Understanding the borderline personality. New York: Avon Books. Kohut, H., & Wolfe, E. (1978). The disorders of the self and their treatment. International Journal of Psych-Analysis, 59, 413–425. Kondrat, M. (2002). Actor-centered social work: Re-visioning “person-in-environment” through a critical theory lens. Social Work, 47, 435–448. Laing, R. D. (1969). The divided self: An existential study in sanity and madness. London: Penguin Books. Lasch, C. (1991). The true and only heaven: Progress and its critics. New York: W. W. Norton. Linehan, M. (1993a). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford Press. Luborsky, L., McLellan, A. T., Woody, G. E., O’Brien, C. P., & Auerbach, A. (1985). Therapist success and its determinants. Archives of General Psychiatry, 42, 602–611. Maltsberger, J. T., & Goldblatt, M. J. (Eds.). (1996). Essential papers on suicide. New York: New York University Press. Marcuse, H. (1991). One-dimensional man: Studies in the ideology of advanced industrial society. London: Routledge & Kegan Paul. Maris, R. W., Berman, A. L., Maltsberger, J. T., & Yufit, R. I. (Eds.). (1992). Assessment and prediction of suicide. New York: Guilford Press. Masterson, J. (1975). The splitting mechanism of the borderline adolescent: Developmental and clinical aspects. In J. Mack (Ed.), Borderline states in psychiatry (pp.). New York: Grune & Stratton. May, R. (1953). Man’s search for himself. New York: W. W. Norton. May, R. (1980). Freedom and destiny. London: Norton. May, R. (1986). The discovery of being: Writings on existential psychology. New York: Norton. Miller, A. (1949). Death of a salesman. New York: Putnam. Miller, W., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press. Miller, W., & Rollnick, S. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325–334. Mills, C. W. (1959). The sociological imagination. New York: Oxford University Press. Morrison, J., Bushell, J., Fentiman, J., & Holdridge-Crone, S. (1977). Relationship between psychiatric patients’ attitudes towards mental illness and attitudes of dependence. Psychological Reports, 41, 1194. Nurnberg, G., Raskin, M., Levine, P., Pollack, S., Seigel, O., & Prince, R. (1991). The comorbidity of borderline personality disorder and other DSM-III-R axis II personality disorders. American Journal of Psychiatry, 148, 1371–1377. Parsons, T. (1951). The social system. Glencoe, IL: The Free Press. Perry, C. (1990). Challenges in validating personality disorders: Beyond description. Journal of Personality Disorders, 4, 273–289.

188

REFERENCES

Proust, M. (1981). Remembrance of things past (C. K. Scott Moncrieff, Terence Kilmartin, & Andreas Mayor, Trans.). New York: Random House, 1981. Riesman, D., Denney, R., & Glazer, N. (1950). The lonely crowd: A study of the changing American character. New Haven, CT: Yale University Press. Robertson, J. D. (1988). Psychiatric malpractice: Liability of mental health professionals. New York: Wiley. Rogers, C. R. (1957). The necessary and sufficient conditions for therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Rosegrant, J. (1995). Borderline diagnosis in projective assessment. Psychoanalytic Psychology, 12, 407–428. Rugala, S. A., & Waldo, M. (1998). An integration of existential psychology and the multimodel model. Journal of Humanistic Psychology, 38, 65–79. Sartre, J. (1956). Being and nothingness: A phenomenological essay on ontology. New York: Washington Square Press. Scheff, J. (1963). The role of the mentally ill and the dynamics of mental disorder: A research framework. Sociometry, 26, 436–453. Siever, L. J. (1997). The biology of borderline personality disorder. The Journal of the California Alliance for the Mentally Ill, 8, 18–19. Silk, K., Lohr, E., Ogata, S., & Westen, D. (1990). Borderline inpatients with affective disorder: Preliminary follow-up data. Journal of Personality Disorders, 4, 213– 224. Silk, K., Westen, D., Lohr, N., Benjamin, J., & Gold, L. (1990). DSM-III and DSM-III-R schizotypal symptoms in borderline personality disorder. Comprehensive Psychiatry, 31, 103–110. Spinelli, E. (2003). The interpreted world: An introduction to phenomenological psychology. London: Sage Publications. Tillich, P. (1952). The courage to be. New Haven, CT: Yale University Press. Truax, C. B., & Carkhuff, R. R. (1967). Toward effective counseling and psychotherapy. Chicago: Aldine Publishing. Truax, C. B., & Mitchell, K. M. (1971). Research on certain therapist interpersonal skills in relation to process and outcome. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change: An empirical analysis (pp. 299– 344). New York: Wiley. Valle, S. K. (1981). Interpersonal functioning of alcoholism counselors and treatment outcome. Journal of Studies on Alcohol, 42, 783–790. VandeCreek, L., Knapp, S., & Herzog, C. (1987). Malpractice risks in the treatment of dangerous patients. Psychotherapy: Theory, Research, and Practice, 24, 145–153. van Deurzen, E. (2002). Existential counseling and psychotherapy in practice (2nd ed.). London: Sage. Warren, C. A. B., & Messinger, S. L. (1988). Sad tales in institutions: A study in the microsociology of knowledge. Journal of Contemporary Ethnography, 17, 164 –182. Washington, J. M. (1986). The essential writings and speeches of Martin Luther King, Jr. San Francisco: Harper.

References

189

Whitt, P., & Meile, L. (1985). Alignment, magnification, and snowballing: Processes in the definition of “symptoms of mental illness.” Social Forces, 63, 682–696. Widiger, T., & Weissman, M. (1991). Epidemiology of borderline personality disorder. Hospital and Community Psychiatry, 42, 1015–1021. Winnicott, D. W. (1967). Playing and reality. New York: Basic Books. Winnicott, D. W. (1971). The maturational process and the facilitating environment. New York: International University Press. Wooley, S., & Blackwell, B. (1975). A behavioral probe into social contingencies on a psychiatric ward. Journal of Applied Behavior Analysis, 8, 337–339. Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.

Index

Pages referring to figures are noted with an f Abandonment, 81 Abuse, 137, 155 Acceptance, 33 Accountability, 16, 109 existential, 17–18, 135, 183 future, 112 struggle for, 101 threats to, 24 Activity, 94 Adjustment, 51 Admission, 42 Advocacy, 145 Affective instability, 4 Agency client, 171 dulled, 179 eagerness exposing, 104 exposing, 65, 159 human, 89 modulation of, 83–84 threats of, 115–120 Agentic powers, 81 Alienation, 181 Aloneness, 25, 126 Altruism, 55 Ambivalence, 93, 127–128, 136 Analysis, 170–171, 177. See also Psychoanalysis Angst, 18 Anxiety, 18, 62, 124, 173 Apology, 123–125 Aptitude, 112 Argument, 134

Assessment, 70f, 157 Assumption, 102, 120 Attention, 59, 112. See also Conditional enduring attention Authenticity, 41, 100, 172 in interaction, 59 levels of, 53 patient careerism antidote of, 61–63 Author of change, 45–46 Authorship, 70f, 117, 128. See also Mutual authorship; Self-authorship Automated care, 78 modes, 108 roles, 66f, 72f, 183 Autonomy, 160 Bad faith, 6, 13, 18–19, 133 Bargaining, 156–157 Behavior adjustment, 51 analysis of, 177 BPD associated, 35 as choice, 128 choice as, 141 client, 103 destructive, 124 deviant, 138 deviating from normalcy, 21 dysfunctional, 147 healthy, 182 interpretation of, 174 leading to injury, 107

191

192

INDEX

Behavior (Continued) multivoting, 171–172 of patient careerism, 110 perception, 45 role seeking/generating, 30 supporting, 172 treatment created, 144 Behaviorism, 136 BPD (Borderline Personality Disorder) behaviors associated with, 35 biological root to, 4–5 concept of, 2 labeling, 58 lynch pin of, 22 medicalization of, 7–11 psychopathology of, 3 strategy, 125 theory, 43 Brainstorming, 170–171, 177 Calls, 162, 164 Care, 78, 118 Career, 33 Case conferences, 87 Causation, 155 Caution, 53 Change, 147 author of, 45–46 avoiding, 27 dialectics of, 22–27 language of, 66f, 71f, 132–136 metanarritive of, 68f, 72f reasons not to, 24–27 as source of interpretation, 129–132 suicidality linked to, 140 Charting, 51 Choice, 128, 135, 141, 147 Circumstance, 133 Client(s) agency, 171 ambivalence, 127–128 behavior, 103 clinician relationship with, 104–105, 123, 162

coaching, 132 crisis, 85 decompensation, 90 disruption from, 165 interest, 111 labeling, 144 pain, 78 perception, 122 support, 88–91 therapist overwhelming, 86 threats from, 108 uniqueness, 110–114 Clinical milieus, 139 Clinician(s) approaches, 49 Assumption, 120 assumption, 102 client relationship with, 104–105, 123, 162 deinstitutionalization of, 17 emergency, 42 empathy, 69f gaze, 47–52, 179 interaction, 75 manipulation of, 132 medusaization by, 56–57 negative feelings directed toward, 57 passivity, 79 reluctance for urgency, 99 response, 92 strategy, 60 worldview informing, 16 Coconstruction, 108, 130 Cognition, 51, 77 Comorbidity, 5 Compromise, 32 Concern, 106 Conditional enduring attention, 34–35 Conflict, 145 Conformity, 21, 29, 55, 182 Constituted subjects, 11–12 Contacts, 66f Context, 127 Control, 19

Index Conversation, 73f, 141 Courage, 20–22 CR (Coping Resources), 44f Creativity, 152 Crisis, 44f, 85 Crisis team, 39, 121 Data collection, 170, 176–177 DBT (Dialectical Behavioral Therapy), 3, 166–167 Decentering expertise, 120–122 Decision making, 163–169 Deficit-orientated organization, 178 Dehumanizing culture, 180f Deinstitutionalization, 17, 149 Demedicalization, 63, 102 Denial, 137 Depression, 87 Description, 7 Desperation, 160 Diagnosis category of, 10 description versus, 7 disease, 175 psychiatric, 21 Dialectical Behavioral Therapy. See DBT Dialectics. See also DBT of change, 22–27 context of, 72f of failure, 49, 60, 100–102, 176 tension, 125 Dichotomous thinking, 4 Disappointment, 173 Disease, 8–10, 175 Disorder defining, 6 factitious, 29 munchausen, 29–30 Distress, 21 Distress Tolerance Approach, 130–132 Doctorhood, 46–48, 54–57 Documentation, 157–160 DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders), 3

193

Dynamics, 41 Dysfunction, 147, 168 Dysphoria, 4 Eagerness, 76–92, 103, 104 Effective ineffectualness, 41–43, 59 Emergency clinician, 42 nature of, 173 replacing, 93–94 Emotional status, 35, 84, 86–87 Empathy clinicians, 69f limits to, 76, 77–80 showing, 71f unsatisfying wins of, 80 Encounters, 105. See also Mutual authorship Encouragement, 148 Ethics, 120 Ethos, 52, 65 Etiology, 5, 113 Evaluation, 108 Existential accountability, 17–18, 135, 183 aloneness, 25, 126 anxiety, 18 circumstance, 133 compromise, 32 context of doctorhood, 54–57 courage, 20–22 guilt, 19–20, 91 honesty, 63, 80 pain, 124 phenomenology, 1, 16–17 precipitants, 85 risk, 115 tenets of The Game, 74 terror, 64 urgency, 93–94, 97–99 Expectation(s) bar of, 131 force of, 101 high, 125 maintaining, 36–40

194

INDEX

Expectation(s) (Continued) modulation, 127 of others, 24 raising, 172 real v. imaginary, 86 Experience, 62, 126 Expertise, 122 Failure continuum of, 27 dialectics of, 49, 60, 100–102, 176 personal, 179 self-defined, 25 successful, 32 Faith. See Bad faith; Good faith Feedback, 131, 183 Focus, 75, 102, 129–132 Foreseeability, 154–157 Friendships. See Quasifriendships Fulfillment, 151 The Game approach of, 63–74 areas of, 103–104 attitudinal conditions of, 75–104 existential tenets of, 74 facilitating, 139 irritating aspects of, 148 parameters of, 176 techniques of, 162 tenets of, 115, 159 Gaze, 47–52, 179 Goals, 55, 160 demarcated, 63–64 intervention, 122 life, 97–98 narrative, 129 positive, 143 postponing, 96 realistic, 151, 175 Goffman, Erving, 11 Good faith, 6, 13, 18–19. See also Bad faith Group activities, 178

problems, 131 therapy, 93 Guesswork, 153 Guilt, 19–20, 91 Health, 182 Hermeneutics, 122–123 Hippocratic oath, 52 Homeostasis, 40 Homogeneity, 181 Honesty, 63, 80 Hope, 90–91 Hospitalization, 83, 161 The Hourglass, 169 Humanity. See also Dehumanizing culture agency of, 89 disease inherent in, 8 fundamentals of, 18 Hypermedicalization, 54, 57 Hypochondriasis, 30 Iatrogenesis, 52, 58 Identity flux of, 9 sanctioned, 34 social, 88 Idiosyncrasy, 74, 92, 116 Illich, Ivan, 7–8 Impotence, 15 Independence, 26, 61, 126 Injury, 87, 107. See also Pain Insanity, 21 Insecurity, 37, 57, 79 Institution(s), 77f. See also Deinstitutionalization arrangement within, 11, 109 expertise, 122 interaction, 149 parasuicidalities marriage to, 46 Instruction, 74 Intention, 65 Interaction, 70f authentic, 59

Index clinician, 75 institution, 149 missing, 37 predetermined, 42 routinization of, 92 stages of, 83 urgency infused with, 96 Interpretation of behavior, 174 change as source of, 129–132 structionalist, 12 Intervention, 76, 104, 146 agreement on, 168 goals, 122 inventing, 172–173, 177–178 multivoting, 173–174 psychiatric, 46 Interviewing, 67f, 134, 136–144 Intimacy, 100. See also Pseudointimacy Judgment, 103 Judgmentalism. See Nonjudgmental Judgmentalism Labels, 58, 144 Liability. See also Malpractice organization of, 153–160 patient careerists, 50 points of, 105–110 rules, 154 threat of, 48, 70f Liberation, 64 Licensure, 106 Linear narrative, 32 Macrosocialogical phenomenon, 31 Maintenance, 36–40, 95 Malpractice, 154 Manipulation, 132, 141, 144 Marginalization, 49, 56, 102 Medical culture, 116 dramaturgy, 109 hegemony, 8

195

roles, 54 worldview, 4, 12 Medicalization. See also Demedicalization; Hypermedicalization of BPD, 7–11 of iatrogenesis, 58 Medicine, 47, 52 Mediocrity, 15 Medusaization, 40–41, 56–57, 171 Meetings initiation of, 169–170 organization of, 174 treatment regarded at, 163–168 Mending, 52–54, 76, 102 Mental health care system, 161 Metamessages, 90 Metanarrative, 68f, 72f, 129–132 Modulation of agency, 83–84 expectation, 127 proximity, 34 Mood, 9 Motivation, 67f, 84–88, 136–144, 147 Multivoting, 171–172, 173–174 Mutual authorship, 60 groundwork for, 116 intention of, 65 protecting, 69f pursuit of, 119 Narcissistic Omnipotence, 29 Narrative, 32, 129. See also Metanarrative Needs, 143 Negligence, 155. See also Malpractice Nonjudgmental judgmentalism, 48–50, 145 Normalcy, 110–114 behavior deviating from, 21 creating, 85 defining, 8 facade of, 6 professional, 156 Nurturing, 76

196

INDEX

Objectivity, 56 Ontological destination, 61 homeostasis, 40 insecurity, 37, 57, 79 safety, 64 security, 23, 68f, 119 Optimism, 90–91 Organization case conference, 87 considerations of, 149 deficit-orientated, 178 of liability, 153–160 of meetings, 174 Pain client, 78 emotional, 84 existential, 124 psychological, 161 Paperwork, 164 Paradox, 33, 146–147 Paranoia, 9 Parasuicidality accessibility of, 50 ameliorativity regarding, 154 approaches to, 16–17 axis of, 22–23 as constituted subjects, 11–12 core cause of, 22 curing, 58 defense of, 45 hypermedicalization of, 57 institution married to, 46 intent of, 139 sin of, 100 suicidality versus, 19 symptom of, 10 threats to, 43 treatment, 12f Passivity breaking, 44 clinician, 79 comfort of, 183

conversation about, 73f patient, 30–41 in patient careerism, 29 of theme, 84–85 Patient careerism, 30–41, 81, 92. See also Career authenticity antidote for, 61–63 behavior of, 110 coconstruction of, 108 defense of, 15–16 destabilizing, 76 as deviance, 63 investigating, 27 it-ification, 119 liability, 50 marginalization, 49 passivity in, 29 skills, 43–46 social ecology of, 57–58 tendencies within, 47 theories of, 2, 135, 170–171 PE (Precipitating Event), 44f Perception, 45, 122 Personality, 8, 183 Personhood, 113 Perspective, 138 Pessimism, 37–39, 81, 90–91 Phenomenology, 1, 16–17 Phenomenon, 6, 31, 95 Play, 152 Police, 81 Positivity, 80–83, 143, 175–176. See also Unconditional positive regard Preparation, 169 Procedure, 39 Professionalism, 120 Protocol, 40, 82. See also Procedure Proximity, 34 Pseudointimacy, 26 Psychache, 158–159, 181 Psychiatry, 21, 46, 47 Psychic defect, 132 energy, 88

Index liberation, 64 resources, 12 Psychoanalysis, 136 Psychology barriers set up by, 151 defensive, 88 distress in, 21 ingredients, 147–148 modernity as gift of, 9 nakedness of, 153 nebulousness of, 174 painful, 161 resources of, 25 Psychopathology, 3 Psychotherapy, 105 Quasifriendships, 26 Quasitherapy, 51 Reality, 101, 151, 175. See also Unreality Recidivism, 10 Reflection, 80, 145–146 Relationships client/clinician, 104–105, 162 flexible, 122 nonsensical, 55 roles versus, 138 symbiotic, 79 tertiary, 35 therapists, 62 Research, 153 Residential programs, 121 Resistance, 144 Resources. See also CR psychic, 12 psychological, 25 relational, 33 Responsibility, 49 Restriction, 163 Review, 168 Risk ability to, 23 assessment, 70f, 157 avoiding, 101

197

existential, 115 issues of, 153 plans, 66f, 160–163 of sameness, 98 treatment, 146 Roles automated, 66f, 72f, 183 medical, 54 relationships versus, 138 Routinization, 36–40, 92, 94 Safety, 39, 64, 118, 133 Sameness, 98, 181 Scheduled calls. See Calls Schneidman, Edwin, 158 Security, 23, 68f. See also Insecurity Self-authorship, 16 Self-definition, 182 Self-disclosure. See Strategic self-disclosure Self-harm, 12, 15, 42, 53 Self-soothing, 38 Sensitivity, 116, 159 Sexual abuse, 155 Shame, 64, 134, 159 Society. See also Macrosocialogical phenomenon acceptance in, 33 ecology of, 57–58 feedback from, 183 identity in, 88 impact on, 43 manipulation of, 144 responsibility in, 49 stimuli, 170 Solipsism, 60 Specialty, 122 Spiritual needs, 179 Status emotional, 35 paradoxical, 33 quo, 95 Stimulation, 148 Strategic self-disclosure, 125–126 Strategy, 60, 63, 125

198

INDEX

Structionalist interpretation, 12 Structure care v., 118 day, 117 freedom in, 152 imposing, 175 time, 168 Style, 75 Success, 32, 177 Suffering, 73f Suicidality change linked to, 140 decreasing, 39–40 parasuicidality v., 19 techniques for minimizing, 158 Suicide, 15 conformity form of, 21 five-second, 98 lawsuits involving, 156 preventing, 162 thoughts of, 38 threats of, 111 triggers of, 118 Superficial listening stance, 78 Supervision, 157–160 Support, 76, 88–91 Surveillance, 41, 154–157 Symbiotic relationships, 79 Symptoms iatrogenic, 52 involuntary, 139 of parasuicidality, 10 variety of, 5 Tautology, 137 Techniques. See also The Hourglass communication, 99 DBT, 167 of the game, 162 perspective, 138 repetition, 38 suicidality minimizing, 158 Theory preceding, 1 Tension, 151

Terror, 128 Theme, 73f, 84–85 Theories BPD, 43 patient careerism, 2, 135, 170–171 preceding technique, 1 Therapists client overwhelmed by, 86 frame, 92–94 relationships, 62 style, 75 Therapy. See also DBT; Psychotherapy; Quasitherapy caution in, 53 coconstruction process in, 130 environment of, 84–88 generic, 129–130 group, 93 losing, 25 mainstay of, 76 paradox in, 146–147 solution/problem focused, 88 Threat(s) to accountability, 24 of agency, 115–120 from clients, 108 of liability, 48, 70f to parasuicidality, 43 of self-harm, 53 of success, 177 of suicide, 111 Time, 106, 168 Tragedy, 93, 97 Treatment behavior created in, 144 meetings regarding, 163–168 models, 176 parasuicidality, 12f protocol, 40 recidivism, 10 repetitive, 24 risk, 146 routinization, 36–40 Trust, 78

Index Unconditional positive regard, 99–104, 132 Universality, 71f Unreality, 10 Urgency clinicians reluctance for, 99 eagerness related to, 91–92 existential, 93–94, 97–99

interaction infused with, 96 judgment married to, 103 Urges, 82, 107, 123 Western medicine, 47 Worldview, 1, 4, 12, 16 Zeitgeist, 183

199