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Tuesday, August 30, 2016

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But some psychiatrist or psychologist somewhere is going to have SUCH a challenging and interesting patient...

I mean, being a judgmental female, it's difficult not to dismiss him as an utter creep, but it's still interesting pondering the moth and flame compulsion. I know nothing about clinical dynamics of exhibitionism, but what intrigues me is trying to think about common threads with things that all of us do that get us into trouble. Namely: we do something that someone, or a lot of people, or even "just" our significant other, or family, say is disgusting or a betrayal or unkind or embarrassing or immature or whatever. We are defensive, mortified, repentant, shamed, hide away, vow never to do it again. It might be talking about family business or getting plastered or flirting with someone not one's spouse, or spending too much money, or making outrageous political remarks, or saying things that mortify one's kid or whatever. And then we just start inching back towards doing it again. We can't help ourselves.

I don't want to cheapen the concept by calling it addictive, because I think that should be reserved for alcohol and substances. But it DOES have to do with the reward centers of the brain, and with stress/relief, and other feedback loops (I'm too tired to be more scientific). We or the nasty person exposing himself get all wound up, tense, uncomfortable, try to distract themself, but then just give in to temptation eventually.

In stupid, greedy ways I see myself doing this as I walk by my coworkers' bowls of icky Hersheys' Kisses every day at work. The first 18 times I walk by them of a work morning, I can resist them. But it get progressively more difficult as I get more irate phone calls, and more people coming to my desk with more complicated demands and/or problems. Finally, someone yells at me or is a little too demeaning, and I grab a handful of the candy, and savagely unwrap it, guzzle it, feel like a sick out of control pig.

Small examples of being greedy and undisciplined give us clues to worse sins that hurt other people more.

I'm judgmental, so my take on the guy is that he's creepy. And yet, part of me is already wondering "what is messing him up so that so obviously intelligent a person would do such a self destructive thing? A thing that so devastates his wife, and that will have such a dreadful effect on his son when he finds out about it as he grows up. THat poor boy will be tormented in school, bullied, hollered at about it...

But I wonder what happened to W as a kid that triggered all this?" If I were a shrink, I would definitely want him as a patient, if nothing else because he has a little boy who deserves to have a father who has got his act together, a kid who needs a father who puts this kind of perverse behavior behind him out of love for that child. I've always believed that it's a GOOD thing for people to get into treatment for the sake of people they love. Because when one first goes in, one is often forced in by circumstances or desperation or ultimata or the law. Or is so low or angry that one doesn't really care to or hope that one can get better. But most parents will do almost anything to become better parents. So maybe he could be motivated to get better for the sake of that sweet little boy, and along the way discover that getting healthier benefits him as well...

It's a different picture from my side.

I've deliberately refrained from commenting publicly on the dynamics of Weiner's behavior, but as you might imagine, I've discussed him with friends/colleagues, and we're all in the same ballpark in our opinions. Not that I don't ever comment publicly on the psychology of a public figure. IMO, on rare occasions, there is a compelling public interest and an abundance of data to test and document hypotheses re public figures, *cough* Trmph *cough*. But I see no compelling public interest in Weiner's case, and while we can ballpark the dynamics, the data is limited to the narrow band of his scandalous behavior, so I'll refrain.

I will say, he's probably not that interesting to most clinicians. Like anyone, there's plenty to look at, but neurotic level problems are generally more interesting than pre-neurotic conditions expressed in compulsions and addictions (I wouldn't use the word addiction in this case either). Thoughtful, introspective people who others might tend to overlook because outwardly they're not a "problem" are often the most fascinating. Borderline personality organization is sometimes an exception to this generalization, but other Cluster B patients, not so much.

There's a countertransference pull to work too hard to succeed with this subset of patients who often present only the most remote possibility of successful treatment. This doesn't mean I don't try or that I lack depth in my thinking or care in my heart. I'm just speaking from cumulative experience (I see a lot of these patients), including the experience of many smart, caring clinicians who commit themselves to working with and studying these exceptionally challenging patients. There are successes from time to time, and I think patients can be misclassified by less sophisticated therapists who automatically classify patients based on symptom categories alone (looks at porn -- diagnose compulsion or addiction--it ain't that simple), but the defenses of Cluster B patients generally make them far less responsive to therapeutic efforts. Analogously, we bring physical ailments to physicians, some of which are highly responsive to treatment, others that are not responsive at all, and everything in between. The doc should do his best, but won't be under the illusion that he's going to save every patient or even the bulk of patients with pancreatic cancer if only he's smart enough and committed enough. Bless those who specialize in those cases, but there is a familiar course that's more tragic than interesting.

There are serious caveats in the generalizations I'm offering, and perhaps I've seen too many Weiners during my career, but honestly, my first private reaction to such patients is a bit of disappointment because I anticipate a taxing patient who will have a difficult time engaging seriously as soon as the immediate crisis has passed. Accurate insight tends to bounce off their primitive defenses, and it typically takes much longer than they're willing to stick around to build a productive therapeutic working relationship.

What I'm saying could be mistaken for cynicism, but that's not what it is. It's candor. I feel for these patients and experience empathy, which is vital to both understanding a patient and forming a therapeutic bond, and quite often I'm very fond of them, but that often means considerable frustrated investment in a patient. I still do it, but it's taxing. I can come home feeling quite depleted after I've seen 3 or 4 of these patients in the daily mix. I probably see more of these patients than the typical clinician because of the nature of my practice (details I won't get into), so I've been over the many variations, permutations and possibilities many times -- it's hard work, and not that interesting when you've seen a couple of hundred over decades.

If you recall my Sausage Party review, I explained that sexual jokes do absolutely nothing for me because of my lack of tension around the subject. That has some bearing here. After seeing so many people about relentless infidelities, their masturbation in diapers, their inability to stop flashing young women and little boys and girls, their sexual attraction to horses and feet, their frotteurism, their prostitutes, their public restroom sex, their child molestation, autoasphyxiation, --- an insight resistant guy with dick pix isn't especially interesting. The novelty of particular disturbances often hidden from the world, wears off, and we're left with an inner impoverishment offering little in the way of a vitality for anything other than symptomatic engagement. These patients are most energetic around avoiding the emptiness.

Back to the tweet I posted, my reaction to the humor in the tweet is an expression of the weariness I can feel about some of these patients. The greatest likelihood of stopping Weiner from engaging in this behavior is some form of external restraint. The joker who posted the tweet isn't a clinician, but IMO the tweet represents a striking insight into the power of Weiner's defenses and symptoms, and the sense of almost inevitable exhaustion of every resource to restrain Weiner's behavior, while, sadly, failing to get anywhere.

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