{"id":42263,"date":"2013-12-12T12:56:03","date_gmt":"2013-12-12T17:56:03","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=42263"},"modified":"2013-12-12T14:53:19","modified_gmt":"2013-12-12T19:53:19","slug":"postscript","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/12\/12\/postscript\/","title":{"rendered":"postscript&#8230;"},"content":{"rendered":"\n<p align=\"justify\">The thing I&#8217;ve most enjoyed about later life and retirement is that I can think about whatever I want to think about, recall what I want to re-call. I wasn&#8217;t aware of it earlier, but in adulthood proper [<em>the productive years<\/em>], there was a gravitas, something about sticking to a topic or completing a thought, that felt a bit like a straight-jacket. As an analyst, free association had an important meaning as a tool for discovery, but as a person it has another meaning &#8211; it&#8217;s just fun. All this talk of the various psychotherapies that have been tried in psychotic illness set me to thinking about a lot of things, and <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2013\/12\/11\/a-significant-loose-thread\/#comment-252921\">Sandra&#8217;s mention<\/a> of the <a target=\"_blank\" href=\"http:\/\/www.theicarusproject.net\/files\/OpenDialog-ApproachAcutePsychosisOlsonSeikkula.pdf\">Open Dialog<\/a> approach in Finland focused those reflections on some things from a long time ago:<\/p>\n<ul>\n<div align=\"justify\" class=\"small\">As an early resident on a clinic rotation. I was referred a patient who had just gotten out of the hospital after an overdose. I saw her once, and the next thing I knew, she was in the hospital again &#8211; another overdose. I saw her in the hospital, and she couldn&#8217;t really explain much about the why of things. The next morning when I showed up in the clinic, there were two notes waiting for me. The first said that she&#8217;d cut her wrists on the unit the night before. And the second said that her parents were waiting for me. I went to my office and they were already inside. They had brought me something. <\/div>\n<p align=\"justify\" class=\"small\">They&#8217;d been to her apartment and found all of her diaries which they&#8217;d read, and thought I needed to read. I asked if the patient knew they were bringing them. She didn&#8217;t even know they had them, so I said that I couldn&#8217;t look at them without her permission. Her mother began to entreat me to read them, but I couldn&#8217;t tell my patient she was the source. The husband began to explain the wisdom of my comment, and they got into a fight. I asked if they argued often about things that had to do with their daughter. They both turned on me explaining that they weren&#8217;t fighting, took her diaries, and marched off in a huff.<\/p>\n<div align=\"justify\" class=\"small\">After my head cleared, I went to see the patient on the unit. Again she claimed no understanding about the wrist cutting. I wasn&#8217;t having it this time and insisted on a minute by minute account of the day before. It was her birthday. Parenthetically, the patient was a short, stocky woman. Her mother was pretty, and quite thin. The night before, her parents had visited, bringing two presents &#8211; a sexy pink nightgown two sizes too small and a huge box of chocolates.       <\/div>\n<\/ul>\n<div align=\"justify\">That was my introduction to <strong><em><font color=\"#200020\">the double bind<\/font><\/em><\/strong>, and it sent me on a protracted visit to the library, reading the likes of <a href=\"http:\/\/en.wikipedia.org\/wiki\/Gregory_Bateson\" target=\"_blank\">Gregory Bateson<\/a>, <a href=\"http:\/\/en.wikipedia.org\/wiki\/Jay_Haley\" target=\"_blank\">Jay Haley<\/a>, <a href=\"http:\/\/en.wikipedia.org\/wiki\/Theodore_Lidz\" target=\"_blank\">Theodore Lidz<\/a>, <a href=\"http:\/\/en.wikipedia.org\/wiki\/Lyman_Wynne\" target=\"_blank\">Lyman Wynne<\/a>, <a href=\"http:\/\/en.wikipedia.org\/wiki\/R._D._Laing\" target=\"_blank\">R.D. Laing<\/a>, <a href=\"http:\/\/en.wikipedia.org\/wiki\/Harold_Searles\" target=\"_blank\">Harold Searles<\/a>, and others. They are an eclectic lot from different disciplines, but all interested in schizophrenia and crazy family communications [which they sometimes proposed caused the illness]. A classic crazy [or crazy-making] family communication pattern is the double bind [that has four parts]:<\/div>\n<ol><span class=\"small\">      <\/p>\n<li>\n<div align=\"justify\">two contradictory injunctions communicated at different levels ie the nightgown and the chocolates. invade her secrets and keep her mother&#8217;s secrets.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">an injunction against addressing the contradiction.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">the injunction to act, even though there&#8217;s no right action.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">punishment for either acting or not acting on the above injunctions.<\/div>\n<\/li>\n<p>      <\/span><\/ol>\n<div align=\"justify\">Another term for the double bind is <em><strong><font color=\"#200020\">the impossible situation<\/font><\/strong><\/em>. The Open Dialog approach comes from the Bateson family therapy tradition with enhancements. I&#8217;ve been thinking about the double bind recently in relation to the Dan Markingson case in Minnesota [<a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2013\/12\/05\/a-patch-of-blue-2\/\">a patch of blue&hellip;<\/a>]. Dan was in double binds too numerous to count. Just one was being enrolled in a drug trial measuring how long patients voluntarily used a medication but being required to take the medication as a condition of staying in a minimally restrictive environment [involuntary]. Not long before his suicide, he was involuntarily recommitted to stay in the&#8230; I can&#8217;t even finish that, it&#8217;s just too impossible to even say. It reminded me of my english professor sister&#8217;s paper on Hamlet &#8211; a prince double bound [&quot;<em>to be, or not to be<\/em>&quot;].<\/div>\n<p align=\"justify\">I&#8217;m not the one to have much to say about double binds in the etiology of psychosis. I&#8217;ve certainly seen those families where these strange impossible patterns abound and drive therapists crazy. The place where I&#8217;ve encounter double binds is in working with the patients labeled with Borderline Personality Disorder. I realized that there was something they do regularly that fit this motif. &quot;<em>Borderline patients create and attempt to maintain impossible situations<\/em>&quot; is how I&#8217;ve said it. It&#8217;s striking. When they&#8217;re in a situation where they want two mutually exclusive things, they attempt to get them both &#8211; moving back and forth with ease. <\/p>\n<p align=\"justify\">So what does one do in a double bind? an impossible situation? The answer is &quot;nothing,&quot; but that&#8217;s hard work. The ancient Greeks called it &quot;the horns of a dilemma,&quot; and advised &quot;going between the horns&quot; &#8211; meaning forget about either of the first two injunctions, and break the vow of silence. Once upon a time, Dr. Otto Kernberg was talking about a case where a patient had put him in an impossible bind. And then he started talking as if he were talking to the patient. He laid out the two contradictory injunctions, discussed how the secrecy made him feel crazy. Then he described what would happen if he acted either way and of the inevitability of his being punished &#8211; lamenting his defeat. I would&#8217;ve thought by then he&#8217;d be out of breath, but he kept on with the most important part &#8211; he explained why the patient had put him in an impossible situation &#8211; to escape one of their own &#8211; and went on to say what that patient&#8217;s dilemma was and asked how he could help. I wanted to clap. I took away two lessons. If you&#8217;re in a double bind, <em><strong><font color=\"#200020\">don&#8217;t act<\/font><\/strong><\/em> but<em> <strong><font color=\"#200020\">start talking about the impossibility<\/font><\/strong><\/em> from your side. Use that talking time to figure out the other person&#8217;s dilemma if you can, and talk about it. If you can&#8217;t figure it out, ask them what it is and stay on that course on that until the two of you figure it out [&quot;<em>you wouldn&#8217;t have put me in that position if you&nbsp; weren&#8217;t in one of those situations yourself<\/em>&quot;].<\/p>\n<div align=\"justify\">As I said, I have no idea about the etiological relationship between double binding&nbsp; and psychosis. It&#8217;s not my area of expertise, though I&#8217;ve certainly seen plenty. Reading over the Open Dialog project, I decided that their therapists are highly skilled at identifying and working empathically with crazy communications, and that the reward of that effort has been remarkably effective, using medication [lite] only when they need to. That is hard work, learned at the bench of experience with a high tolerance for failure and frustration. Said the Zen Master:  <\/div>\n<ul>\n<div align=\"justify\" class=\"small\"><em>You can&#8217;t learn it from books. You can&#8217;t learn it without books.<\/em>  <\/div>\n<\/ul>\n<div align=\"justify\">I know that learning about double binds was invaluable to me in my work and my life. One particular place was in directing a residency training program in psychiatry, sending green residents to work in the emergency rooms and on the acute wards I&#8217;d left just a few years before. In those situations, they were in double binds with almost every patient, and being able to identify them and parse their way through them was a skill needed on the first day [and every day thereafter]. Being in double binds does make one nutty as a fruitcake, and it&#8217;s hard to think about the patient when you feel the kind of crazy those situations provoke. Over time, it became my first lecture to new residents, using the situations they were about to be walking into as the primo examples. Many later said it was a big help &#8211; like when I run into them now 30+ years later. <\/div>\n<hr size=\"1\" \/>\n<div align=\"justify\" class=\"small\">Postscript: I saw the patient above for four or five years through countless subsequent overdoses. It was a success in that <strike>she<\/strike> <strike>we<\/strike> she survived. Some ten or more years later, I got a package in the mail with no return address. She had sent me the diaries I hadn&#8217;t read all those years before.<\/div>\n","protected":false},"excerpt":{"rendered":"<p>The thing I&#8217;ve most enjoyed about later life and retirement is that I can think about whatever I want to think about, recall what I want to re-call. I wasn&#8217;t aware of it earlier, but in adulthood proper [the productive years], there was a gravitas, something about sticking to a topic or completing a thought, [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-42263","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42263","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=42263"}],"version-history":[{"count":20,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42263\/revisions"}],"predecessor-version":[{"id":42289,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42263\/revisions\/42289"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=42263"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=42263"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=42263"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}