hart caplan

hart caplan

Counselling - General
Shane Trudell

Antipsychiatry and Depathologization in Cormac McCarthy’s Stella Maris

I’m a therapist so I like to see this stuff wherever I look. But Cormac makes it pretty explicit in this book that he is taking aim at the psy-disciplines: at one point Alicia dissects her “reservations about the souldoctors”, saying “Maybe their lack of imagination. Their confusion about the categories into which they’re given to sorting their patients. As if name and cure were one. The way they ignore the total lack of evidence for the least efficacy in their treatments. Other than that they’re fine”

March 23, 2023
strikethrough a
ADHD
hart caplan

What is adult adhd?

Adult adhd is not a thing. It is as I described in my previous post, a corrupt name that follows a corrupt concept.

February 16, 2023

Confidence as an Intervention: Part I

This article is Part I in a series on the meaning, felt sense, and therapeutic importance of “confidence.” Part I focuses on defining terms, including the use of story (and jokes!). Though I am starting here on a more conceptual note, I am ultimately interested in the relationship between Counsellor and client. And as such, it is my hope that the audience for essays such as this are both clinician and client.
 
In the context of a discussion with another Counsellor discussing the early going of the therapeutic relationship, Shane Trudell, one of the co-founders of Nightingale, noted the following: “confidence is an intervention.” That caught my ear, because confidence is something I’ve been thinking a lot about recently, and in that moment I felt that this was the most succinct way of expressing the relationship between the Counsellor’s confidence (in themselves? in the client? in the therapeutic process?) and the problem the client has brought to session.
 
To intervene means to come between. First, a therapeutic intervention is the process by which the Counsellor demonstrates that there is a distinction between the client and their problem. Second, in the development of the awareness that there is, in fact, a difference between the client and their problem, a therapeutic intervention attempts to disrupt the current relationship between client and problem in the pursuit of a new way of being. It’s worth noting that this new way of being doesn’t necessarily result in a greater degree of peace or serenity. For some clients, this new way of being maybe be a different relationship with their anger or the development of stronger boundaries. Put another way, an intervention isn’t designed to “heal,” as we might have gathered from the ways in which therapy is more often than not represented in social media. Rather, an intervention is designed to bring the truth of the matter to the fore, which then confronts the client with the question: how to proceed? An intervention is a disruption to the client’s system of daily living.
 
Let’s take a moment to focus on the first aspect here, because the second is more in the realm of what we generally think psychotherapy is: i.e. therapist and client working to disrupt patterns of thinking and feeling (emotions and bodily sensations) and ultimately behaving. But before a client can join their therapist in the space between them and their problem, it must first be demonstrated that their is an in-between.
 
Clients regularly come into my office and say things such as the following: “I’m anxious,” or “I’m depressed.” In that formulation, there is no space between the client and their problem, because contained in the language of their “diagnosis” is the idea that they are the problem. The client doesn’t claim that they experience anxiety or depression but that they are anxiety and depression. Expressing the problem in this way is to make the problem indistinguishable from the person of the client.
 
The first thing the therapist must do is to communicate to the client that their problem is distinct from their person. Here’s how I commonly do that: I ask the anxious client about the contexts in which their anxiety arises. For the vast majority of clients, problems are contextual or situational or environmental. That is, the problem isn’t in them but is produced in the context of particular environment. I’ll ask questions that attempt to demonstrate a sense of difference. For instance, “in what domain do you experience anxiety: work or your romantic relationship or your friendships or family connections?” The problems that clients bring to session tend to exist in particular places with particular people at particular times. For instance, a client might note that every time they see their boss’s email show up in their inbox, they feel a rush of anxiety, owing to something they imagine they’ve done and some terrible consequence will follow. I then ask about the different domains of their life: “when you get an email or text from your partner, do you experience the same thing?” They regularly answer, “no. I really only have that feeling at work. My (insert partner’s title here) is a great support.”
 
I am a very “cards on the table kind” of therapist, and I like to consciously bring the client’s attention to this difference, because the fact that there is a difference means that the problem is not the client but the client plus a whole series of contextual features. And so… if the problem isn’t the client or isn’t even in the client, then before there is even any talk of therapeutic intervention, you have already established in the client the possibility of change. Even better, you have communicated to the client that those things that might need to change are not in them but in their relationship to and with particular environments.
 
I am reminded here of the very old joke:

Patient: Doc. It hurts when I do this.
Doctor: Well... then don’t do that.

Henny Youngman
The joke works on the same premise I’ve described above—it’s not that the patient has a global problem of pain. The pain in the patient is produced when that patient does something in a particular way. The patient could take the Doctor’s advice and simply stop doing whatever is producing the pain. Or the patient could think about the relationship they have with the action that produces the pain. The point is that problems are generally not the client and not even in the client but are the product of the client and their relationship to other people, places, objects, and even intervals of time, e.g. the time of day or relation to one’s menstrual cycle or time of year.
 
We could update the joke to make it more pertinent to a psychotherapeutic context:

Client: Every time I go over to my parents’ place for brunch, I’m faced with the feeling of not living up to my potential.
Therapist: Then don’t go over to your parents for brunch.

I started this essay with the intent of discussing confidence, so let’s return there. I’ve started with the last part first, i.e. defining “intervention” in the context of a therapeutic relationship between Counsellor and client. But before we talk about confidence as an intervention, what exactly is confidence?
 
For those who read these posts, you know that population that I spend the majority of my time working with and thinking about are people with adhd (for an explanation of my way of representing adhd, please read Kill the meaning. Keep the name). My experience with adhd—my own and my clients—has been, in part, a confrontation with the problem of confidence.
 
People with adhd lean heavily towards the indecisive. The metabolic resources that people with adhd put into their decision making processes are staggering. Unfortunately, there is no metric that represents the difference between the resources consumed by neurotypical vs neurodiverse populations. I can’t say that on average a person with adhd spends x times more minutes or burns x times more glucose in decision making mode. I can tell you though that people with adhd regularly suffer from fatigue—sometimes crushing fatigue—that is the result of this constant and conscious requirement to make decisions and adjudications on a moment-by-moment basis. But how does this speak to the question at hand, on the topic of confidence?
 
This is my hypothesis: confidence is not a thing. It is not a positive or affirmative state. Confidence is a state of absence or a lack. Confidence is the relative absence of doubt and indecisiveness. Confidence is the incapacity to see and take seriously the ways in which things can go wrong. Confidence is a particular relationship to the future.
 
Contrast this with the first few lines of the Wikipedia entry on confidence:

Confidence is a state of being clear-headed: either that a hypothesis or prediction is correct, or that a chosen course of action is the best or most effective. Confidence comes from a Latin word 'fidere' which means "to trust"; therefore, having self-confidence is having trust in one's self.

The standard definition of confidence, as the lines immediately above demonstrates, suggests that confidence is a something, i.e. it is a state of relatively greater amount of clear-headedness. That means that clear-headedness is a positive attribute. If this is true, then the way to greater confidence is achieved by moving towards greater clarity. But again I come back to my same hypothesis: clarity is not a positive state but rather the absence of doubt or ambiguity or indecisiveness.

Ringing Bell

And this is where the experience of working with an adhd population has been so instructive in my thinking. Increasingly, my fundamental description of the experience of being a person with adhd is in terms of being relatively more open and undefended vis a vis one’s environment (please see my previous post on The No of ADHD). The result of that undefendeness (again a state of absence) is that those of us with adhd experience a much greater degree of noise in our environments. As I wrote earlier, that noise can be actual auditory noisiness, but it can also be emotional/relational noisiness—the experience of not being able to distinguish other people’s desires and emotional states from your own—the noisiness of perceived disorder, spatial noisiness, and even the noisiness of our own bodies and pasts, i.e. our memories. Taken in total, this produces in people with adhd a discordant symphony of noise. That is what it means to live as a person with adhd. It is not that people with adhd are fundamentally inattentive and or hyperactive. Those are simply the downstream behavioural effects. They are the effects of living in that discordant symphony of noise, day after day, and year after year.

Let me take a short detour to hopefully drive home the discussion of the effects of noisiness using a very extreme example. I do so with a little trepidation, because I want to make certain that what I would like to introduce is done so respectfully given the brutality in which this example originated.
 
The extreme example I would like to introduce is the use of particular torture techniques that were used during the illegal detention of prisoners of war in Guantanamo Bay. Starting in 2003, the authorities at the prison started to use noise as a technique of torture. Piercingly loud music was aimed at prisoners, who were unable to move, unable to protect their hearing, unable to protect themselves. This would go on all day everyday, sometimes for weeks and sometimes for months. What follows is part of an account by a person who suffered this torture:

It makes you feel like you are going mad. You lose the plot and it's very scary to think that you might go crazy because of all the music, because of the loud noise, and because after a while you don't hear the lyrics at all, all you hear is heavy banging.

Ruhal Ahmed

I make this comparison cautiously, but I think you can see the relationship of this technique of torture to the experience of being a person with adhd: the experience of being unable to turn the volume down on your environment. Notice what Ahmed says here: “you lose the plot… because of all the music.” What’s the plot? My reading of his use of “the plot” is something like the narrative of his life or sense of self. If the only thing that you hear on a loop is the theme song to the children’s show “Barney” or “Fuck your God” by Deicide—both compositions that were used for the purpose of torture in Guantanamo Bay—you might forget the story of your life. You might even forget that you are a person. That’s what it might feel like to “go mad.”

MadnessIs “madness” an outcome of adhd? Generally it is not. But for certain, there are many difficult outcomes that are regularly associated with adhd. The technical term for these outcomes is “comorbidities.” I generally don’t like the use of “comorbidity,” because the term suggests that they are phenomena “that present at the same time” (link). The reason I mostly reject comorbidity as a descriptor is for the following: it is my hypothesis that these phenomena do not present at the same time but, rather, flow from others. For instance, a list of outcomes that are listed as comorbidities but I think are actually consequences of adhd are the following: depression, dysthymia, panic disorder, PTSD, sleep disorders, and substance abuse disorders. Anxiety is a different type of phenomenon that I will discuss in full in a later post.

The experience of people with adhd speaks so directly to the discussion of confidence, because it brings to the fore the question of whether the experience of a feeling of confidence is a positive or a negative attribute. It further speaks to the question of whether the characteristics regularly attributed to people with adhd,—e.g. hyperactivity, restlessness, inattention, and forgetfulness to name a few—are also positive or negative attributes. It is important to reiterate that positive and negative do not have any relationship to judgment, i.e. goodness and badness. Positive here simply means present and negative absent.

Let me conclude Part I here by restating my hypothesis: confidence is the absence of doubt. It is the inability to see the ways in which things can go wrong. Through a certain lens, confidence can be seen as a lack of imagination. The corollary of that hypothesis is that doubt precedes confidence. Doubt is the starting place. Doubt is the place in which we fundamentally dwell. Confidence is the ability—not a conscious ability—to inhibit the noise of doubt.

In the posts that follow, I will return to the way in which confidence can be an intervention through a discussion of a Counsellor’s relationship to confidence and doubt and knowing and not knowing.