Although I really do listen to the content of a session, and take a truly detailed history (without which I would not presume to begin treatment of anybody), my third ear is tuned to the affects displayed by the person I'm now getting to know. Joseph seems awash in shame, with a tiny nod to guilt; while I worked to get a set of clear answers to my history format, I would be looking for information about the history of his affective expression. From the tiny amount we've heard so far, what in medicine we call the "history of the present illness," we know that he has been overwhelmed by intense emotions that have left him poorly able to live in his world. Apparently he is afraid that he is an unworthy person, and that bad things may happen to him because of what he has actually done or because of thoughts that have occured to him. Usually the history is colored by the affects that have brought someone into treatment. In Joseph's case, we are led to believe that the affects associated with two major diagnostic categories have been out of control on those occasions he has needed clinical attention. Bipolar affective illness is always characterized by problems with the expression and modulation of the affect interest-excitement: when the patient expresses excitement out of proportion to what we therapists consider a normal range of response to a stimulus, we say s/he is hypomanic; when the patient is less able than someone in the normal range of affective expression to demonstrate interest-excitement, we use wastebacket terms like "depression." In any of us, just by the normal physiology of affect, of affect dynamics, whenever interest-excitement is impeded (in a situation when there is adequate reason for that affect to be maintained), shame affect is triggered; the normal responses to shame affect have been described as the four points of a compass---withdrawal, pathological deference (attack self), narcissistic self aggrandizement (avoidance), and attack other. Hypomanic patients are usually brought to clinical attention when they express anger as part of the attack other response to shame. If the way they express anger involves the "idea" that others are trying to shame them (the basic content of many or most delusions and halucinations, if one cares enough to ask for such data), then they are often seen as paranoid. Indeed, before psychiatrists in the USA had any exposure to the use of Lithium salts in the late 60s, we diagnosed bipolar affective illness only rarely, as opposed to our European colleagues, who "saw" it much more frequently. Now clinicians on both sides of the big lake make these diagnoses at pretty much the same frequency. All this to suggest that it is really quite common in hospital work to see patients who have been diagnosed with both paranoid schizophrenia (or schizophreniform illness, or schizoaffective disorder) as well as manic depressive illness. Whether these two clinical conditions can co-exist as stable illnesses each with its own course has been the subject of some debate, although most of us do believe that people can have all the bad luck they can handle. As for Joseph, I suspect that we will learn quite a bit about his nearness to shame, and that every aspect of his case in the first portion of therapy will revolve around the way he behaves or thinks when experiencing shame. As I've described this situation elsewhere, I think he will go 'round the compass of shame like a propeller on a beanie. Withdrawal, attack self, avoidance, and attack other. In or out of sequence, but so frequently that therapy will hinge largely on the therapist's sophistication in the realm of shame.
Replies:
|
| Behavior OnLine Home Page | Disclaimer |
Copyright © 1996-2004 Behavior OnLine, Inc. All rights reserved.