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How you attach to people may explain a lot about your inner life | Science

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In 2006, a team of Norwegian researchers set out to study how experienced psychotherapists help people to change. Led by Michael Rønnestad, a professor of clinical psychology at the University of Oslo, the team followed 50 therapist-patient pairs, tracking, in minute detail, what the therapists did that made them so effective. Margrethe Halvorsen, a post-doc at the time, was given the job of interviewing the patients at the end of the treatment.

That’s how she met Cora – a woman in her late 40s, single, childless, easy to like. As a kid, Cora (a pseudonym) had suffered repeated sexual abuse at the hands of her mother and her mother’s friends. Before entering therapy, she habitually self-harmed. She’d tried to kill herself a number of times, too, her body still scarred by the remnants of suicides not carried through.

“Her story was in the room,” Halvorsen tells me, then grows quiet as she stumbles to convey the strong impression that Cora left on her. Seven years after they met, it’s still hard to articulate: “Maybe presence is the right word.”

It was the way that Cora spoke of the atrocities done to her – in a steady voice, with clear eyes – that made the researcher wonder how someone so scarred could seem so alive, and undiminished.

At one point during their interview, when Halvorsen asked Cora to describe her therapy in a picture or a word, she’d blurted out: “It saved my life.” Intrigued, she invited three fellow psychologists to help her delve deeper into Cora’s case and uncover what had happened in the therapy room.

“We didn’t know what we were getting into,” Halvorsen told me. Following initial interviews with both Cora and her therapist, the researchers ploughed through a total of 242 summary notes that the two had written after each session over the course of the three-year study. From this data, the team selected and transcribed verbatim 25 sessions that seemed particularly important. The final material approached 500 pages of single-spaced text. Halvorsen and her colleagues puzzled over it for more than two years in a bid to understand what, exactly, had saved Cora’s life.

When you delve into it, the question of how people change through therapy can make your head swim. Here’s a psychological intervention that seems to work as well as drugs (and, studies suggest, possibly better over the long term), and yet what is it, precisely, that works? Two people sit in a room and talk, every week, for a set amount of time, and at some point one of them walks out the door a different person, no longer beleaguered by pain, crippled by fear or crushed by despair. Why? How?

Things get even more puzzling if you consider the sheer number of therapies on offer and the conflicting methods that they often employ. Some want you to feel more (eg, psychodynamic and emotion-focused approaches); others to feel less and think more (eg cognitive behavioural therapies, or CBT). The former see difficult emotions as something that needs to come out, be worked through and re-assimilated; the latter as something to be challenged and controlled through conscious modification of negative thoughts.

Some therapists don’t even talk much of the time, letting the silence wring uncomfortable truths out of their clients; others hardly pause between structured sequences of exercises and homework assignments. Across more than 400 psychotherapies available today, your shrink can take the form of a healer, a confidante, a clinical expert, a mental-fitness coach or any combination, shade and hue of these.

Over the past three years, I’ve talked to dozens of therapists from various schools, trying to understand how therapy works – and by this I mean heals: the darker entrapments of compulsive confession or the complex entanglements of unresolved transference are not my subjects here. Lately, I’ve broadened my quest to understand the basis of therapeutic efficacy to include researchers as well as practitioners, but most of these conversations left me feeling that neither the experts studying therapeutic change nor those effecting it could, when pressed, convincingly explain how people heal.

Begrudgingly, I kept going back to what Alan Kazdin, a professor of psychology and child psychiatry at Yale University, said in 2009 in a widely cited paper: “It is remarkable that after decades of psychotherapy research we cannot provide an evidence-based explanation for how or why even our most well-studied interventions produce change.”

To complicate matters, numerous studies over the past few decades have reached what seems a counterintuitive conclusion: that all psychotherapies have roughly equal effects. This is known as the “dodo bird verdict” – named after a character in Alice in Wonderland (1865) who declares after a running contest: “Everybody has won and all must have prizes.” That no single form of therapy has proved superior to others might come as a surprise to readers, but it’s mightily familiar to researchers in the field. “There is so much data for this conclusion that if it were not so threatening to specific theories it would long ago have been accepted as one of psychology’s major findings,” writes Arthur Bohart, professor emeritus at California State University, Dominguez Hills, and author of several books on psychotherapy.

Even so, this alleged equivalence among various therapies is a product of statistics. It says nothing about what works best for each specific individual, nor does it imply that you can pick any therapy and obtain the same benefit. Perhaps some people fare well with the structure and direction of a cognitive approach, while others respond better to the open-ended exploration and sense-making offered by psychodynamic or existential perspectives. When aggregated, these individual differences can cancel out, making all therapies appear equally effective.

A lot of researchers, however, believe that this is not the only explanation. For them, the deeper reason why no single psychotherapy seems to provide unique advantages over any other is that they all work because of shared elements. Chief among these is the therapeutic relationship, connected to positive outcomes by a wealth of evidence.

The emotional bond and the collaboration between client and therapist – called the alliance – have emerged as a strong predictor of improvement, even in therapies that don’t emphasise relational factors.

Until recently, most studies of this alliance could show only that it correlates with better mental health in clients, but advances in research methods now find evidence for a causal link, suggesting that the therapy relationship might indeed be healing. Similarly, research into the traits of effective therapists has revealed that their greater experience with or a stricter adherence to a specific approach do not lead to improved outcomes whereas empathy, warmth, hopefulness and emotional expressiveness do.

All of this suggests a tantalising alternative to both the medical professional’s and the layperson’s view of therapy: that what happens between client and therapist goes beyond mere talking, and goes deeper than clinical treatment. The relationship is both greater and more primal, and it compares with the developmental strides that play out between mother and baby, and that help to turn a diapered mess into a normal, healthy person. I am referring to attachment.

To push the analogy further, what if, attachment theory asks, therapy gives you the chance to reach back and repair your earliest emotional bonds, correcting, as you do, the noxious mechanics of your mental afflictions?

Attachment theory traces its roots to the British psychoanalyst John Bowlby, who in the 1950s combined evolutionary theory and psychoanalysis into a brave new paradigm. Aghast at his profession’s lack of academic rigour, Bowlby turned to the burgeoning science of animal behaviour. Experiments with infant monkeys (some so plainly cruel that no ethical board would permit them today) had challenged the then prevailing notion that infants see their mothers chiefly as a source of food.

Bowlby realised that “the mother-infant bond is not purely generated by the drive to latch onto the breast, but it’s also motivated by this idea of comfort”, says Jeremy Holmes, a British professor of psychological therapies (now part-retired) and co-author of the book Attachment in Therapeutic Practice (2018).

The search for comfort, or security, Bowlby argued, is an inborn need: we’ve evolved to seek attachment to “older, wiser” caregivers to protect us from danger during the long spell of helplessness known as childhood. The attachment figure, usually one or both parents, becomes a secure base from which to explore the world, and a safe haven to return to for comfort. According to Holmes, Bowlby saw in attachment theory “the beginning of a science of intimate relationships” and the promise that “if we could study parents and children, and the way they relate to each other, we can begin to understand what happens in the consulting room” between client and therapist.

Research on attachment theory suggests that early interactions with caregivers can dramatically affect your beliefs about yourself, your expectations of others, and the way you process information, cope with stress and regulate your emotions as an adult. For example, children of sensitive mothers – the cooing, soothing type – develop secure attachment, learn to accept and express negative feelings, lean on others for help, and trust their own ability to deal with stress.

By contrast, children of unresponsive or insensitive caregivers form insecure attachment. They become anxious and easily distressed by the smallest sign of separation from their attachment figure. Harsh or dismissive mothers produce avoidant infants, who suppress their emotions and deal with stress alone. Finally, children with abusive caregivers become disorganised: they switch between avoidant and anxious coping, engage in odd behaviours and, like Cora, often self-harm.

Anxious, avoidant and disorganised attachment styles develop as responses to inadequate caregiving: a case of “making the best of a bad situation”. But the repeated interactions with deficient early attachment figures can become neurally encoded and then subconsciously activated later in life, especially in stressful and intimate situations. That’s how your childhood attachment patterns can solidify into a corrosive part of your personality, distorting how you see and experience the world, and how you interact with other people.

The psychologist Mario Mikulincer of the Interdisciplinary Center Herzliya in Israel is one of the pioneers of modern attachment theory, studying precisely such cascading effects. In a number of experiments spanning two decades, he has found that, as adults, anxious people have low self-esteem and are easily overwhelmed by negative emotions. They also tend to exaggerate threats and doubt their ability to deal with them. Driven by a desperate need for safety, such people seek to “merge” with their partners and they can become suspicious, jealous or angry towards them, often without objective cause.

If the anxious among us crave connection, avoidant people strive for distance and control. They detach from strong emotions (both positive and negative), withdraw from conflicts and avoid intimacy. Their self-reliance means that they see themselves as strong and independent, but this positive image comes at the expense of maintaining a negative view of others. As a result, their close relationships remain superficial, cool and unsatisfying. And while being emotionally numb can help avoidant people weather ordinary challenges, research shows that, in the midst of a crisis, their defences can crumble and leave them extremely vulnerable.

It isn’t hard to see how such attachment patterns can undermine mental health. Both anxious and avoidant coping have been linked to a heightened risk of anxiety, depression, loneliness, eating and conduct disorders, alcohol dependence, substance abuse and hostility. The way to treat these problems, say attachment theorists, is in and through a new relationship. On this view, the good therapist becomes a temporary attachment figure, assuming the functions of a nurturing mother, repairing lost trust, restoring security, and instilling two of the key skills engendered by a normal childhood: the regulation of emotions and a healthy intimacy.

When Cora began therapy, it was clear that she would be a challenging patient. The letter from her GP asked for someone “courageous” to treat her, and you could see why: she insisted on retaining her right to self-harm and suicide. “I had the feeling that she could kill herself in the middle of the therapy, and I just had to take that risk,” her therapist told the researchers at the end of the study. So how did he manage to pull Cora back from the brink?

In teasing out some answers from the reams of data they’d collected, Halvorsen and her team found a curious call-and-response pattern emerging between Cora and the therapist, which has an analogue in mother-infant interactions. First, Cora would put herself down, then the therapist would acknowledge her negative emotions but also deflect them right away, recasting her destructive tendencies as survival mechanisms that she’d used as a kid to protect herself from the trauma but which hampered her as an adult. Gently but firmly, he challenged her self-loathing by reframing what she saw as damning and unacceptable about herself into something human and understandable.

Often, he asked her to think of “the child on the staircase”, referring to a memory that Cora had shared in an earlier session. “It is a really upsetting scene,” Halvorsen told me – one in which Cora’s mother gets angry at her. ‘I think she filled a suitcase with some of the child’s clothes and told the little girl to leave. And the girl was sitting outside on the staircase for many hours, and didn’t know what to do or where to go.” The therapist, Halvorsen noticed, would return to this scene over and over again, trying to evoke Cora’s self-compassion and counter her unrelenting self-criticism.

This pattern of empathising, then reframing and de-shaming looks uncannily like the mirroring-and-soothing exchanges between mother and infant in the first years of life. Spend any amount of time around a newborn and you’ll see that, when baby cries, mum swoops in, picks him up and then scrunches her face in an exaggerated imitation of his distress. According to Peter Fonagy, a psychopathology researcher at University College London, who has long studied children and young people, the mother’s amplified reflection forms a key part of the child’s developing a sense of self and emotional control. “Anxiety, for example, is for the infant a confusing mixture of physical changes, ideas and behaviours,” he told me. “When the mother reflects, or mirrors, the child’s anxiety, he now ‘knows’ what he’s feeling.”

This knowledge, says Fonagy, doesn’t come prewired into us. We don’t understand the meaning of our internal experiences until we see them externalised, or played out for us in the faces and reactions of our caregivers. “Paradoxically, even though I now know perfectly well when I feel anxious,” Fonagy explains in a video interview from 2016, “the anxiety that I recognise as my anxiety is actually not my own anxiety but is my picture of my mum looking back at me when I as a baby felt anxious.” The sensitive mother picks up on the infant’s mental and emotional state and mirrors it; the child learns to recognise his internal experience as “sadness” or “anxiety” or “joy”. Previously chaotic sensations now become coherent and integrated into the infant’s sense of who he is, allowing emotions to be processed, predicted and appropriately navigated.

But mum doesn’t just mirror baby’s emotional pain; she soothes it. Rocking the infant in her arms or cooing in that mellifluous voice that stops tears in their tracks, the responsive mother contains the baby’s negative feelings. Distress, writes Holmes in 2015, “is transmitted from baby to mother, ‘metabolised’ via mother’s musings” and so predigested. It is given back to the baby in an altered, less intense form.

Cora’s therapist likewise helped her to assimilate her most painful feelings. By learning to tolerate negative states, she could develop resilience in the face of her darker inner experiences. He encouraged her to let out her shame and anger, reflecting them back empathically in a way that made her feel seen and known. But he also contained and transformed those emotions for her by re-narrating them in terms of adaptation, protection and survival. Like a good mother, he predigested Cora’s distress by making sense of it and, by giving it a meaning and explanation, he transformed it into something that could be accepted and endured.

Eventually, the co-regulation of emotions between mother and infant, or therapist and client, paves the way to self-mastery and self-regulation. One way this happens in the early years, writes Mikulincer in 2003, is by internalising the caregiver: her voice and attitude become a part of you, and when you hit a rough patch, you pick yourself up using the same words your mother once used to soothe you. Another way to be weaned off emotional dependence in childhood is to grow your own inner resources by tackling and learning from challenges. In stretching herself, the young child confronts the inevitable risk of failure, as well as fighting the allure of myriad other activities, such as playing with toys or sticking her fingers into power sockets. “With the support, reassurance, guidance and encouragement of a caring and loving attachment figure, children can cope better with failure, persist in the task despite obstacles, and inhibit other impulses and distractions,” Mikulincer told me. In this way, kids increase their tolerance of negative emotions, and master valuable skills to deal with problems on their own.

A similar process occurs in therapy. After a while, clients internalise the warmth and understanding of their therapist, turning it into an internal resource to draw on for strength and support. A new, compassionate voice flickers into life, silencing that of the inner critic – itself an echo of insensitive earlier attachment figures. But this transformation doesn’t come easy. As the poet WH Auden wrote in The Age of Anxiety (1947): “We would rather be ruined than changed.” It is the therapist’s job, as a secure base and safe haven, to guide clients as they journey into unfamiliar waters, helping them stay hopeful and to persist through the pain, sadness, anger, fear, anxiety and despair they might need to face.

This happens not just through talking but wordlessly, too. In fact, according to the psychologist Allan Schore of the University of California, Los Angeles, who has studied attachment from the viewpoint of neurobiology over the past 20 years, change in therapy occurs not so much in the intellectual communication between client and therapist but in a more imperceptible way – through a conversation between two brains and two bodies. Perhaps this mode of attachment predominates in therapies where there is less talking, and more rule-following.

Once again, the process mirrors good caregiving early in life. Long before speech, mother and infant communicate with each other via nonverbal cues – facial expression, mutual gaze, vocal nuance, gesture and touch. In the squeeze of his fist, in the batting of an eyelash, the sensitive mother “reads” her child’s emotional states and responds appropriately through her own body. These wordless communications, writes Schore, get registered and processed by the baby’s right-brain hemisphere, shaping the nascent neural systems involved in emotion processing and automatic stress responses. Mum’s nonverbal signals become encoded as implicit, non-conscious strategies that the infant’s right brain will later activate unconsciously to regulate his emotions.

Again, something similar plays out in therapy. The good practitioner subconsciously tunes in to those emotions left unsaid, to the internal states the client might not even be aware of. Moment by moment, the therapist adjusts her own body language in response to her client’s internal rhythms, engaging them in a kind of dance in which both partners mutually influence and synchronise themselves to each other. According to Schore, over time the nonverbal attachment communications from the therapist can become imprinted into the client’s right brain, revising stored coping patterns, and giving rise to more flexible and adaptive ones.

To Fonagy, a factor that is just as fundamental to the restoration of wellbeing in therapy is social learning. From the vantage point of evolution, we might be hardwired to mistrust others because a negative bias serves survival. Yet, for an intensely social species such as ours, being constantly on guard doesn’t bode well. How, then, do we trust, cooperate and connect with other people while also protecting ourselves from the threat that they might pose?

The theory of natural pedagogy, proposed in 2011 by Gergely Csibra and György Gergely, professors of cognitive science at the Central European University in Budapest, suggests an answer. In this view, evolution has engineered a nifty mechanism to relax our natural vigilance so that we can learn from others. To recognise relevant and trustworthy sources of information, we rely on certain visual and verbal cues or signals. In childhood, writes Fonagy in 2014, these cues are the same ones that underlie secure attachment (the special vocalisations of “motherese”, for example). Babies, in other words, are primed to trust the sensitive caregiver, who, in turn, teaches them how to trust others and navigate their social world. A study from Harvard University in 2009 shows that securely attached children are discerning judges of credibility – they trust mum when she is being reasonable but go with their own judgments when her statements run against reality. Their security in themselves and others turns these kids into adults open to new information, comfortable with uncertainty and flexible with changing their views in light of new data.

The opposite holds for the insecurely attached. Anxious people tend to distort social cues and exaggerate threats, and this can mislead them into seeing their partners as unreliable, unsupportive or uninterested. Avoidant people focus on protecting themselves, which can make them cling to negative stereotypes of others in the face of ample evidence to the contrary. For example, Mikulincer’s study in 2003 had married couples rate their partner’s behaviour over the course of three weeks. While anxious people gave higher ratings when their spouses were objectively more supportive, avoidant people completely failed to register positive changes in their partners.

Insecure attachment, it appears, perpetuates our natural suspicion, keeping us closed off and unreceptive to socially relevant information. Fonagy calls this “epistemic mistrust”, and for him it might be the common denominator of many mental-health problems, explaining their severity and persistence. The chief value of psychotherapy, he says, lies in its potential to rekindle our epistemic trust and jumpstart our ability to learn from others in our social environment. By restoring attachment security, therapy lowers our social vigilance and opens us to trusting one person – the therapist – which eventually allows us to go out into the world and trust other people. The importance of this recognition is such that even in CBT sessions, when therapists are bombarded by clients’ upset feelings, they will temporarily shift their usual agenda or stance to empathise with the feeling state, and then shift back to emphasising cognitive themes and the rational control of emotional experience.

The restoration of secure attachment is what happened with Cora, too. In her last sessions, she realised that she wasn’t actually alone. She had a friend she could count on, and a sister who shared her childhood memories. It wasn’t that these people were absent before; she just wasn’t seeing them, or perhaps not trusting what was right in front of her. But her growing trust – first in the therapist, then in the goodwill of the world and her own ability to navigate it – allowed her to see others “more as opportunities for social contact, rather than threats”. Cora was by no means cured by her therapy: her trauma ran too deep. But she was saved. She was ready to live and to keep healing.

In their last session together, Cora left the therapist a parting gift – a carabiner. It is how, in the mountains, two climbers stay securely attached by rope, so that, if one stumbles, the link with the other will keep him from falling into the precipice.

This essay was originally published in Aeon. It was made possible through the support of a grant to Aeon from the John Templeton Foundation. The opinions expressed in this publication are those of the author and do not necessarily reflect the views of the Foundation. Funders to Aeon Magazine are not involved in editorial decision-making.

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diannemharris
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Placebo effect seems to neatly describe the benefits of therapy.
iridesce
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Facial recognition for the public: Yandex

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You can use Yandex Image Search right now as a pretty good facial recognition system for anyone who has labelled photos on the Web. I believe this is the first generally accessible facial recognition system with a large database. Yandex isn’t designed for this purpose. The trick is to upload photos cropped to a face and it’ll work more or less to find similar faces.

This post was inspired by Bellingcat’s recent post on image search which noted Yandex’s image search as something particularly good and particularly called out the facial recognition. I’m just elaborating on what he found.

Demonstration with a selfie

Here’s a selfie I took today. It’s never been on the web before this post and appears in no databases as I do these searches. This is a good clear photo of me, which makes the results better, but it works with less good photos too.

Now pretend you didn’t know my name. Put the image in to Yandex. Here’s the result you get.

The first two images are me. Click on either of them and the web page it takes you to has my name on it. Now you know who I am!

It’s not perfect; there’s no name provided directly, someone has to read the linked page to find one. And a person still has to sift through the near-matches of faces. But it’s pretty good. The only limit is Yandex’s database. That’s kind of “the whole web”, but their index is nowhere as comprehensive as Google.

Demonstration with Andrew Yang

Recognizing myself is easy. How about a stranger? I used this today to identify who the “Yang” was in this image from CNBC. It’s supposed to be Andrew Yang, the presidential candidate, but it is not.

Crop the image to Yang’s face, put it in Yandex, and you get this

All five of the first images look like our guy. The first result on the Yandex result page also leads directly to his home page: Geoff Yang. Some CNBC intern is gonna be in so much trouble! (This post is not an endorsement of Andrew Yang.)

Facial recognition vs image search

The new thing here is that Yandex is working not just as a reverse image search tool; it seems to be doing facial matching. None of the images it finds look much like the original image; different aspect ratio, different background, different details. But the faces match. It even matches my selfie both to a much younger version of me without a beard and to a version of me holding a box up obscuring part of my face. That’s pretty wild.

FWIW, here’s what other image search engines do with my selfie. I tested Google, Baidu, Bing, and TinEye. TinEye returned 0 results.

Google
Baidu
Bing

Look at all the beardy white guys with some yellow in the image! None of them are me. It’s not a bad guess; I gave it a head shot, it found me similar head shots. But it didn’t find my face. Yandex finds my face. (Arguably TinEye’s 0 results is the right answer for this query; this image does not exist online.)

Why this matters

We’re on the cusp of a major change in day to day privacy with facial recognition algorithms. AI has now gotten good enough that it can do excellent facial recognition; modern software can take a blurry photo of half a face and match it to other faces of the same person. It’s a pretty scary future, particularly as already put into place by authoritarian governments like in Xinjiang, but it is inevitable and unstoppable.

Right now an ordinary person still can’t, for free, take a random photo of a stranger and find the name for him or her. But with Yandex they can. Yandex has been around a long time and is one of the few companies in the world that is competitive to Google. Their index is heavily biased to Eastern European data, but they have enough global data to find me and Andrew Yang.

If you use Google Photos or Facebook you’ve probably encountered their facial recognition. It’s magic, the matching works great. It’s also very limited. Facebook seems to only show you names for faces that people you have some sort of Facebook connection to. Google Photos similarly doesn’t volunteer random names. They could do more; Facebook could match a face to any Facebook user, for instance. But both services seem to have made a deliberate decision not to be a general purpose facial recognition service to identify strangers.

There is at least one public recognition service out there: FindClone (hat tip to Brad F). You can read more about FindClone here. (It used to be known a FindFace, and SearchFace.) However it’s limited to photos from VKontakte, the Facebook for the Russian speaking world. It’s a big dataset. But it’s not international like the Yandex search engine is.

I imagine within a few years this “look up a name from a face” will become as common as “look up a name from a phone number”. Not quite ubiquitous because everyone finds it creepy, but easy enough to access if you need it.



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WSJ: Trump Admin Threatened Iraq's Access To NY Fed Account Over Proposed Troop Withdrawal

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The Trump administration reportedly threatened to cut off Iraq’s access to its account with the Federal Reserve Bank of New York over a proposed withdrawal of American troops.

The Wall Street Journal reported Saturday that the State Department threatened to cut off Iraq’s New York Fed account in a phone call Wednesday with Prime Minister Adel Abdul-Mahdi, according to unnamed Iraqi officials. The resulting cash shortage would hurt Iraq’s economy.

Many countries maintain accounts with the New York Fed in order to store government revenue in the form of U.S. dollars. In Iraq’s case, much of that comes from oil sales.

The State Department didn’t respond to TPM’s request for comment on Saturday.

Abdul-Mahdi and Iraq’s parliament have called for American troops to exit the country following the killing, ordered by President Donald Trump, of the top Iranian general Qassem Soleimani outside Baghdad International Airport a week ago.

Trump in turn threatened to sanction Iraq if U.S. troops were expelled. The State Department has refused to recognize Iraq’s call for the troops to leave.

“At this time, any delegation sent to Iraq would be dedicated to discussing how best to recommit to our strategic partnership — not to discuss troop withdrawal,” the State Department said in a statement quoted by The Washington Post Friday.

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iridesce
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mareino
9 days ago
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Remember when Trump was going to withdraw from Iraq on Inauguration Day, regardless of what the Iraqis want?
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The Importance Of Making Everything Easier ❧ Current Affairs

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Junkie Communism | M. E. O’Brien

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No one is disposable.

In November of 1970, the Young Lords and the Black Panther Party seized a section of Lincoln Hospital, establishing the first drug detox program in the South Bronx, the center of the city’s heroin epidemic. The “People’s Detox” operated out of the old nurses’ residence under a coalition of Black and Puerto Rican left nationalists, socialists, and radical medical workers. Influenced by the psychological work of Frantz Fanon, they saw revolutionary political education as essential for overcoming drug addiction. Mutulu Shakur, Vicente “Panama” Alba, Cleo Silvers, Dr. Richard Taft, and others who ran the program innovated the use of acupuncture as a drug treatment modality in the US, a practice that has since become institutionalized and widespread. They won city funding for the detox program in 1971. They continued to run it until the police raided the detox facility in 1978, expelling the revolutionary leadership. These years were peak periods of political organizing for the Bronx, as well as the years that HIV — still unnamed and unnoticed by medical authorities — first started to claim the lives of injection drug users.

The Lincoln Hospital Offensive, as the Young Lords called it, was one of their several health-related campaigns. The Young Lords held a sit-in at a health commissioner’s office demanding lead paint screening for children in East Harlem and the South Bronx, and hijacked a mobile X-ray truck to screen for tuberculosis. In this way, they anticipated the coming decades of crack addiction, the epidemic of HIV and AIDS, and the rapid growth of mass incarceration. They were also recognizing a limit to their own organizing, as drug addiction contributed to the unraveling of the revolutionary organizing and mass insurgency of the early 1970s.

These initiatives took place in the context of a broader movement to improve, democratize, and seize the considerable social democratic infrastructure New York City had built after WWII. Black women in the welfare rights movement staged sit-ins to gain welfare benefits. Black and Puerto Rican labor activists successfully organized to expand hiring for unionized municipal government jobs. Students occupied buildings of the city’s free public university system, winning “open enrollment.” These militants confronted the racial contradictions of New York, seeking to transform a labor-backed social democracy to serve and be subject to the city’s growing Black and brown working class.

By focusing the Lincoln Hospital Offensive on establishing the Bronx’s first detox program, the Young Lords and their allies staked a position on one of the most contentious questions of twentieth-century socialism: the political role of those members of the working class who are rarely able to hold down a job. The mass socialist parties of Europe, seeking a politics of working-class respectability, had long been ambivalent towards the “lumpenproletariat,” “the underclass,” “the poor.” If the dignity of work is the basis of socialism, junkies unable to maintain stable employment have no place in the revolutionary project. By turns seeking the moralistic redemption of the poor by absorbing them into the working class proper or excluding them from the socialist imagination altogether, the workers’ movement saw the poor as those outside their constituency. In the US, the lumpen were unambiguously racialized, associated with the Black and brown youth who rioted in over 150 cities during the late 1960s.

“If the dignity of work is the basis of socialism, junkies unable to maintain stable employment have no place in the revolutionary project.”

Drug dealers and drug users embodied the qualities of the lumpen masses that socialists had long scorned: unreliable, undisciplined, easily vulnerable to the pressures police put on them to rat out their comrades. Inspired by the Black Panthers, the Young Lords broke with this socialist orthodoxy, instead basing their organizing on recruiting the young men of color hustling on the streets of urban America. The Young Lords understood that the chaos of drug addiction was wreaking havoc on working-class life, and sought a way of transforming addicts into revolutionary subjects.

These struggles of the criminalized and racialized poor were particularly potent because they were not severed from the broader working-class insurgency of the time. The Black workers leading a wave of strikes in auto manufacturing, healthcare, and municipal jobs broadly sympathized and overlapped with those joining the riots of the late 1960s. The Health Revolutionary Union Movement (HRUM), the militant medical-workers group that joined the Young Lords at the Lincoln occupation, took their inspiration from the Dodge Revolutionary Union Movement (DRUM), an organization of Black workers in Detroit’s auto plants. Within Black and Puerto Rican movements of the time, different sectors of the working class built real relationships of solidarity and struggle.

The Young Lords’ organizing with drug users recognized an essential feature of the communist endeavor: the miseries of life under capitalism fracture the working class, breaking people’s bodies, and disposing of our lives. Overcoming class society will require a practice of healing, a reclamation of the universal dignity of human life, and a means of building solidarity and love across these fractures within the working class. Nowhere is this understanding more crucial or more difficult than with those trapped in severe and chaotic drug addiction.

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I learned about the militant origins of the Lincoln Hospital Detox Program shortly after I moved to East Harlem to work at a syringe exchange program based in the South Bronx. Early each morning we would load a van and a utility truck full of empty sharps containers and boxes filled with sterile
medical syringes. We would follow the traffic onto the Bruckner Expressway to that morning’s exchange site. My coworker Angel would take the lead, setting up tents and tables and stacking our supplies. On especially cold days, we would fire up gasoline-powered heaters. A couple of the staff would take seats at the exchange table, and begin chatting with the steady stream of participants who came through. Isaiah, an African-American man in his early seventies, would staff the acupuncture tent. The exchange’s best-dressed employee, with his colored suits and fedora, Isaiah provided stress-relieving, ear-based acupuncture in chairs set up on the sidewalk alongside our exchange.

I’d begin my shifts moving boxes around, making coffee for the syringe-table workers, then chatting with my coworker Ricky. Originally from Puerto Rico, Ricky had spent the 1970s and 1980s dealing heroin in the Bronx to keep up his own steady use. He remembered the early hip-hop parties organized by Kool Herc at the Bronx River Houses. He eventually got clean and has been employed at syringe exchanges ever since. Most of our coworkers were former users, but we knew a few still shot up regularly. I would talk to Ricky about books. I was reading on New York City history, the Young Lords, or the city government leaving the Bronx to burn. He would tell me about growing up in the projects, the time he spent in and out of jail, and occasionally crossing paths with the revolutionary parties and nationalist sects that competed for new recruits in the Bronx.

The participants in our program — we called people who came for syringes and services “participants” rather than the more hierarchical and institutional-sounding “clients” or “patients” — came for clean syringes because they cared about their lives and the lives of those they used with. They shared a common experience of using injectable drugs, mostly heroin, and enough difficulties in their lives that they couldn’t arrange to order their syringes discreetly online. Most had spent years homeless or passing in and out of jail. Many grew up in the Bronx, while others had recently moved from the Caribbean. Many trans women came by the exchange for syringes. Like many women who came to our exchange, they had spent time getting by through sex work.

Two or three times a day, a participant would ask about getting into a detox program. I would set aside the flyers I was handing out, and we’d sit in the back of a utility truck together and talk through options. My job was to find people a bed in a detox facility somewhere in the city, and to arrange the transportation to get them there. Detox programs were designed as a first step in a long process of getting clean after many years of severe addiction. Occasionally participants I’d work with would aspire to stay clean, but for many others detoxes were instead the means of getting off the street for a few days, getting away from the stresses of chaotic home lives, or avoiding a demanding creditor or angry dealer. Detox programs would provide enough medication to take the edge off of drug withdrawal, and detox could be a way of resetting and pulling oneself together. Many participants lacked any form of identification after periods of homelessness. I would help them track down offices where they had previously received medical care, hoping a photocopy of some ID was still on file. I would help untangle people’s Medicaid; after repeated detox visits their government-provided insurance would be restricted to a single facility, forcing them to obtain special permission to receive services elsewhere.

I would often refer people to detox at the public hospitals if they couldn’t easily qualify for Medicaid, particularly immigrant participants. Only public hospitals would accept people who were not eligible for medical insurance. Though the detox program at Lincoln Hospital no longer incorporated revolutionary political education, it remained open and available over three decades after the Young Lords’ takeover. Lincoln also hosted a detox-focused acupuncture training program where Isaiah and many other syringe exchange workers had been trained.

I would follow up on my referrals by calling their detox programs after a couple of days. If the detox wasn’t going to find them a rehab program, I would help the participant find one. Detox addresses the medical issues of drug withdrawal. Rehab offers some of the skills necessary to stay clean. For the majority of my referrals, participants would be back on the streets a few weeks later. Our syringe exchange was always available, uncritical and nonjudgmental, providing clean syringes to help protect people injecting heroin from HIV and Hep C transmission.

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Syringe exchange programs were established in cities across North America in the late 1980s by activists combating the devastation of the AIDS epidemic. Heroin users in the late 1980s and early 1990s were dying of AIDS at staggering rates. Clean syringes saved lives far more effectively than any other intervention. Many of the early syringe exchange programs in the US were illegal. Volunteers faced the risk of incarceration or losing their medical licenses. Heroin users politicized by the AIDS movement staffed the exchanges themselves, alongside nurses and doctors, anarchists, and other activists concerned with the racial and class divisions within the AIDS movement.For anarchists, the exchanges were a form of radical mutual aid free of the moralism and condescension of most social services. AIDS organizing groups fought for syringe exchanges, alongside campaigns against homelessness, police violence, and AIDS criminalization, and to defend the rights of sex workers. The AIDS movement was largely unable to build ties with the now-weakened labor movement or civil rights organizations. Decades of economic crisis, criminalization, and the collapse of the left had effectively severed the solidarity between wage workers and the lumpenproletariat within Black and brown communities.

Syringe exchanges were part of an ethical and political vision known as harm reduction. Harm reduction stands in sharp contrast to “abstinence-based” drug treatment, and the criminalization of drug use. Most social services — housing programs, mental health counseling and treatment programs, cash transfer benefits, even food programs — ban all people who are known or suspected to be using any street drugs or off-label medications. Drug treatment programs in particular, like the rehab programs I would refer participants to, are based on authoritarian treatment models founded on a principle that people forfeit their right to make their own decisions when they become addicted to crack or heroin.

Harm reduction activists recognized that many people aren’t ready or able to discontinue drug use altogether. Demanding abstinence as a precondition to accessing services further isolates drug users, contributing to more destructive use patterns. These programs instead sought to reduce the harms both directly associated with drug use and those stemming from the social stigma around it. Harm reduction seeks to aid users in pursuing their own self-identified goals and needs that may not include abstinence at this time, or ever. This approach calls on an ethical and practical orientation that is as rare in social services as it is in radical politics: engaging the painful, traumatized, and self-destructive parts of people with care, taking seriously the possibility of transformation and healing, without a narrow, preset judgment about where people have to be now, or where they are headed.

“Our revolutionary politics must embrace the many broken and miserable places inside ourselves.”

I first became interested in harm reduction while living in Philadelphia. I had been transitioning my gender, and got my first white-collar job providing HIV services to other trans people. I was involved in the anarchist scene, but was rethinking my commitments in light of the sexism and transphobia I experienced coming out as a woman. While organizing with homeless trans women around shelter access, I was also becoming increasingly frustrated with the politics of social work. Around that time, a friend in Philadelphia killed herself, and I came to see our scene’s intense moralistic judgements of each other as partially to blame. We could either love or critique, but rarely do both together. I was dealing with my own mental health challenges, and found little understanding in my radical circles as I sorted through the contradictions of how to get care. I vacillated between feeling ashamed that I couldn’t figure out my shit right away, and posturing that I didn’t have any problems to begin with. Harm reduction seemed to offer a path towards a different sort of practice: an alternative ethical framework that allowed us to stop constantly judging others — and ourselves — according to the rigid criteria of political righteousness. Instead we could learn to care for each other with dignity, to challenge our capacity for harm by lovingly welcoming the most painful parts of ourselves.

From my coworkers at the syringe exchange who had spent much of their lives as dealers and users, I saw how harm reduction had helped politicize their experiences, transforming individual misery into a collective practice of solidarity and a basis for social critique. From my coworkers and harm reduction trainings, I learned how to relate to someone having a very rough time in a way that was relaxed, warm, and built a connection; a crucial skill in most political activity. I learned a lot about the street drugs popular in the Bronx, and the many ways drug use is woven through daily life. My coworkers taught me a bit more about how to love well in this difficult and painful world.

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In the last three years, the growing rates of overdose and suicide have lowered American life expectancy. This is the first decline in US life expectancy since the height of the AIDS crisis, and the most sustained decline in a century. Opioids now account for more American deaths than car crashes, gun violence, and HIV.

For many, opioids are a form of refuge from ongoing social disintegration. Decades of deindustrialization, wage stagnation, poor access to healthcare, and weakening unions came to a head after the 2008 economic crisis. People have turned to prescription painkillers to manage workplace injuries, depression, and untreated health problems. In the words of one public-health study, opioids serve “as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness.” A 2017 study by the National Bureau of Economic Research showed that when the unemployment rate rises by 1 percent, emergency-room visits increase by 7 percent and the opioid-related mortality rate rises by 3.6 percent. Two economists recently coined the phrase “deaths of despair” to describe this loss of life.

As the crisis of capitalism and working-class life deepens, insurgent movements will need to grapple with drug addiction. Today we need a practice of liberation that recognizes and embraces the fundamental dignity and potential revolutionary agency of drug users and calls on new approaches to interpersonal care, mental illness, and profound personal misery.

We need a communist politics that does not assume respectability or stability, that does not divide the world between the innocently poor and the chaotically dangerous. When refusing their imposed disposability and isolation through revolutionary activity, junkies and their friends move towards a communism not based on the dignity of work, but on the unconditional value of our lives. Our revolutionary politics must embrace the many broken and miserable places inside ourselves. It is from these places of pain that our fiercest revolutionary potential emerges. We need a communist politics that welcomes us all and engages us fully as whatever we are — as freaks and fuck-ups, as faggots and trannies, as wreckers and miserable wrecks, as addicts and crazies. We need a junkie communism.

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The Great Dehumanization

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