The Independence Journey

Tomorrow, in my “Play Class” we will talk about Winnicott’s paper (1963)  about emotional growth in “terms of the journey from dependence to independence”. In this essay he coins his famous phrase “primary maternal preoccupation,” the time in a mother’s life, third trimester pregnancy along with the first few months of infancy, where the mother can think of little else besides her baby. The significance of this concept is that a mother has the challenge to follow a parallel journey with her child; a journey which begins with a merger, and ends with separateness. This parenting process is hard because it is overwhelming to feel responsible for another human being, and then it is overwhelming again, to let go of that responsibility so that the child can develop his/her own ego. A mother/caretaker has to have the emotional sophistication to know when to be hovering and when to let go. This, the lay public might say, is a “mother’s instinct”. Winnicott teaches us that without a mature mother, a child is psychologically damaged because he/she does not have the opportunity for ego development, for coping skills. For example, if a mother is afraid of their child’s upset, then she might feed them continuously. If the child never gets hungry, then the child does not know how to cope with the need for self-care, possibly leading to an eating disorder. The process of development, of maturation, demands that the child experience frustration followed by gratification. Optimal frustration is the key to healthy growth, as the child learns that needs can be met with thought and patience. Without optimal frustration the child is vulnerable to feeling omnipotent, where every need is immediately met, and hence arrogance ensues. The proof of healthy development, Winnicott would say, is quality interpersonal relationships, where quality is defined by mutual satisfaction. In other words, the metric of good mental health, is socialization. The ability to cultivate relationships requires flexibility and compromise. This has to be learned  in the tender developmental years, and then again, throughout life. Winnicott’s theory still holds true, fifty years later. Let’s see if my students feel the same way.

Re-Posting A Popular Post: The Report Card

Betsy, age ten, a patient of mine  since she was six years old, comes into my office with her mom, Gloria.  Betsy and I play catch and talk about her summer. She tells me about the books she is reading, her friends, shesays that she hates camp, and she is nervous about going back to school next month. Given Betsy’s long history of anxiety, poor eye contact, poor social relationships, poor behavior at school, I am  pleased at our relaxed interchange. The appointment winds up with our usual routine. Gloria  and I make the next appointment. Gloria reaches into her purse, and says “here  is Betsy’s report card. It is really good.” Gloria has handed me Betsy’s report cards for years, but this is the first time she announced it in front of Betsy. Dramatically, Betsy became irritable, angry, and rude. She grabbed the envelope out of my hand and said “this is none of your business.” Gloria says, “Betsy, I have given her report cards for years.” Betsy gets more upset. “She is not related to me, so she should not see my report card,” Betsy screams. Gloria responds “but it is a really good report card, what is the problem?” “It is just none of her business,” Betsy screams louder. “Just pay her and let’s go,” Betsy says.

Why did Betsy get so mad about me seeing her report card? I speculated to myself that this is an issue of intimacy. Betsy and I, although we have known each other for many years,  is not comfortable sharing herself with me in that way. As such, she felt violated that her mom exposed a part of herself, her report card, that she was not ready to share. I understood Betsy’s discomfort and I felt bad that I was a party to it. At the same time, at the time of the interaction, I was surprised by her strong reaction. Betsy’s sensitivity helped me understand her relationships. She enjoys interacting with others, but she is also afraid that getting too close to people could result in painful humiliation. Even though her report card was good, she seemed afraid that my reaction would make her feel bad. Betsy’s anger might have protected her from having to suffer from my unsatisfactory response to her school evaluation. In another context, Betsy might be seen as bipolar, or quick to anger, but had this happened, Betsy would have been misunderstood. Her hair-trigger response was not a “manic” experience; rather it was a response which protected her ego. In the end,  Gloria and I felt sad that Betsy was so upset; it was a hard learning experience.

Case Presentation

My “play class” continues, shifting from reading articles to presenting cases. Seven students, all in their tenth year of post-graduate education, are put in the vulnerable position of talking about their experiences working with one particular child. The potential for humiliation, in front of their peers, in particular, is huge. Likewise, the opportunity to impress each other is also available. The anxiety can interfere with the quality of the presentation, and of course, may not reflect the quality of the student’s work. On the other hand, these students have been presenting cases for many years, to many attendings. They are well rehearsed in this area of summarizing a patient’s history and presenting the story in a coherent and pertinent way. Now, it is my turn to present a case. It is my turn to demonstrate my experience, while still protecting confidentiality. I am brought back to the days of my past. I look forward to hearing what others say about my clinical challenge, while at the same time, I hope I can convey an experience which is both verbal and non-verbal. In the case of child work, there are more players, and hence more dynamics to anticipate and explain. I hope to convey both confidence and humility, this subtle combination which is easily mistaken for arrogance and/or insecurity. This misunderstanding could be a result of the “intersubjective space” between me and my students. This is the space which has our unconscious processes which could want to idealize me and/or devalue me. More likely, we will have an interesting discussion which is not fraught with challenging feelings. Stay tuned.

The Narcissistic Pat

“Look at my Lego,” a seven-year old says to his mom, clearly asking for enthusiastic praise. “Wouldn’t it be wonderful if we could all ask for narcissistic pats, like children so easily do from their parents?” I pose to my ‘play class’. “Why do we lose our ability to get our needs met so simply?” I continue to ask my students, thinking about how children seem biologically programmed to demand praise, and parents, in turn, seem biologically programmed to understand the necessity for a passioned response. Somewhere, around puberty, getting affirmations become much more difficult. The relationship with parents are now more ambivalent. The praise has to come from peers, but the request for positive responsiveness is indirect and unclear. Competition sets in, meaning that friends hurt each other and help each other, at the same time. I wanted to say to my students today, “look at me, I am such a great teacher,” but somehow that did not feel right, so as a grown-up, I taught my class, hoping quietly that maybe, just maybe, a student would offer up some praise. I was having a day where I was needing a narcissistic pat, but asking for it, and knowing who to ask it from, seemed humiliating and inappropriate. The desire to have the excitement of showing off an accomplishment, knowing with almost certainty, that enthusiasm would flow readily, is still there. Some childhood wishes never go away. Wanting a narcissistic pat is one of them. Some days they are more important than others.

 

See also….http://shirahvollmermd.wordpress.com/2011/01/25/parenting-narcissism/

Exhibitionism

Nolan, nine years old, wants to show off his muscles to me. He comes in with such enthusiasm, clearly wanting my praise. He appears hungry, in a good way, for positive attention. I think about how we, as adults, lose our openness about wanting to be admired. We.  adults, seem to pretend that we don’t need admiration. How do we change from being open about wanting affirmation to being ashamed about that? This was our discussion in what I call my “play class”. Sometimes kids utilize a child psychiatrist to feel good about themselves. They do this in a way which is clear and to the point. Adults, by contrast, also want our admiration, but it usually takes a lot more time for this to be  obvious. “This is normal?” One student asks about Nolan. “Absolutely. It is not just normal,” I reply, “but it is also a positive sign about Nolan’s self-confidence. “He understands that I want to appreciate him, and at some deep level, he knows that he needs appreciation.” I say, trying to explain the importance of affirming children, in order to build self-esteem. At the same time, I am mindful of the notion that our current generation of ‘emerging adults’ are criticized for being affirmed too much for too little. Parenting in the 80s seemed to be about the need for affirmation, possibly resulting in a generation of adults who feel entitled to tell their bosses what to do. This notion may have some truth, but that does not mean that we should not encourage parents to recognize the strengths in their children. Parents, generally speaking, should encourage exhibitionism as a sign of forward developmental motion. The confidence and pride in one’s own accomplishment is something that many adults have trouble holding on to, maybe as a result of the lack of recognition in childhood. Many folks think of exhibitionism as boastful and insensitive which it can be, but when done with the sweetness of childhood enthusiasm, it is neither. After talking about how so many things can go wrong in child development, I think my students were surprised I said something positive.

Child Safety

http://www.latimes.com/business/la-fi-lazarus-20120831,0,2539605.column

Accidents at home, leading to children dying keep happening, despite media attention and legal action. Cords are dangerous for children. Even cords within the blinds hurt and kill children. As a Child Psychiatrist, as a human being, I want to use this media to encourage folks to be mindful of household dangers. Prevention goes a long way.

“To Be Alone In The Presence of Another,” Winnicott (1958)

Therapy offers, as Winnicott eloquently says, a patient “to be alone in the presence of another.”  Deep relationships offer this as well. This is the  luxury of experiencing one’s internal world, while a caring person is present in the room, but not intrusive into one’s internal process. Parents provide this for their children, or at least most do. They allow their children to play, without interruption, but they are in the room, or in the house, representing a caring person who is content knowing that their child is entertaining himself. This model of relationships is especially critical to those who feel that their internal worlds are constantly disrupted by an intrusive other. “I want to kill my wife,” Ward, forty-one, says to me, not looking for a response, but wanting to experience his own feelings in my presence. To say, or even to think, “you don’t really want to kill your wife,” would invade his internal space of feelings and fantasies. This tolerant approach allows Ward to explore his frustrations, anger and disappointment with his relationship. To intrude, or to interrupt, would cause him to question his feelings leading to internal confusion and harsh superego judgment. Indeed, the art of deep relationships is to allow the other to be alone in your presence. A lay person might say this is about  ”giving him space,” and Winnicott would add-on by saying, yes, but while you are physically present. Winnicott shines again.

The Autistic Spectrum: Problems With Imagination

Carson, a thirteen year old boy, I have known since he was six, has always “suffered from a lack of imagination,” I said to his mom. When he was in latency, his play consisted of banging toys together, without creating a narrative. His play was limited to being aggressive with his toys, without the ability to create stories around his aggression. Now, at thirteen, he reads voraciously, but only about the guns used during the Civil War. The narrowness of his interests are startling. He prefers to be alone, with very little interest in friends or family. The persistence of his restricted interests suggests that his brain only fires up with a minimal slate of activities. His mom, Kerrie, agrees and understands. She always has. It is not that Carson does not enjoy his life. It is that he is an outlier, a child who does not fall in the bell-shaped curve in terms of his leisure activities. Imagination, like every other skill, falls into a spectrum. As with all spectrums there are people in the extremes. Understanding is the first step. Kerrie models this step for so many parents. She intervenes and helps Carson, while at the same time, accepting his limitations. I admire her.

Parenting Makes A Difference…At Least…..Do No Harm….

Featured in Journal Watch: Long-Term Adverse Effects of Corporal Punishment

Adults who recalled experiencing harsh physical punishment during childhood had significantly greater risk for lifetime adult mental problems, including mood disorders, anxiety disorders, alcohol or drug abuse or dependence, and some personality disorders.

In Journal Watch Pediatrics and Adolescent Medicine, Martin T. Stein writes: “Counseling parents about appropriate responses to aggressive behavior is among the most challenging work of pediatricians.” He adds that these results could encourage some parents to learn about behavior modification.

http://pediatrics.jwatch.org/cgi/content/full/2012/815/3

Play Class: Update

My class is called the “Clinical Practicum,” but I would like to rename it the “Play Class.” I love that I am teaching students, hovering thirty, with so much education under their belts (along with huge debt), and yet we are talking about how to play, both for our own enjoyment and for the therapeutic benefit of our patients of all ages. We lament together how play has somehow gotten lost in our society of overscheduled children and adults. “What happened to the public schools?” One student asked. This seemed to be the central question. With parents extremely anxious about where their child goes to school, has come a pressure on children to justify the additional effort of either a private school or a public school which is a burden geographically. Now that most children are driven to school, this creates a dependency on adults in which the child is then driven to after-school activities. The social norm, at least in West LA, seems to dictate that if the child is not learning a new language, involved in a sport, and learning an instrument, then he/she is somehow going to suffer as he/she enters into the “real world.” “We need to remind parents that children need play time to expand their imaginations and develop creativity.” I say firmly and repeatedly. “Yes, but we don’t have time to do that with our fifteen minute appointments,” they respond with frustration. “Yes, so we need to lobby for more time with patients.” I say, again, feeling argumentative, even though we are all on the same page. “There are not enough child psychiatrists to play with all the children that need our help,” another student says. “Yes, that is true, but we can promote the value of play such that we can help other professionals play with children in a therapeutic manner.” I say, alluding to the idea that our job needs to be much broader than psychopharmacology. The class ends with what I call “positive frustration.” We all want to see the field change. We all want to play with our patients.