The Cost of Therapy

Alexander, seventy-two is spending his retirement money on therapy. His friends and family tell him he is “crazy”. “They don’t understand that I have very strange and bothersome thoughts and I have no one to talk to about that.” Alex explains to me, even though I know that. He is feeling defensive and misunderstood by his village. “On the one hand I know these people care and they are trying to help me so that I don’t run out of money, but on the other hand, they have no idea what I struggle with internally.” He tells me, again, even though we have discussed this many times. I hear the loneliness of someone who has such invisible suffering that no one, other than a mental health professional, can understand. The torture of brain suffering is beyond the comprehension of most people, even beyond some trained in the helping profession. Plus, friends and family presume to know his financial situation and this presumption hurts Alex’s feelings since he feels demeaned that they do not respect his decision-making. “Maybe you have lead them to believe that you have financial problems so they are confused why you invest so much of your resources into psychotherapy.” I say, knowing that he does need to be careful with his money, but at the same time, therapy, for Alex, is a life-line. “Yes, I do complain about money, but this expense is not optional for me. At least it does not feel that way.” Alex explains, mostly to himself. I am left feeling privileged with my medical training. Years of seeing how the brain can cause so much invisible misery has sensitized me to Alex’s issue. He suffers in ways, if he were to explain to his loved ones, would only alienate them and scare them away. Understanding goes a really long way, particularly for Alex.

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.

Inertia and Denial: The Case for Psychoanalysis

“Why did you want me to come more often?” Harold, forty-two, asks me after working with me for ten years. Inertia and denial,” I responded quickly. “When I see you less often, you lapse into old patterns of unconscious living, so the more we can focus the light on the issues, the more we can battle the forces of both inertia and denial.” I repeat. As Freud taught us, the mind is tug of war between wanting to grow and develop and wanting to maintain the status quo, maintain our current defense system. This to and fro of the mind creates a need for what Kohut called “working through,” meaning the necessary repetition of looking at how one’s behaviors and judgments messes with their own enjoyment of their lives. The “internal saboteur,” and yet another term for describing how so often the individual is their own worst enemy. The more intensely one can focus on internal conflicts, the more likely a healthy resolution can happen. This is a simple concept. Almost anything, when done repetitively and consistently will improve: tennis, hiking, yoga are all examples of this. So, psychotherapy fits in to this paradigm as well.

Attention Spectrum Disorder

This blog is part of my series on psychopathology.

In my previous blog I spoke about how ADHD is both a cognitive issue and an ego or personality issue. Children with ADHD have a problem with inhibition and as such, they do not wait to hear what the other person has to say. In turn, friendships can be quite challenging. When severe, ADHD children can be very lonely and subsequently depressed. This clinical picture of the lonely, depressed ADHD child can resemble a child with Asperger’s Syndrome.

My six year old female patient who is highly intelligent, unable to focus, hyperactive, has poor frustration tolerance and has no friends. What is the diagnosis? As I have mentioned many times, all psychiatric diagnoses are clinical diagnoses and as such they are subjective. One doctor would call her Asperger’s, another would call her ADHD and a third would say she has both. What do I say? I say that her primary diagnosis is ADHD as she has trouble with focus, trouble controlling her body and trouble containing her frustration. If these problems could be addressed then she would be able to have friends.

Theory of mind is the ability to attribute mental states-beliefs, intents, desires, pretending, knowledge-to oneself and others and to understand that others have beliefs, desires and intentions are different from one’s own. It is typically assumed that others have minds by analogy with one’s own. Based on the reciprocal nature of social interaction, as observed in joint attention, the functional use of language and understanding of others’ emotions and actions. Having a theory of mind allows one to attribute thoughts, desires and intentions to others, to predict or explain their actions and to posit their intentions.

Joint attention is key to a theory of mind, such that a problem with attention will lead to problems in theories of mind. Hence, with my six year old patient, I say that her primary diagnosis is ADHD and not Asperger’s Syndrome. As such, I propose that the explosion in the diagnosis of autism spectrum disorders is in part a result of clinicians missing the diagnosis of ADHD. It seems to me that since clinicians think of ADHD as a series of cognitive deficits and they think of Asperger’s Syndrome as a series of social deficits, there is an artificial separation between these two diagnoses. I propose that we see ADHD as a spectrum disorder and as such, put children into the category of Attention Spectrum Disorder. Once again, I hear my critics worried about funding, since Autism Spectrum Disorders receive state and federal funding, whereas the diagnosis of ADHD does not, in our current system, warrant such funding. I do not want to take funding away from children who need it. At the same time, I do want to focus on having more accurate diagnoses so that we can better comprehend what we are dealing with. We need to give the child and his family greater insight into their struggles. Understanding is our first step.

ADHD: Is It A Thinking Problem or a Personality Problem?

This blog is part of my series on psychopathology.

When I was a child psychiatry fellow from 1989-91, I was taught by Dennis Cantwell MD, a world leader in ADHD, who stated that kids who have problems concentrating have different brains than other kids. As such, they have struggles that other children do not have. Typically, this means that an ADHD child cannot focus on things that he has no interest in, whereas another child of the same age, could force himself to focus on something, even if it bores him.

Karen Gilmore MD, as have child psychoanalysts before her, add that children with  ADHD,  also have problems regulating their ego. Personality is often defined by how one monitors themselves. The word ego, in this sense, is interchangeable with the word personality. Dr. Gilmore argues that the inconsistency and variability of the integrative, organizational and synthetic functions of personality are really the problem in ADHD. In other words, the child with ADHD suffers because he has a harder time forming relationships, in addition to suffering because he has a harder time learning.

Historically, at the turn of the last century in England, George Still (great name) observed a group of children in his practice who showed a pattern of aggressiveness, defiance, resistance to discipline, excessive emotionality, little “inhibitory volition,” “lawlessness,”  spitefulness and cruelty; these children were also notable for their impaired attention, over activity, and a “defect” in moral control” (Still 1902).This syndrome was attributed to an underlying neurological deficiency.

More recent research has taught us that ADHD has pointed us to areas of the brain which may be affected such as the frontal lobes, the inhibitory mechanism of the cortex, the limbic system and the reticular activating system. It has been said that 70% of the brain is there to inhibit the other 30% of the brain. It is possible that those with ADHD have a lower percentage of inhibition.

To meld these psychoanalytic ideas with the neurological notions, I have come to understand that ADHD children have a hard time with inhibition. As such, learning is difficult, particularly for tasks with low enjoyment, and relationships are difficult, particularly if they involve a reliance on verbal interchange. In general, school is hard for kids who do not feel rewarded by pleasing others. The same could be said for relationships. As such, it is easy to understand the child with ADHD in that he struggles in school and he may also suffer with friendships. Having said this, each child with ADHD is  unique, such that some will have more difficulties with school, others will have more difficulties with relationships, and the most severe cases will have difficulties with both.

As we look to Russell Barkley’s work, we derive the answer. Although attention may be a prominent part of ADHD, the most disabling symptom is the inability to control impulses. Without the ability to control impulses, no one will cut you slack: not your friends and not your teachers. If no one wants to help, then the child will have problems learning things which do not interest him, and he will have problems being patient with friends. Impulse control is an ego function. Impulse control is  a cognitive skill. Both are true. Dr. Cantwell, may he rest in peace, would agree.