Belonging as Affirmation

Joanie, seventy-one, comes in, wearing a red shirt and beige pants, and so was I. She says, “we look alike”, reminding me of  https://shirahvollmermd.wordpress.com/2010/03/10/belonging/. Peter Blos, an expert on adolescent development coined the term uniformism to describe the teenager’s need to be just like his peer group. Judith Harris, another authority on adolescents, proposed that peer relationships are more important in character formation than parental values. Joanie continues in the session telling me how she has never “felt a part of anything.” She describes her childhood where her mother was overwhelmed with her five children. Her dad, never had an emotion, “at least not one I could see,” she says, almost as if she is trying to be funny. “I miss not belonging,” she says, causing me to  wonder about her choice of the word “miss”. “It is interesting that you miss something you never had; it is like a yearning, an imaginary experience in which you think belonging would solve your inner discomfort,” I say, not wanting to be too picky about her word choice, but at the same time, wanting to separate out missing from yearning. “Yes, I can see that,” she responds quickly, seeming to have a deep understanding of my point; her projection, or her idea, that she wants to believe that  belonging would solve her issues of painful insecurities. She says “it  is a wish to have an external fix for an internal problem. ” At the same time, Joanie and I both acknowledge that group affiliation can be character affirming. The weaving of the internal and the external are alive in our session today. Our matching color choices made her feel like she came to the right place. She belonged.

Should Parents Pay Their Children to Volunteer?

    The economy is really tough for some folks; particularly for young folks without a college education. Anna, twenty, lives at home, cannot find a job, and is so bored she is “driving everyone nuts,” her father tells me. “She needs to get a job,” he says, as if saying it emphatically is going to make it happen. “What if she gets a volunteer job?” I ask, thinking that this economy lends itself to charity work. “I will pay her to do that,” he replies instantly. I pause. Volunteering promotes mental health. People feel good when they give of themselves. I wonder if the equation changes if the parent pays. It is an interesting idea. I hope Anna follows through.

Resilience

     In line with https://shirahvollmermd.wordpress.com/2010/10/24/nowhere-boy/, Salvatore, forty-eight, is a story of remarkable resilience. Resilience, as a teacher friend of mine told me, is a concept that schools do not pay enough attention to. Educational institutions look to the lowest performing children and ask why are they failing, rather than looking at the high performing students and ask why are they succeeding? Michael Rutter MD, a British Child Psychiatrist, pioneered this exploration of resilience; the characteristics of children who thrive, despite what appears to be overwhelming trauma and neglect.

     Salvatore comes back to my mind. He is the youngest of nine children, born to an alcoholic mother and a physically abusive father. His maternal grandmother was schizophrenic. One sibling killed herself by hanging; another died tragically in a car accident when the sibling was ten and he was eight. Sal’s been married three times; he has one autistic son, Manuel, age twenty-four. Having seen Sal for many years, I have never experienced him as pessimistic, bitter, angry or resentful. By contrast, I see him accepting his life’s circumstances, while at the same time striving to have a better life than his parents had. Sal, in mid-life, took out college loans to get his degree. That landed him a good job, where he is financially solvent, and proud of it. He sees me because “it helps to talk,” he says. Sal has good friends, although there are times they disappoint him. Sal takes good care of Manuel. He is plugged into the Regional Center; he lives in a condominium with other autistic young adults, and together, they share in-home services so that they can live semi-independently. Sal feels good about that. Sal is dating, a “lovely” woman with two young kids. He is optimistic.

   Sal’s dad passed away recently so Sal had a family gathering at his house. Although I knew the story about his family of origin, he refreshed my memory, only this time with more detail. His six remaining siblings are all struggling, financially and emotionally. Sal helps them out occasionally, but by Sal’s account, none of them express gratitude. As I inquire about each sibling, their lives, their children, their physical and psychological struggles, I keep asking myself, what made Sal so different? I am impressed with Sal’s executive functioning skills. He is organized, thoughtful and diligent. He plans well. Maybe that is an important piece, but of course, I do not know the other siblings. Yet,  from what I hear, they all suffer from a lack of long-term thinking; they all sound impulsive.

      The frontal lobes, particularly the prefrontal cortex, is the area of the brain which is thought to be responsible for executive functioning skills. I am guessing that Sal lucked out in the frontal lobes lottery, but I also know that is not the whole story. Sal loved his mom, despite her persistent alcohol use throughout his childhood. Sal describes his mom holding him down while his father beat him with a belt buckle, but he tells me that tale with no anger towards his mom. “She had a hard life,” he says, with great compassion for her. “She should not have had children; reproduction was a bad idea for her,” he says, as I laugh, but he maintains a straight face. I am perplexed; how does Sal develop compassion for a woman who held him down while he was beaten? Maybe that was a relatively rare event, I wonder to myself. Maybe as I get to know Sal more deeply, I will understand this issue better, but I know that although I am deeply curious, that is not Sal’s agenda. Sal wants to “talk things out.” I understand. Some questions stay silent.

Middle School Applications

     Lily, age eleven, is in the sixth grade, which I imagine for most children, is a relatively low-stress time in their lives, unless they live in a major city where the competition for private seventh grade education feels like their world will tilt towards success or failure depending on this admissions process. Childhood anxiety, or rather, household anxiety, for these children is an experience which, to the unfamiliar, would seem bizarre and unnecessary, yet to those who live through this phase with multiple children, and/or in a professional capacity, begins to seem like a normal growth phase. “I want to wave my wand and make all your anxiety go away,” I say to Lily’s parents. Lily is bright, creative, fun-loving, with lots of friends and multiple academic and non-academic interests. Yet, Lily’s parents are fretting over a math test: “she could have done better,” Lily’s mom, Sophia,  says with impatience and fear. “And so,” I respond. “And so, she might be screwing up her chances,” Lily’s mom replies, as if I missed the obvious. “You mean her chances for going to a good school for seventh grade,” I say out loud so that Lily’s mom can hear how her fears sound when they are repeated back to her. “I know it is not logical,” Sophia replies. “Lily is going to go to seventh grade and she is going to make the school work for her. She is just that kind of kid,” I say, knowing that by emphasizing Lily’s adaptability, Sophia might be able to relax.

   One challenge in child psychiatry is that I need to manage Sophia’s anxiety to help Lily, but Sophia is not my patient. Sophia has given me permission to help Lily thrive in her world, but she has not given me permission to help her (Sophia) manage her stress. Navigating these waters is my challenge. Sophia encourages me to see Lily as “anxious” and I urge Sophia that although that maybe true, it might also be true that Lily is echoing Sophia’s anxiety, and as such, Lily will calm down when Sophia does. Sophia understands, but she is not interested in her own personal treatment; she only wants Lily to calm down. In essence, she understands that by changing her attitude she can help Lily, but she does not feel that it is worth her time or money to explore her issues around Lily’s middle school applications. Maybe I am stuck, but maybe I can keep working with Sophia to help her to see that indeed, it may be worth her time and money to look at the meaning of Lily’s academic achievements for Sophia. At the same time, I can work with Lily to cope with the multitude of stressors which go with this transition time in her life. Having said that, I wish that eleven year olds were not faced with these pressures. I wish that schools were seamless; children matriculated based on personal accomplishments, rather than the number of slots open versus the number of applicants. If my wish came true, the mental health of these families would improve substantially. I won’t go so far to say that it should be a public health mandate to have more options for seventh grade, but I would like to.

Nowhere Boy

     Elvis saved John Lennon. Aunt Mimi saved John Lennon. Musical talent did too. The ingredients of resilience-positive identification, devoted caretaker, inborn skills-gave John Lennon a chance to get beyond focusing on and repeating the tragedies of his early childhood. If he had ended up behind bars, no one would have been surprised. He was angry, he was confused, and he was not a particularly good student.  Those characteristics could have led to a life of hateful behaviors and aggression. Instead, he made art; he lived his dream. Retrospect is cheating, I always feel. Anyone can look back and say “aha” and take one aspect of his childhood and say that that circumstance gave him the power to see a future; the power to pursue his dream. Clearly, it is a constellation which makes young angry adolescent males turn around into thriving adults, and it is a constellation which makes them go down a path of uncivil behaviors. Father Boyle https://shirahvollmermd.wordpress.com/2010/06/16/father-boyle/ seems to understand this, and as such, he hopes for each young man, each with painful pasts, that they can bounce back to wholesome living. Devoting one’s life to a developing child goes a long way to helping them see their personal power. At the same time, that child needs to grab on to role models outside of his family so that he can imagine a life which makes sense to him. Finally, he needs some basic talent to apply those skills to his chosen field.  John Lennon went from nowhere to somewhere-the universal dream for ourselves and our loved ones.By saying that those three ingredients were the key to John Lennon’s success is speculative to be sure. Speculation is that first step to a deeper understanding of resilience. Looking retrospectively, however flawed that may be, helps us to ask: why do some kids get beyond their traumas, and other kids get buried by them? I would like to know.

Physicians for Social Responsibility

    This is a shameless posting promoting my work with Physicians for Social Responsibility (PSR). As a psychiatrist in my office, I try to help individuals and families, yet only through changing policy, can I help the mental health of millions.  So, I joined PSR to volunteer my time to promote public health. As a physicians organization, we view nuclear war as perhaps the ultimate public health threat. In the event of a nuclear detonation, physicians would be expected to provide care, yet there would be precious little we could do to help. The psychological fall out would be overwhelming. Dealing with massive trauma would be a challenge we, in the mental health community, are not prepared for. Further, the burning of human beings, requiring burn units would exceed our capacity. There are 1500 beds in burn units nationwide, most of which are occupied. A single nuclear weapon could produce 10,000 severe burn cases. Radiation impedes emergency personnel from attending the injured. Emergency personnel would also be victims and their facilities destroyed or damaged. Destruction of transportation, communication and energy networks would create gigantic obstacles to evacuate victims and long delays to bring in outside help. PSR  takes the adage that we must “prevent what we cannot cure.” This means advocating for nuclear policy that will gradually reduce the risk of a nuclear disaster. As the saying goes, “We are the ones we have been waiting for.” We turn the fear of nuclear terrorism and nuclear war into the action of prevention. This is scary and important work. Yet, I like the way my colleague puts it best, “I just like thinking about nukes, that’s why I am here.”

Detaching

   Stuart, fifty-six, says “I feel like slowly each hook is coming undone and I am slowly moving on,” to his girlfriend of twenty years, Lela. “I just can’t accept what is going on here,” Stuart continues. “Lela, you are so connected to your family that you just can’t incorporate me into your emotional life,” Stuart says tearfully. “But I love you,” Lela responds. “And I love you too,” Stuart says, “but I don’t like you any more.” Lela is passive. She does not know what to say. She is sad, but she seems unable to respond to Stuart in a way that is meaningful to him. “How can I help?” I ask, knowing that they have discussed their feelings many times before. “He is not being fair,” Lela says. “Well, actually,” I say, “he is telling you how he feels and that is fair.”

    Stuart and Lela got along pretty well until Lela’s father passed away four months ago. Lela has since engaged in a punishing relationship with her younger sister, such that her sister is physically abusive to her. Stuart says he cannot continue to bear witness to such horrible treatment. “Lela either has to stand up for herself, or I am out of here,” Stuart says. “Lela is paralyzed right now,” I say, trying to help Stuart understand that Lela does not see that she has choices when it comes to her sister. “Maybe so,” Stuart says, but I am not going to wait for her to start moving,” he says, as if he does not mean it, but he wants to appear firm and clear. “This is a hard time,” I say, trying to remind them both that the death of a parent can create a long and hard struggle downstream. “Call me,” I say, “let me know when you want to come back.” “How about tomorrow?” Lela says, “just kidding”.

Adolescence

    Gila, sixteen, with tremendous energy and passion, along with streaming tears, said “Dr. Vollmer, you just don’t understand. My mom is just not there for me. It is unbearable.” I waited. Within minutes, she calmed down, and as she was leaving she calmly said “thank you, see ya tomorrow.” The seemingly sudden changes from rage to sadness to calmness all seemed comfortable to Gila. Comfortable may seem like an unusual word, but Gila seemed to need to express herself with deep feeling, such that once she did that, she felt better. Is this the hallmark of adolescence? Was she premenstrual? Maybe this is just Gila: strong, dramatic, expressive, passionate. I am not sure. How much can I attribute emotion to a developmental phase? To a hormonal state? Maybe it does not matter. Gila was expressing herself; she was using therapy to describe, verbally and nonverbally, how she felt in that moment. I am left to wonder, living with the uncertainty of seeing Gila in a way that I have never seen her before, thinking about nature, nurture, and developmental change.

Emptiness

           Maravel, fifty-six, received a large year-end bonus on top of her “substantial” salary. She feels good that she can start a college fund for her four young children. Beyond that, she has no emotional connection to her success. She worked hard on a deal for her company. The deal went through; she was rewarded generously. Maravel is flat. She has no sense of joy. She recently left her husband of fifteen years for another man. She feels this was the right move; she is in love, “sometimes” she says. Maravel dreamed of the day when she was successful at work; now that that day has come, she is disappointed with how it feels for her. “Maybe you have some ambivalent feelings about leaving your husband,” I say, thinking that Maravel’s marriage was troubling, but it was also rewarding at the same time. “No, I don’t think that is it,” she says, quietly, thoughtfully. “Maybe the transition in your personal life is causing you to pause to see that professional success is not always as sweet as it sounds,” I say, thinking about Maravel’s terrible sense of emptiness. In some ways, it is as if her professional success exacerbated her emotional state of confusion and flatness. “I don’t know,” she says, exuding a painful internal disturbance. “I wonder if you feel that your husband helped you to succeed and so now it is almost not fair that your success is yours alone and you do not need to share it with him.” I say, thinking that Maravel might have painful guilt for dividing her family. “Yea, sort of,” she says, recognizing that her life is different since her new boyfriend does not have the same history with her as her husband did. “I am not sorry I left my husband,” Maravel says hastily. “Did I say that?” I ask, helping her to see that she is responding to her own sense of agony, rather than responding to my inquiry. “I guess not,” she says sheepishly. “It is time to stop,” I say, feeling the helplessness and confusion in the room. “OK,” she says, as she slowly leaves.

Traffic

Luigi, forty-two, hates to be late, but he also does not account for traffic in his calculation in coming to my office, despite the fact that I have seen him for ten years. One day, Luigi, frustrated with himself that he is fifteen minutes late, realizing that since he is unemployed he has time, says seemingly to himself “I could come early, get a cup of coffee, and that way I will never be late. I don’t know why I did not think of that before,” he says, as if the fog cleared. In the past, Luigi used to repeatedly say “if it were not for traffic I would have been here on time,” as if that explains his lateness. Luigi does not want there to be traffic so he acts as if it does not happen: denial. “Is pretending things not to be so, a theme in your life?” I wonder aloud. “I guess so,” he laughs. “Reality is hard to hold on to,” I say, thinking that that did not come out right. “Especially when we wish it were not so,” he finishes my sentence. “Yes, but coming here late hurts you,” I say, stating the obvious. “I know,” he says, “but leaving my house earlier somehow does not sit well with me.” “That is interesting. Instead of dealing with the realities of traffic, you pretend that you can make it here as if the freeways flowed smoothly, and then when the reality hits you, you get angry with yourself and you walk in here irritable,” I say, again, stating the obvious. “Maybe I am avoiding talking about other things, since we do spend a lot of time talking about the freeway,” he says, to my surprise. “Avoidance and denial do seem to go together. I can see how it is almost convenient to discuss the frustrations of traffic, given that it is a common irritant among Angelenos.,” I say, pleased that we can discuss how he has woven traffic into his therapy to protect him from talking about more sensitive issues. “I am going to get better at this on-time thing. You watch,” he says, as if to challenge himself and to surprise me. “That’s a deal,” I say, noting the enthusiasm and sense of renewal in his voice. Traffic might actually help us out.