The Fatigue Question

“I am so tired,” Melanie, thirty-two, says at the beginning of each visit, twice a week, for the past year. “I think you should go to your primary care physician to check that out,” I say, repeatedly. “I don’t want to go to the doctor. He is going to tell me I am crazy.” Melanie says, inviting me to argue with her. “Well, what if you tell him that I thought you should go?” I respond. “Oh, I don’t want him to know I am seeing a psychiatrist. Then, he will really think I am crazy.” Melanie says, reminding me that I am part of her secret life. She does not wish to disclose our relationship to anyone. “Why do you think you are so tired?” I ask, probing to see whether she thinks her fatigue is secondary to her mental state. “I think I have a blood disorder of some kind, but I am too reluctant to check that out.” Melanie says, knowing that I will be frustrated by her comment. “If you do have a blood disorder then you could feel much better if it were treated,” I say, stating the obvious, but feeling like it needed to be said. “I know that,” she responds impatiently. “How can I help you?”  I ask, pointing out that she has put me in a bind. “I know you are not a primary care doctor, but I wish you could order the lab tests,” she says, almost begging me, but knowing that I won’t do that. “Well, even if I did order the tests, I would need a primary care doctor to review the results with me,” I say, again, stating the obvious. “I know. Forget I asked. I will just be tired all the time,” Melanie says, firming up her original position. “That’s a shame,” I say, pointing out that she is not taking care of herself. “I know,” Melanie responds with tears in her eyes. “I wish I knew how to take care of myself,” she says with deep feeling. “Well, maybe I can help you with that,” I say, reminding her that is one of the reasons she comes to see me. “You are just one of the few people I trust,” she says, reminding me that one of her reasons she is reluctant to pursue a work-up of her fatigues is a basic mistrust of most people. “So, maybe you can use your trust in me to mobilize you to see a primary care doctor, since I think it is important that you go,” I say, trying to use our relationship to mobilize her to constructive action. “Maybe,” Melanie responds, sounding a bit more open to the idea.

The Olympics and the Wonders of Play

Is the Olympics a form of play? What does play mean and can it be therapeutic? These are the questions I ask my students as we read Neil Altman’s book entitled “Relational Child Psychotherapy.” Sutton-Smith (1995) argues that there are seven characteristics of play: progress, fate, frivolity, power, imagination, self-experience and identity. For example, the dimension of fate emphasizes the chancy and external nature of events, beyond our own individual control, evident in gambling, the belief in magic and the play of the gods. The dimension of power emphasizes the competitive, agonistic aspects of play, and the way in which play functions to establish a certain civilized power structure. The Olympics, according to a noted cultural historian Huizinga (1955) stressed the way in which play,  through competitive contests, games and rituals, helps to bring order to society and to civilize a range of human impulses.

In child therapy, the therapist uses play to civilize a child. The virtue of play as a therapeutic pursuit, among other virtues, is its freedom from real consequences and thus its apparent safety as a vehicle for self-expression. Play has two faces. On the one hand there are games in society which create a world that is make-believe and yet involves some of the things that matter most to people. As with the Olympics, games sometimes give meaning to our lives. On another level, in play, we can try out new forms of behavior, new roles, new solutions and we can create new understanding and knowledge. The paradox of play, be it inside or outside a therapist’s office is that it is both an inconsequential activity (just playing) and it can be our most profound endeavor. As such, maybe, just maybe, dare I say, that sometimes, a child can grow through psychotherapy and not need psychotropic medication. At the very least, a trial of “play” may sometimes be a good idea before launching into psychopharmacology. There, I said it.

See also..http://en.wikipedia.org/wiki/Brian_Sutton-Smith

http://en.wikipedia.org/w/index.php?title=Johan_Huizinga&printable=yes

https://shirahvollmermd.wordpress.com/2012/04/25/do-child-psychiatrists-still-play-with-kids/

https://shirahvollmermd.wordpress.com/2011/10/12/i-cant-believe-you-got-on-the-floor/

The Horror Of Your Own Words

Monte and Marla, https://shirahvollmermd.wordpress.com/2012/05/06/i-am-willing-to-talk-to-you/ return, much to Jon’s dismay. Jon has consistently commented to these posts that Marla is one of Monte’s toxic relationship, and as such, he should move on so that Monte can develop self-esteem without the inevitable setbacks that his relationship with Marla encourages. The fictional Monte sees me, where we discuss his relationship with Marla to examine how this serves Monte on an unconscious level. At times, Monte sides with Jon, feeling like distance is the answer. Other times, Monte seeks Marla’s professional consultation for work-related dilemmas. Still other times, Marla solicits Monte’s advice about teaching opportunities and teaching experiences. Recently, Marla contacted Monte, leading Monte to remind Marla of her last interchange in which Marla said “I am willing to talk to you,” much to the horror of Monte. Marla, upon hearing her words reflected back at her, begins to understand the arrogance of her words. She is not exactly remorseful, but she is aware of the haughty nature of that comment. Marla, somehow seeming that she wants to apologize, but never quite saying that, suggests that they meet to talk about that some more. Monte comes to me with the dilemma. “She seemed upset by her words, but I know we are in a cycle of hurt followed by reconciliation followed by hurt again.” Monte says with understanding, along with wishing that their relationship could reach equanimity.  “Why do you think it is so important that you get peace with Marla?” I ask, knowing that I have inquired about this repeatedly, but also knowing that each time I ask I get a slightly different answer. “Two of my mentors have passed away recently, and so there are so few people in my life who have seen me grow professionally, that I want to hold on to Marla because of our long history.” Monte says in a way which makes me understand his yearning, but also in a way which makes me think that he is living in wishes. He seems to be yearning for a parental figure who will nurture him through his career, but he and I both know that Marla cannot be that person. “Sometimes you have to go around the block a few times with people before you really understand how they impact you,” I say, pointing Monte to the idea that we know how this tale ends. We know that Monte will get hurt again. “Yea, I do know how this tale ends, yet for reasons I don’t understand, I want to go around the block again. I am sure I will end up saying you told me so, but I still need to give Marla another chance.” Monte says to me, with both cognitive understanding and deep emotional yearning for a connection with Marla, for reasons we have yet to explore.

“What’s Your Name?” I Ask My Students

The Clinical Practicum, the name for my class on child psychotherapy for UCLA Child Psychiatry Fellows, is, as the name implies, a “practical” class about how to begin treatment with children. My seven students are licensed physicians, able to practice as an adult psychiatrist, but wanting, for various reasons, to pursue further training in child psychiatry. The group hovers around thirty, which, of course, is the new twenty, or so people say. “So, what should your seven-year old patient call you?” I ask, somewhat to the shock of my students. “Dr. Sarah” (not her real name, of course), said, making sure that the child knows she is a doctor, but that he/she should use her first name. Another student got passionate. “Oh no, I am Doctor Green. I think it is essential that the child use my last name so that they understand that we are not just playing together.” She says with conviction. “What do they call you?” Another student asks me. “Shirah,” I said. “Over the years, I have become the most comfortable with that,” I say, trying to encourage the students to do what feels right for them, rather than look for the ‘right answer’. “My goal is to make you guys more conscious of your choices. The idea is that whatever they call you is going to set up a frame on the relationship which may or may not add meaning to the treatment. Deciding how you want to be addressed is a very serious matter.” I say, highlighting the idea that every decision, every interaction with the child and his/her parents, is, to use an overused expression, grist for that therapeutic mill.  The end of the class was very similar to how it began. There were questions. No conclusions were drawn. I like that.

See also….https://shirahvollmermd.wordpress.com/2011/03/08/whats-my-name/

Feral Cat

Ursula, forty-one, has been orphaned since she was sixteen. Both her parents were killed in a car accident, leaving her to the care of her not-so maternal grandmother, who then passed away when Ursula was twenty-one. For the last twenty years, Ursula has had menial jobs, “getting by” as she says. Ursula, to her surprise, met Patrick, forty-five, ten years ago and now they have been happily married for ten years. Ursula’s issue is with Patrick’s parents. She feels them to be “abusive” to Patrick, since they sometimes comment on his life’s choices. “I feel like a feral cat,” she says, “since I can’t really remember having parents, I am not sure what role they play in adult children’s lives.” I begin to think about her “feral cat” comment. When are parents helpful and nurturing and when do they become intrusive?  How does an adult child take in the advice of parents without feeling shamed and bewildered? Is the issue one of self-confidence? If Ursula were more internally secure, then maybe she would be more appreciative of the support offered by Patrick’s parents? Or, are Patrick’s parents trying to ground themselves by latching on to the lives of Ursula and Patrick? “Tell me more” I say, in characteristic fashion. “They think that Patrick should shoot for a better job and I think it is not their business.” Ursula says with a tone of self-doubt. “I mean, I agree that Patrick could do better, but that is for Patrick to decide,” Ursula says, almost inviting me to argue with her. “What if we entertained the thought that Patrick’s parents have a point. Maybe they see a problem and they want to prod Patrick into a more challenging job.” I say, trying to examine this issue from all sides. “That is what confuses me. Maybe that is true, but I just don’t understand parents. I am not a parent, so I do not understand that relationship.” Ursula says, with humility and confusion. She also points to her own sadness for her losses. “Maybe, you feel envious that Patrick have parents who think about his life, and maybe it is just so painful for you to think about what you don’t have.” I say, treading lightly on a profoundly difficult subject. “Maybe,” Ursula says, as she cries deeply.

White Matter, Matters

http://www.latimes.com/news/science/la-sci-orphan-brains-20120724,0,1723553.story

“What they found was striking: Brains of children who had remained in institutions had less white matter — the type of tissue that connects different regions of the brain — than orphans who were placed in foster care or children living with their own families.

Reductions in white matter have been found in numerous neurological and psychiatric conditions, including autism, schizophrenia and attention deficit hyperactivity disorder, or ADHD.”

Children need families. This is news, seriously. The LA Times reported today of a randomized studies in which orphans were either sent to foster care or institutions. Those sent to institutions had less white matter in their brains, thanks to imaging studies. Now, we finally have proof that nurture, the factor that I struggle with in some of my posts, is critical to the developing brain. Brains need stimulation. To paraphrase Winnicott,  a baby is nothing without a mother.  Now, we can say with more certainty that intimate connections help a baby develop security by helping the brain develop white matter. The more white matter that develops, the less likely the child will suffer from numerous mental disorders including childhood anxiety. The attachment theorists are having a good day. This study supports the notion that a primary attachment is critical for development. This small window of time, infancy, is key to having the brain grow properly. Now, does this mean that if one misses out on a good attachment, and hence has less white matter, that he/she is bound to have psychiatric disorders? Maybe. Is it harder to compensate for this deficiency as one ages? Always. Still, understanding is still critical to our personal enhancement and empowerment. We now know that as a society, we should try to strengthen families, and not provide alternative ways of raising children. We also know that given an inadequate early childhood experience, mental disorders are more likely, and hence there might be a role for medication to attempt to compensate, however slightly, for these deficits. As a Child Psychiatrist, I feel excited to have data to support what children need from the moment they leave the womb until they are able to enter school. Now, we can have a public relations campaign……White Matter, Matters! You heard it here first!

 

Myopia

Stacy, thirty-two, wants to travel world for a year and then decide how she wants to make a living. Her aunt Mo thinks she is making a horrible mistake. Stacy and Mo love each other, but now they cannot be in the same room. “She called me myopic,” Stacy says, bewildered.  “What does she think you should do?” I ask. “She thinks I should get a career path, get married and have kids. I want those things. I just don’t want them now.” Stacy says, with a sound of protest which resembles an adolescent. “It sounds like Mo hit a nerve,” I say, implying that she has some insecurities about her travel plans. “Well, yes, I am really not sure what I want to do with my life and so traveling postpones that decision for a year, but I don’t want to admit that to Mo.” Stacy says with candor and shame. “You don’t want to admit that to Mo because you want her to believe that you feel more confident than you actually do.” I say, pointing out her embarrassment over her uncertainties. “Yea, and I don’t want to tell her that she has a point.” Stacy says, as if she and Mo are at war. “Why can’t you tell her that you understand and appreciate her concern?” I say, pointing out that people who are interested in your welfare are hard to come by. “I have told her that, but I also think she should trust me that I will figure it out.” Stacy says, with the irony that she does not trust herself to “figure it out.” “You mean that her questioning your decision makes you feel that she has no faith in you?” I say, trying to show her that Stacy is projecting her insecurities on to Mo. “Yes, when she questions me, I question myself and I don’t like that feeling.” Stacy says, revealing that the problem with the question is that it makes her uncomfortable because it hits on unresolved issues for her. I repeat, “So Mo hit a nerve and now you are in pain.” “I guess so,” she agrees, but still confused about how to handle her relationship with Mo. “Maybe you can tell her that your life is uncertain, and that you can live with that and you hope she can too.” I suggest, hoping that an honesty about her internal state might be helpful. “I will try that,” Stacy agrees, with a hopeful tone.

Parents Worried About Their Six Year Old: Who Is The Patient?

“The fact that the parents bring in their child, that does not mean the child is the patient,” a trainee tells me with the wisdom of a more seasoned clinician. “Yes,” I enthusiastically agree. The patient’s opinion of the problem and the clinician’s opinion do not always agree, particularly in the field of child psychiatry where the “identified patient” may not be the one with psychological issues, but rather the target of family dysfunction. Herein lies the job of child psychiatrists, to discern the stated problem from the underlying problem. Johnnny, the fictional six-year old, may have behavior problems, but at the risk of offending my loyal reader Shelly, those behavior problems may not lie within Johnny, but rather they could stem from the discord between his parents. I reference Shelly here, as she is frequently concerned that I have a “blame the parents” approach to childhood assessment. Certainly, one size does not fit all, and sensitive parents can have children with severe behavior issues, yet, at the same time, there are times when severe aggression is a result of an environment which is chaotic and frustrating for the child. Johnny’s parents may be taken aback at the notion that his behavior is a result of insensitive parenting, and yet, this may be the message that the clinician needs to convey. What I am calling “insensitive parents” may then be so angry that their child is “misunderstood” that they will seek a professional who shares their point of view about their child. This inherent issue, that parents can only tolerate so much information about their parenting style, is the challenge of all child psychiatrists. Telling parents what they don’t want to hear is never easy, even if it means telling them that their child is normal and healthy. And one wonders why there is a shortage of child psychiatrists? Not.

Unconscious Messages

Lela, forty-two, is mostly concerned with what her dad thinks of her. Lela is married with two kids, but she does not seem to care for her husband too much. “I tolerate him,” she tells me. By contrast, her emotions rise as she discusses how her dad has mistreated her for years. Her persistent refrain is that he loves her siblings more than he loves her. Lela understands that she was probably a “mistake” given that she is ten years younger from her youngest sibling, and twelve years younger from her older sibling. Lela’s narrative was that her dad wanted her mom to have an abortion, but her mom refused and hence she was born. Lela believes this based on one argument in which the mom suggested that was true, but she was indirect about it. Lela and her dad have a weekly lunch date where they are both faithful to this date, but when there are family functions, Lela is notoriously late and scattered. She often “forgets” the time or location, causing the other family members to wonder where she is. “Maybe you are sending an unconscious message to your dad that when it comes to family functions, you are painfully reminded that you were unwanted, but when you and your dad meet alone, then you feel special to him. As a result, you are on time for your weekly dinners, and late for family gatherings.” I say to Lela, thinking about how timeliness, or lack thereof, communicates huge unconscious messages of respect and motivation. “I just don’t see it that way,” Lela protests. “I mean, I do agree that the family gatherings usually work on everyone else’s schedule and not mine, and that makes me angry and hurt, but I am not sure that is why I am often late.” Lela says, reflecting on her family dynamics and her reaction to them. “Although that could explain why you were late. It is possible that you were mad that you were not included in the original planning, and so you express your anger by making everyone wait for you.” I say, explaining that this scenario could be an unconscious communication to her family that she is upset with what she perceives to be a lack of respect. “Yea, it could be, but I don’t think so,” Lela continues to protest. Her protest feels to me like a way of saving face. She feels guilty about her behavior, but she also dislikes how she feels with her family. I know she will think about our discussion, given our long history of struggling with her self-sabotaging behaviors. Lela wants to be loved by her dad. That seems to be her life’s goal. Now, that is a bit more conscious.

The “A” Team

“I would have been happy if my mom did not die when I was twelve,” Eliot, age thirty, says with a bold and straightforward sense of truthfulness, without the expected sadness that such a strong statement implies. “I have a lot of friends, but I just don’t feel supported,” Fred, age twenty-five, says about his emotional well-being, implying that his family of origin has emotionally abandoned him. Both Eliot and Fred lack the “A-team” I tell them, saying that a parental support system is something that one needs throughout life. There is this craving for nurturing and care taking that only a parental figure can provide. This parental love, I explain, is this asymmetrical relationship where the parental figure wants to see the childlike figure flourish to the best of his ability. This relationship is sometimes created in adulthood  through mentorship,  through marriage, and/or through psychotherapy, but friendships rarely create that kind of sustained nurturing. The lack of this parental feeling creates in both Eliot and Fred a sense of “missing,” despite having so many other important relationships in their lives. “It is hard to tell people that you wish you had parents, meaning people in your life who cared for you in that nurturing way,” I say to Eliot, as he begins to cry. The loneliness of this missing, and the difficulty in conveying this absence, is so deeply painful. “Everyone needs an ‘A’ team,” I repeat to Fred, who often wonders why he is so despairing at times. “Yea, and I don’t have one,” he says with dismay, communicating that his family of origin has let him down and that he does not feel like our relationship serves that function for him. “Maybe you will be able to create one,” I say, hinting that he can cultivate relationships, including ours, to help himself feel more loved and cared for.