Toxic Stress

“Toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years.”

http://developingchild.harvard.edu/topics/science_of_early_childhood/toxic_stress_response/

See also…http://opinionator.blogs.nytimes.com/2013/10/30/protecting-children-from-toxic-stress/?gwh=4A5E6CBAAE9D19C51946C9B4A47C3B49

Parents may facilitate development, but more likely they need to “get out-of-the-way,” as I like to say. Getting out-of-the-way means protecting kids from what is now labeled as “toxic stress”. Children are biologically programmed to develop and mature, and with a basic environment of positive affirmations, good attachments, and provisions for food, sleep, friends, and education, most children and grow and flourish and reach their biological potential. However, in the face of tension, violence, or deprivation, then the child must go into what I call “brain freeze” and this stunts the development of the brain, in terms of understanding and knowing how to please oneself. Psychotherapy steps into to deal with toxic stress, but this requires many hours of trying to understand what happened in the preverbal period, where most memories are implicit and not explicit, Uncovering the trauma, so the adult can return to the developmental train where they learn to love themselves is a lengthy process, involving struggle and psychological pain.

Emily, fifty-six, youngest of eight children, always felt like she was a “burden” and consequently, never experienced love from her mom. As a result, Emily spends her time feeling angry, at little things and big things. She is angry with her husband, her children, her friends and her co-workers. She collects all of their misdeeds and she stew over them, simmering with ill feelings day in and day out. By Emily’s account, all of these people in her life are trying to make her feel better. I suggest an alternative viewpoint that Emily is really angry at her mom, for depriving her of a loving environment, and now that anger is transferred on to the meaningful people in her life. “It is a struggle for me to see that,” she says, as she cries. “The struggle is a good one,” I say, highlighting that understanding projection is a struggle, and it is hard to see when a feeling is being displaced. “The struggle implies that you are trying to see another point of view, and in that angst, there will be growth and understanding. Emily’s toxic stress hit her pretty hard, such that the only way she can handle a feeling is to throw it out to someone else and then feel victimized by that feeling, rather than owning that feeling and then trying to metabolize it. The toxin is the neglect. The anti-toxin is her awareness of it.

The Invisible Children: Hope at UCLA

http://nyti.ms/1cqQcId

http://www.nytimes.com/2013/11/03/education/edlife/extra-support-can-make-all-the-difference-for-foster-youth.html?partner=rss&emc=rss&src=ig

Tone: The Royal Road

 

Multiple levels,. causing complexity in communication, is the theme of my teaching tonight. We will discuss Louis Sander’s work,http://psychoanalyticmuse.blogspot.com/2012/12/louis-sander-passed-away-november-28.html,

 

” Louis Sander’s bold and ambitious theoretical synthesis deserves careful attention from psychoanalysts of all persuasions. Sander’s cutting-edge approach draws on infant observation research, nonlinear dynamic systems theories, and current biology, physics, and other “hard” sciences. He is rethinking the psychoanalytic approach to psychic structure, motivation, and therapeutic action. In so doing, he updates Freud’s project of linkingpsychoanalysis with scientific paradigms, but without reductionism, epistemological naivete, or an implicit antipsychological attitude.”

 

In that, we will learn how non-verbal communication, communication through tone, creates a warmth and love, vital to human development, as in the caretaker/infant relationship, and vital to therapeutic action. We will then discuss the work of Takeo Doi, http://en.wikipedia.org/wiki/Takeo_Doi,

“Amae (甘え) is the nominal form of the verb amaeru, which Doi uses to describe the behavior of a person attempting to induce an authority figure, such as a parent, spouse, teacher, or supervisor, to take care of him. The word is rarely used of oneself, but rather is applied descriptively to the behavior of other people. The person who is carrying out amae may beg or plead, or alternatively act selfishly while secure in the knowledge that the caregiver will indulge him. The behavior of children towards their parents is perhaps the most common example of amae, but Doi argued that child-rearing practices in the Western world seek to stop this kind of dependence, whereas in Japan it persists into adulthood in all kinds of social relationships.^[1]“

Amae refers to the tone of “please help me, shelter me,” such that the person feels the relationship is asymmetrical. I liken this communication to the dog who comes up to you, and clearly, wants to be petted. In humans, this communication is often conveyed by patients reporting their activities, with the apparent unconscious wish, for deep listening and affirmation. The tug to say “that’s great” is a hint for the possible amae. If, by chance, or on purpose, the therapist does not say “that’s great,” then the shift to sullenness, might be a clue that, in that moment, the patient experienced deprivation. The addition or subtraction of liveliness is the clue to a change in the internal state, and hence another (in addition to dreams) royal road to the unconscious.

Nao, sixty-seven, female, comes in, explaining to me her various experiences on match.com, giving me the feeling that she wants me to root her on. I have the sense that she wants me to comment on her courage, at her “advanced age” (her words), to seek a life partner. Nao, in these moments, remind me of my three year old patient, Frances, who builds Legos, and then says “look at what I made.” If I do not respond to Frances, he will keep saying, “look, look,” suggesting that it is not that he wants me to look, it is that he needs me to look in order for him to be proud of his work. Similarly, Nao seems to need my encouragement for her to proceed, suggesting that she is in a phase in her life in which she feels the need for a maternal caretaker. Nao, unlike Frances, can come to see that her tone suggests her parental neediness, and as such, this awareness can inform Nao of how her friends and loved ones, might be hearing her tales. This understanding speaks to the therapeutic action of psychotherapy. My helping Nao understand how she comes across to others, at least in this phase of her life, will deepen her self-understanding, and thereby, deepen her connections to others.

 

 

NYer Cartoon Contest

 

I think, they think, they are getting somewhere.

The Friend Becomes A Therapist: Oh My!

 

Julia and Rebecca, both fifty-nine, have been friends for fifty years. Ten years ago, Rebecca, after getting divorced decided to become a psychotherapist.  Now, Rebecca has a private practice, but she has noticed that her relationship with Julia suddenly took a strange turn. “You are not trying to analyze me,” Julia will say to Rebecca, with hostility and fear. Rebecca, disarmed by the comment, and scared, in turn, about the hostile feelings being transmitted, “You have known me so long, do I sound any different than I did before I became a therapist?” Rebecca asks, trying to deflate the intensity of the moment. Julia does not answer. Rebecca comes to me for help, trying to understand how her new professional identity is impacting her relationships in general, and with Julia, in particular. “I think some people forget what I do for a living, whereas other people get very anxious, as if I can read their mind, and others still, seem to hope that I will say something brilliant, even though I am tired and trying to relax. ” Rebecca says, reminding me how surprised she feels that a change in her career has this unintended consequence. “I wonder if those of your friends and family feel like you can glimpse at their unconscious, then maybe that scares them.” I say, highlighting the issue that the unconscious can rise and fall in awareness, and that Rebecca’s presence might remind them of this undulating experience. “Yes, but what am I to do?” Rebecca asks impatiently. “Maybe you need to make sure there is mutuality in the relationship so that the asymmetry of a a therapeutic relationship is not replicated in your personal relationships.” I say, knowing personally, how hard this is, and thinking about my own experiences in this regard. “Yes, but I want to listen and yes, I also want to be listened to,” but when I do listen, I feel like I am making Julia, in particular, uncomfortable.” Rebecca says with frustration and sadness. “Like any other bump in a relationship, it seems like you need to put it on the table.” I say, suggesting that an open dialogue could ease the flow. “I wish I had thought about this before jumping into this career.” Rebecca says, perhaps suggesting a major regret, but I am not sure. Here, Rebecca is a therapist, a patient, and a friend. As such, she is struggling to become comfortable or fluid within all of these relationships. This fluidity will help her balance her life in such a way that she is more comfortable in her skin. Maybe her unconscious desire to become a therapist was a search for meaning in all of her connections and so now she is despairing to think that her career path might, in fact,  scare  her loved ones.  This discussion will be for another time.

 

Julia,

Rent-A-Friend Vs. Psychoanalytic Listening

Rent-A-Friend, was how Professor L. described psychotherapy, letting us know, he did not have a lot of respect for the field. “The days of rent-a-friend are numbered,” he used to say, hoping we would all chuckle with delight and not squirm with discomfort, as many of us did. The squirming then did not make sense to me, but preparing for my class recently, I was able to piece together the components to that squirm. Salman Akhtar MD outlines the issue.

1. There is an entirely different sort of verbal material…in other words patients say things in therapy that they are too ashamed, or too scared to talk about with their friends.

2. The listening is for both conscious and unconscious aspects of the subject at hand.

3. The listening is done with the point of understanding on multiple levels, rather than merely providing support.

4. There is explicit consent that the listener can comment on deeper, and perhaps unsavory, motivations.

5. The mind of the analyst prepares for receptivity (I call this getting in the zone), in order to have what Freud described as “evenly hovering attention”.

When girlfriends go in a dressing room and one says “that does not look good on you,” there is love in that comment, which taken out of context would sound like a criticism. So too, with analytic discussions, “you were mean to your friend” may be unsupportive in a morning walk, but in a therapy room, that is a comment which inspires deep reflection. The courage to hold up that mirror, as the friend does in the dressing room, is the courage invested in a deeply meaningful relationship in which chances are taken in order to help the other go out into the world with consciousness and confidence. With all due respect to Professor L, who I love dearly for all that he gave me, the “rent-a-friend” comment was uncalled for, and demeaning to my other professors at the time, and now, to me, as well.

Listening And Vulnerability

In-depth listening, the work of the psychotherapist, mandates a vulnerability to uncomfortable feelings. Listening to trauma, difficult and sometimes horrendous experience, determining the meaning of this difficult experience in the context of the patient’s prior experiences, requires an openness to the imagination of terror, fear, sadness and a disintegration of the ego, or the complete inability to formulate thought, in the face of a traumatic event. Salman Akhtar MD, says that the therapist cannot be “manic,” meaning they must provide a calmness, which allows the patient to pour their experiences into a welcome receptacle.  He further explains that this receptacle is a “maternal” function, analogous to the sexual organs of receptivity. This vulnerability in the therapist, as in the vulnerability of motherhood, means that the therapist must tolerate whatever uncomfortable experiences or feelings the patient brings into the consultation room. Once again, I am reminded that my argument against the “T” therapies, those that are manual-based, never address this necessary vulnerability, critical for the patient to feel heard, understood and important. Lesley, forty-two, had a long childhood history of cruel and unusual treatment by her uncle. Her terror, withdrawal, dissociative, at times, leading to anger, resentment and self-hatred, were just a few of her experiences through her psychotherapeutic journey. My psychological pain in listening to her story is real, and profound, and Lesley knows and appreciates my emotional resonance. This therapist-vulnerability needs to be preserved as we go through this major transition in our health care delivery system. There,  I have said it again and so I will keep saying it. The patient/therapist relationship deeply matters.

 

ADHD: The Problem of Subjectivity

http://www.nytimes.com/2013/10/20/magazine/the-not-so-hidden-cause-behind-the-adhd-epidemic.html?_r=0

“Stephen Hinshaw, a professor of psychology at University of California, Berkeley, has found another telling correlation. Hinshaw was struck by the disorder’s uneven geographical distribution. In 2007, 15.6 percent of kids between the ages of 4 and 17 in North Carolina had at some point received an A.D.H.D. diagnosis. In California, that number was 6.2 percent. This disparity between the two states is representative of big differences, generally speaking, in the rates of diagnosis between the South and West. Even after Hinshaw’s team accounted for differences like race and income, they still found that kids in North Carolina were nearly twice as likely to be given diagnoses of A.D.H.D. as those in California.”

 

“Today many sociologists and neuroscientists believe that regardless of A.D.H.D.’s biological basis, the explosion in rates of diagnosis is caused by sociological factors — especially ones related to education and the changing expectations we have for kids. During the same 30 years when A.D.H.D. diagnoses increased, American childhood drastically changed. Even at the grade-school level, kids now have more homework, less recess and a lot less unstructured free time to relax and play. ”

 

This is the old saw. A “disorder” based on a history, with no objective findings, can be both over and under-diagnosed, in large measure, by cultural expectations and societal pressures. If a diagnosis is tied to services, to helping teachers explain test scores, or to an entry into a special pool, such as priority enrollment, then the incidence of the diagnosis is going to go up, resulting in an “epidemic” which really represents a change in the environmental pressures to make this diagnosis. This was our discussion in class yesterday, as we tried to open a conversation between medicating and over-medicating children. The lines are not clear, once again, taking us back to the importance of good history-taking and close monitoring. Even with that, we cannot ignore the societal pressures to make the diagnosis and we cannot pretend that these factors do not influence our decision-making. So, what if we, as professionals, are honest about our work? What if I confess that the reason I am giving your child a diagnosis is that, his symptoms put him on the border of a diagnosis, but given the upside of extended time on tests, for example, then the benefits of the diagnosis outweigh the harm. As my student said, “I like the transparency in that.” As psychiatrists, or old-fashioned psychiatrists, I should say, the most important tool to better mental health is intellectual honesty and authenticity. As such, we would be hypocrites to pretend that we have certainty where there is none. We would also be hypocrites to suggest that we are immune from external pressures. Being forthright about these issues is the first step to establishing credibility and thereby allowing us to move forward in the field. Otherwise, like in neurosis, we are stuck in a web of wishes and fantasies, far from the harsh reality of the uncertainty in everyday practice.

Sick One: Healthy One, No Way!

Heinrich Racker says “the first distortion of truth in ‘the myth of the analytic situation’ is that analysis is an interaction between a sick person and a healthy one. The truth is that it is an interaction between two personalities, in both of which the ego is under pressure.”

This concept of “egos in the ring” as I like to say, is often resisted, as Kathleen, seventy-one, likes to say, “well you are the expert,” to which I respond, “I can’t possibly be the expert about your internal experience, but together, maybe we can come closer to understanding that.” So, Kathleen, based on her upbringing, needs to see me as the omnipotent one, needing an idealized helper who guides her through her life, and I, the professional, educated for many years, and yet, still insisting that there is no one truth, only a way of understanding her psychic landscape. This struggle, as I like to teach my students, is the “working through,” the experience of re-framing long-held beliefs in which one feels anxious, dependent and insecure, rather than the confidence to gather one’s internal experience to make thoughtful and measured decisions. So, unlike other professional/patient relationships, the psychotherapeutic relationship has no expert, only a willing guide through the sometimes dark internal world, of the curious. The stripping of the expert job, again, does not sit well with massive systems which try to pinhole psychotherapy into small bits, as this “egos in the ring” is not a small bit, but a decisively nonlinear activity.

Listening To A Story

 

https://soundcloud.com/snapjudgment/most-wanted-snap-judgment-walk

This podcast speaks to the value of psychotherapy. “You showed me love,” Richard, the deceased criminal tells the chaplain who visited him one on one, every week. This is the love of listening, of hearing the pain, the suffering, the loneliness, and the fear. Richard was a man, it seems to me, who wanted to be known, and he made that happen, in the last chapter of his life. I know he was a hardened criminal, who was sentenced to life in prison, but at the same time, he was a young man who realized what he did not get, and so  he lived in fantasy, dreaming of a life he could have, as he invaded homes. As he suggests, the intrusion, gave him a substrate, in which to imagine another life; a life so different than what he had. A life, where he had stability, and consistency. He speaks to going into a home, sitting in a living room, and using his thoughts to bring himself away from his past of being cast about in the world, at an age, too young, for him to cope on his own. This is a sad and happy story. Richard found love, at the end of his short life, through a chaplain, who experienced love, in return. This brief relationship illustrates the power of connection; the power of one human to connect to another, and thereby bring, for a moment, a sense of meaning to both parties. I am moved.

 

After writing this, I saw this comment posted on the internet….by Lisa1122 “I was so touched by Chris’ account of Richard and his life story. It brought tears to my eyes and I thought – this is the reason that I do therapy! To validate those stories that are less than perfect, often times tragic. I believe they were both enriched by the time they shared together. Thanks for the great story.”