Depression or Misery?

“Depression as a feature of mental illness is the misery of childhood translated into the present….” Charles Brenner MD

 

As we enter into the Thanksgiving holiday and remind ourselves of what we are grateful for, I am also reminded that relieving human suffering is the goal of my work as a clinician, and my work as a teacher. As such, understanding suffering is critical to a meaningful intervention. Children who suffer in childhood are likely to suffer as adults because those are the limited tools they are given to cope with a challenging and uncertain world. This understanding has multiple layers. One obvious layer is that we, as a society, need to do what we can to make sure that childhoods are supported by a rich infrastructure of nuturance, through schools, community clubs and religious organizations. Second, those who did suffer greatly as children, who grow to adulthood, need intensive intervention and understanding to create a new, more optimistic schema of their world. Third, mental health practitioners need to understand the connection from past to present in order to help the depressed adult. One cannot just look at the here and now, without thinking about what this current suffering hearkens back to.

Robyn, fifty-five, male, comes to mind. He dreads the Thanksgiving Holiday and so this time of year he retreats into his apartment and does not go out much, except for work. “What was Thanksgiving like as a kid?” I ask, trying to tie past with present. “Oh, I hated it. My family would get together and they would be mean to each other. My mother would tell my father that he was lazy and did not do any of the work. My brother and sister would fight, leading my brother to make holes in the wall, as that is how he discharged his anger. My mother would then praise my brother for hitting the wall and not a person. The more I think about those days, the more sad I am about the family I grew up in,” Robyn says, with deep feelings which make me feel both sad and interested in his past. “Do you think those memories have carried forward such that you are re-living them every year around this time?” I ask, wondering if he sees the connection between past and present. “Actually, I did not think about that, but as you say it, it sounds so obvious,” Robyn says with obvious excitement over this understanding. “Maybe you can layer over those memories by creating happy times for yourself around the holidays. Maybe you need to make an extra effort to do that, as a way of pushing down further the memories of your Thanksgiving table.” I say, not encouraging repression of memories, but layering over them, consciously, with times which create very different associations to the holiday. “Maybe you need to ask your friends for an invitation, so you won’t be alone?” I say, encouraging him to reach out to those who care about him. “Yes, of course that is what I should do, but I need to think about it, as I am afraid I will be a downer.” “Maybe if you are around people you care about, your mood will lift and people will enjoy your company,” I say, pushing him to interact over this sensitive time of year. “Maybe,” Robyn says, with extreme hesitation.

The Lying Relative

 

Mom and dad have both passed away, leaving four siblings to deal with the modest estate. Two of them, number one and three, by birth order are charged with the job of joint trustees. The other two, numbers two and four, live in the same state, and are not sure why they were not “chosen”. Number four, Jorge, is my patient, age fifty-six and essentially happy with his current life, but becomes massively tearful when talking about his childhood. “The number of times my mother lied to me are so numerous, that I can hardly stand it,” Jorge says with the feeling as if he spoke to his mother yesterday, but, in fact, she has been dead for five years. “My nephew lived with my parents for an entire year and they never told me that was happening, until the end of the year, when they invited me to graduation, which was local. All that time I thought he was in another city. Can you imagine how awful I felt?” He says, with characteristic rage and shame, as if wondering what was wrong with him that his mother did not give him the courtesy of including him in family news. “You have so many complicated feelings about this withholding of information. It seems like you are both angry and self-denigrating about his omission.” I say, highlighting that at times he is more focused on his rage, whereas other times, he focuses on his shame and poor self-regard, resulting from being treated without respect.

Jorge, a successful university professor, flies off the handle, internally that is, when a student does not show him respect. “Sure, no one likes these millennials who think the world owes them everything, but I am particularly sensitive to their entitlement,” he tells me. “I had a student who told me that she did not like my assigned readings.  That was so painful for me.  A part of me knows that I cannot please everyone, and another part of me knows I should review the chapters I assign to make sure they are relevant for my students, but the biggest part of me felt hurt and disrespected, bringing back these terrible memories from my childhood, where nothing I said mattered. You know, when I saw the play Fiddler On The Roof, as a child, I said repeatedly, those two younger kids never spoke, no one knew what they were thinking, and that was just like me. So, now my sibs are dealing with the estate, and how can I trust anyone when my mother was so dishonest? Why did she pick her ‘favorites’ to deal with the estate? Did she just want to rub it in even deeper, how mean she could be?”

Jorge jumped from his class, to his childhood, to his current struggle with his family of origin, all without my prompting. This chain of associations, free association, if you will, helps me to understand how he is working at connecting past to present, and how his present classroom situation makes him feel bad about his past and how his. past, his childhood,  makes him feel bad about his present situation with the estate.  My job is to facilitate this narrative where he can come to understand his hurt, so that the student who criticizes his choice of readings, is seen as feedback, and not as deep dig into his psychic world. Likewise, the estate is bringing up for him, the dishonesty, and hence the anxiety he had in his childhood of  not knowing who to trust, but that does not mean that he cannot trust the other intimate people in his life. Not confusing past with present, or present with past, is challenging, as every experience brings up memories, and so it is hard to maintain perspective. The opportunity, however, to consider past and present together is the gift that Jorge gives himself. Dishonesty is a malignant experience in childhood. If Jorge were not mindful, he would grow up convinced that no one cares about him, enough to be honest with him, thereby not allowing himself the intimacy of relationships.

“If your own parents lie to you, how do you recover from that? ” Jorge asks me, not necessarily wanting an answer. “It is hard,” I say, “very hard”.
 

 

Judy Garland

 

Thinking about Judy Garland, having  just seen “End of the Rainbow” http://articles.latimes.com/2013/mar/16/entertainment/la-et-cm-tracie-bennett-end-rainbow-20130317, with fellow psychiatrists, we engaged in a heated debate about the nature of her suffering. ?Bipolar, ?ADHD, was the launching pad for the discussion, and yet my thoughts turned to her horribly sad childhood in which, she made money for the studios, and in the process, she was fed prescription drugs to keep the “machine” going. “Trauma,” I said firmly, in trying to understand this icon. She seemed robbed of a time in her life to “play” even though some might say that acting is a form of playing, Judy Garland had to play like she was told and so, by definition, this was not the kind of play in which she could make up her own rules, and have a time in her life in which her activities were inconsequential. This left an inner emptiness, a “zombie state,” as a colleague of mine says, in which she could never experience the sensation of being alive, but rather she enlisted her superego to do what she “was supposed to,” thereby leaving her feeling without satisfaction or fulfillment. She never had a chance to experience her ego, as her superego was running her life, from such an early age. Her many husbands, it seems to me, provided this superego, until one of them tired of the emptiness. She never seemed to know herself, to know her ego, and as such, she could never find a path towards happiness. As Ray Bolger, her co-star in the Wizard of Oz, succinctly stated, “”she just plain wore out.” Like a machine, the gears could no longer turn. Sad, sad, and sad. There is no diagnosis, as far as I can see, but only an incredibly talented woman who never developed a sense of herself. What do we call that? I call that child abuse.

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.

The Anxious Kid/The Disorganized Mom-Chicken or Egg?

   Leanne, fifty-one, is always confusing appointments, losing pieces of paper, and is in general a very disorganized person and a disorganized mom. Lesley, her twelve-year old daughter, feels she can’t count on her mom to follow-through in a timely fashion on scheduling doctor visits, or picking up things she needs so that she can be in the school play. Lesley compensates for Leanne’s unreliability by making a multitude of lists in which she tracks what needs to get done. At the same time, Lesley is constantly in a state of anxiety in which she is worried that she will not complete her task list. Lesley’s dad has suggested that she take medication for her anxiety. I question Lesley, “do you think you would be so anxious if your mom was more organized?” I wondered if Leanne’s unreliability made Lesley feel fearful that so much of the responsibility of moving forward in her life now fell on Lesley since her mom was not providing a safety net for her. In other words, the maternal role for an adolescent child is in large measure the job of making sure that the teenager can go to their various activities and that they have the right supplies. Without this infrastructure, teenagers are going to be impaired in their ability to engage in multiple life experiences.

 Lack of reliability can create anxiety in someone who is dependent on them. That is straightforward. Am I “blaming” Leanne for Lesley’s mental state, or am I understanding what Lesley is up against? Am I stepping on the therapist’s toes, by suggesting that the more Lesley understands that she is anxious because her mom is disorganized, the better Lesley will be able to cope with the demands of her life. The nature/nurture debate continues. Lesley is probably wired to tilt towards anxiety-an internalizer as we say. Her environment exacerbates her condition. She can learn coping skills and she can probably also benefit from medication. This is not a binary system. Yet, our brains wish for binary. We want answer, and sometimes that answer is medication. Multiple answers are usually harder to grasp, especially in crisis. Staying broad-minded is the goal. Lesley is going to do well. She needs help understanding her mom and her mom’s frailties, and she also needs help understanding the vulnerability in her brain to be anxious. She is up for both of those tasks. So, chicken/egg, does not matter.

Nature or Nurture: Will The Debate Ever End?

   Daniel https://shirahvollmermd.wordpress.com/2012/02/07/the-aggressive-child/ is out of control in that he throws chairs when he gets frustrated with his video games. He punches his mother when she asks him to do homework. Is the problem a parenting issue or a mental health problem or both? Although seemingly complex, the issues become straightforward. All children, especially aggressive children, need to have very clear limits: a “holding environment” as Winnicott has taught us. By clear limits, I mean that Daniel has to be told that hitting is not acceptable. He needs help to use his words when he gets frustrated. He needs to be exposed to video games which are age-appropriate. He needs to have guidance with self-regulation when it comes to eating and sleeping. The parents need to make sure that he eats well and has a regular bedtime. They also need to make sure that the school is attending to his academic and emotional needs. Finally, they need to make sure that Daniel is exposed to playdates so that he has the opportunity to learn social behaviors from his peers. When all of this is in place, and Daniel still has problems with frustration and aggression, then the discussion about diagnosis and medication management needs to begin. It is not that Daniel’s parents are responsible for Daniel’s aggression, it is that Daniel’s parents can provide the basic nurturing environment such that we can see that even with a clear “holding environment” whether Daniel can control his impulses. It is hard to know if Daniel can control his impulses when the environment is chaotic and unpredictable. In this latter circumstance, many kids, with or without a mental illness, become anxious and physical. I think I am stating the obvious, and yet controversy ensues. What am I missing?

The Oedipal Triangle: Freud Lives

  Elaine lives out Freud’s hypothesis that negotiating the oedipal triangle is one of the big challenges of development. Elaine is  thirteen, loves both her parents, yet her parents do not love each other. Gloria and Edward, Elaine’s parents, feel that it was a mistake to get married, but they cannot get divorced because “it will hurt the children.” Instead, Gloria and Edward live completely separate lives. Gloria goes to Church every Sunday. Edward does not think much of religion. Elaine is forced to go to Church, even though Edward says “that’s ridiculous.” Elaine is rude to Edward, and by Edward’s report, Gloria secretly encourages Elaine’s disrespectful behavior.

   Crisis, Elaine’s crisis, has forced Gloria and Edward into my office. Elaine got suspended from her parochial school. Edward is not too unhappy. He wanted her to go to public school any way. Gloria is quite upset as there are few other school choices which suit Gloria’s criteria. Nevertheless, both Gloria and Edward are worried that Elaine is having behavior problems at school. They want help for Elaine, but they are not willing to compromise with each other. Elaine is torn between pleasing her mother and alienating her father or the other way around. Elaine cannot see how to navigate her family life such that her parents are both happy and as such, she is acting up at school in an attempt to bring her parents together, or so it seems to me. By contrast, if Gloria and Edward could present a united front, be they married or divorced, then Elaine could identify with her mother, but still feel the love from her father: a successful oedipal resolution. Elaine’s inability to come to such a resolution creates such inner torment that following the rules at school seem nearly impossible to her. Without Freud’s understanding of this oedipal triangle, it would be more difficult to articulate why Elaine is having behavior problems. Freud did not help us treat kids like Elaine, but he sure helped us understand them.

Teaching Psychoanalysis and Child Development: Together Again

 I am back to my teaching role, that I posted over a year ago about how sad I was to end my class. https://shirahvollmermd.wordpress.com/2010/11/18/the-last-class/ Now, I am with five new students to me, although they are second year students, at a psychoanalytic institute in town. This is not the psychoanalytic institute I trained at, so although I have taught there for years, I still feel like a visiting professor. Perhaps that is because I pay dues to the organization that birthed me as a psychoanalyst. Like families, psychoanalytic training is a developmental process where there seems to be undying loyalty to where you started. The personal and professional transformation that takes place as one goes through training is hard to articulate, yet it feels like a major personal growth spurt, with all of the tumult of a second, and maybe for some of us, a first, adolescence.

  Our first two-hour session is a meet and greet along with reviewing three articles that I assigned to them. The meet and greet part is fun and interesting, but of course, I start out a bit nervous, as I enter into an unknown world of a class, like all classes, has a dynamic that I am not familiar with. I don’t know who likes to talk a lot. I don’t know who is shy and reserved. I don’t know if one person likes to dominate another, but I will find all that out in short order.  Meeting these five new folks was inspiring. These are five (three women, two men), hard-working individuals who are devoting a substantial amount of time and money re-tooling themselves to work in their private practice with  psychoanalytic tools. I give them a lot of credit for that, given how hard it is to find the resources to be so focused in this day and age of continual multi-tasking.

  After about twenty minutes, I calmed down internally. We were getting to know each other, and the enthusiasm carried us through the uncertainty of whether we could all work together for the next ten weeks (eight week class with a two week break for the holidays). We then dived into the material; material I love to talk about. We talked about how important childhood is for the development of enjoying leisure time. The “latency” of childhood refers to the only time in one’s life which is free of the sexual pressures of pursuing bodily passions. We discuss how schools influence the childhood sense of morality and how certain schools reinforce the parents’ value system over others. We have a rich interchange involving patients, personal experiences, and raising one’s children. Understanding the developmental train, leading to the formation of personality is fascinating. It is nice to share that fascination with like-minded curious and dedicated folks. Like my blog, my teaching is a labor of love. The romance has begun.

Moderate ADHD

   Larry, eleven, entering sixth grade, is about to enter into the pressured-filled world of applying to seventh grade, secondary school. Like the pressure of eleventh grade, where kids have to seriously consider how hard they work might impact their choices for college, so too, in the private school world, going to sixth grade forces kids to pay attention to their grades, not only for the sake of pride, but for the practical reason that their performance in school, to a large measure, will determine their secondary school. Larry is thrown into this pressure cooker, with the added burden of ADHD, and as such, although he is very bright, he does not perform up to his potential. He does not check his work. He hurries through his tests. He often forgets to turn in assignments. He has tutors, extended time, and he is on medication, but with that support, he is still underperforming, based on the discrepancy between his IQ and his grades. Should the parents try harder to have Larry perform in a way which matches his IQ? I wonder. Or, should they accept that ADHD limits his scholarly performance and that is just who Larry is? Maybe. Or, as Larry’s parents did, should they tell Larry to work harder because it is “really important.” 

  Understanding ADHD, like understanding anxiety, is a deep issue. Larry’s mom, Carol,  has ADHD, yet that does not seem to give her empathy for Larry’s struggles. Carol did fine in school, although now she has trouble organizing her life. I explain to Carol and Joe, Larry’s parents, that helping Larry with medication, educational tutoring, and extended time, is useful, it is also useful to understand that Larry may not perform to his potential, and maybe, just maybe, that is fine for now. Yes, he may go to what they call a “tier two” school, but maybe that is appropriate for him. Larry, like many ADHD kids, tend to be late bloomers. “Maybe he won’t hit his stride until college and maybe that is fine for him,” I say, knowing that Carol and Joe are thinking that he won’t go to a good college unless he goes to a “tier one” secondary school. Although I understand their concerns, the linear nature of their thinking concerns me. Like so many parents, there is a feeling that if things don’t go right when the child is eleven, (or even earlier in some circles), then the child will then be denied all of the privileges of the élite. There seems to be little allowance for deviating from the “path”. There also seems to be fear that such deviation will land that child in a “different” world, a world unfamiliar to the parents. It is not that Carol and Joe do not want the best for Larry. They do. Understanding what “the best for Larry” means is the tricky part. I offer an alternative point of view of the “best for Larry” based on my understanding of the disabilities associated with moderate ADHD. Layered over that, I feel for Larry and his struggles. Larry is a nice, sweet and charming kid. I wish he could just go seamlessly into the seventh grade. Unfortunately, that is not going to happen.

ADHD: Slowly Developing Brain

   “When is she ever going to grow up?” Arline, the mother of Jolie, age eighteen, asks me, with a tone of frustration, impatience and anger. “ADHD tends to cause a three-year lag in emotional development,” I try to explain to her in a flat tone to say that Jolie is going through a slower developmental trajectory than the average child her age. “Yea, but look at her,” Arline continues, “she is not motivated to do her homework. She is texting all the time. I mean all the time.” Arline continues with her frustrated tone. “I think you should use an incentive program for her to do her work, but at the same time, I think you need to understand that she is a late bloomer, so you need to have some patience with her development.” I try to explain in a way which is supportive to Arline and Jolie at the same time.

    Developmental change, the rate of development, is a variable in personality which is hard to contemplate because we cannot measure it. I imagine that the brain is developing, along with the other organs in the body, and as such, the DNA instructs this rate of development, as it does for height. Everyone grows at different rates, but most people stop growing around twenty. The rate at which people achieve their final height varies. Some people are done at twelve, whereas others are still growing in college. Girls tend to start their growth spurt before boys, and they tend to stop growing before boys as well. Brain development is probably similar. Girls mature before boys. In general, they reach their developmental milestones earlier. They develop speech sooner. Girls, in general,  are not smarter than boys, but a three-year old girl who has sophisticated speech seems smarter than a three-year old boy who is still speaking like a telegraph. Understanding that the brain is also developing at a rate which we cannot measure, but we can infer from the type of decisions the person makes, helps us understand that growth is in progress. With this understanding, intervention can be tailored to the person’s developmental, not chronological age.

    Arline looks at me and says “do you have children?” She seems to be trying to figure out if I have any idea about her parental frustrations, her worries, and her guilt. “I am happy to answer that question,” I say, “but tell me why you are curious. Do you think that if I have children, then I have a better idea of what it might be like to be concerned about how a child is eventually going to be independent, whereas if I don’t have children, then I would not be clued in to the feelings associated with having a child who is not responsible.” I ask, trying to guess why she is feeling so alone in our session. “Yea, I am not sure you understand how worried I am.” Arline says with deep feeling. “I am sorry if I have not conveyed my understanding, but I feel as if I do understand,” I say, trying to state that although she feels alone, I can feel, at least in part, her trembling anxiety over Jolie’s future. “I am going to think about this slowly developing brain idea, but right now, I don’t get it,” Arline says in a calmer voice. “Think about it,” I say, feeling like Arline is a bit more open, and perhaps more able to accept Jolie’s biology. “It is not easy being a mom,” Arline says with lightness. “Yep, I get that,” I say, mirroring her easy going tone. “There is a lot at play in helping a human being develop,” I say, stating the obvious, but feeling like I need to express the complexity of parenting. “More than I ever thought,” Arline says, allowing us to connect in a warm way.