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.

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.

Tele-Psychiatry for Kids?

At the risk of sounding like an old fart, I am not prepared to accept the changing nature of psychiatry, yet again! For many years, I have appreciated the advancement in technology leading to Tele-Psychiatry, where people who cannot leave their homes, or who live far away, can connect remotely to a psychiatrist, allowing for access which would otherwise be impossible.  For adult patients, I am excited by expansion of our services. Now, let’s move into Child Psychiatry. Can a Child Psychiatrist do an assessment through a computer screen? It seems to me that evaluating children, working with families, mandates a three-dimensional exposure which would be severely limited by Tele-Psychiatry. As so much interaction is non-verbal, and as so much of an assessment includes “playing” with the child, I do not see how remote communication can simulate this encounter. Two-way communication devices are wonderful advances in medical settings where doctors do not need to touch their patients, but as a Child Psychiatrist, the “touching,” or more specifically, the shared use of space is critical to understanding how a child navigates their world. Some kids come and sit quietly, whereas other kids have a hard time staying still. Sometimes my words help kids focus, whereas other times, a child needs to be active in my office. These nuances will be lost with a remote access device. Once again, I am left thinking that change can be good, but then again, not always. I understand the dilemma between improving access and quality assessments. I also understand that as a field Psychiatry, particularly, Child Psychiatry, has to hold on to the key tenets of the profession. For me, this includes being in the physical presence of a family is an important component to the understanding of powerful relationships and their sequelae. I am not sure I would be willing to compromise on that issue. Technology should aid us in our goals, not detract us from them. Tele-Psychiatry for kids seems to move my field in the wrong direction.

Exhibitionism

Nolan, nine years old, wants to show off his muscles to me. He comes in with such enthusiasm, clearly wanting my praise. He appears hungry, in a good way, for positive attention. I think about how we, as adults, lose our openness about wanting to be admired. We.  adults, seem to pretend that we don’t need admiration. How do we change from being open about wanting affirmation to being ashamed about that? This was our discussion in what I call my “play class”. Sometimes kids utilize a child psychiatrist to feel good about themselves. They do this in a way which is clear and to the point. Adults, by contrast, also want our admiration, but it usually takes a lot more time for this to be  obvious. “This is normal?” One student asks about Nolan. “Absolutely. It is not just normal,” I reply, “but it is also a positive sign about Nolan’s self-confidence. “He understands that I want to appreciate him, and at some deep level, he knows that he needs appreciation.” I say, trying to explain the importance of affirming children, in order to build self-esteem. At the same time, I am mindful of the notion that our current generation of ’emerging adults’ are criticized for being affirmed too much for too little. Parenting in the 80s seemed to be about the need for affirmation, possibly resulting in a generation of adults who feel entitled to tell their bosses what to do. This notion may have some truth, but that does not mean that we should not encourage parents to recognize the strengths in their children. Parents, generally speaking, should encourage exhibitionism as a sign of forward developmental motion. The confidence and pride in one’s own accomplishment is something that many adults have trouble holding on to, maybe as a result of the lack of recognition in childhood. Many folks think of exhibitionism as boastful and insensitive which it can be, but when done with the sweetness of childhood enthusiasm, it is neither. After talking about how so many things can go wrong in child development, I think my students were surprised I said something positive.

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 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/

Do Child Psychiatrists Still Play With Kids?

I have a new job-a volunteer job, that is! On July 12, 2012, I will begin teaching “Clinical Practicum,” which is a six month child psychotherapy course to first year child psychiatry fellows at UCLA. I will have seven students with varying degrees of interest in doing child psychotherapy. “Can I give my students articles to read?” I ask, my new boss. “You can do whatever you want,” she tells me with a smile. I am excited to walk into an environment in which psychopharmacology is the dominant modality, with the hope, that maybe, just maybe, I can remind my students, budding professionals, that listening and explaining are still valuable skills. Maybe, I can encourage play. By that I mean, maybe I can inspire them to play with their patients as a way of getting to know them.

I have a goal, but my question to myself is how best to achieve that goal. We can read and discuss articles. I can talk about my clinical experience, by disguising identifying features in order to preserve privacy.  If I choose that path, should I pick one patient and go into depth about his treatment, or should I discuss vignettes of multiple patients? I can have them bring in their clinical experience, and we can have a group supervision group where we share ideas about how to get into the inner workings of both the child and his/her family. If I have the child psychiatry fellow bring in a case, then should I divide up the 26 weeks among seven fellows so that everyone has an equal opportunity? Should I limit the class to the treatment of pre-pubertal kids, since treating adolescence is a very different skill set? The best path is not clear to me.

I need to connect with them in a way which expands their experience, but does not seem “outdated.”  I fear that they will see the idea that one must  spend a lot of time with a child and his family before plunking down a diagnosis  as “unrealistic.” To help them see that understanding and explaining is a journey contradicts the notion that parents need immediate answers to their concerns about their child. On the other hand, this is a University, so a multiplicity of ideas should be embraced by both students and faculty. I hope that my exploration of different ways to approach this class will be in line with my goal that different approaches all have value. The more one learns, the more tools one can draw upon. This is a simple notion, but even in the most open minded families, I mean institutions, this idea gets lost. Am I too grandiose to think that I can bring back a discussion of family dynamics to a scene which is so heavily based in neurobiology? Or, do I need that grandiosity to enter into this adventure? As always, I welcome your thoughts.

The Aggressive Child

Daniel, six, with a two-year old brother, Jonathan, knew that Jonathan was the favorite. He was angry when Jonathan was born, very angry. Daniel acted out his anger with aggression, which further confirmed to Daniel’s parents, that he was the “bad child.” This was my theory as to why Daniel was so violent, both at school and at home. Many teachers, family members, and other professionals saw his aggression as either part of a “spectrum” disorder or an impulse-control disorder such as ADHD. In my office, Daniel was indeed quite aggressive. He would take off his shoes so that he could throw them at me. Yet, I saw his aggression as a way that he communicated that his emotional needs were not getting met, and he needed me to understand that. I explained to Daniel that throwing his shoes was unacceptable in that I did not want to get hurt and I  did not want him to hurt others. We could use my pillows to “play” in a way which might get out some of his aggression, but we could not use the pillows to hurt each other. He understood the fine line between physical play and aggression. Eventually, Daniel calmed down in my office, but he continued his aggression at school and at home. With that in mind, I began seeing his parents on a monthly basis. Both the mother and father agreed that Jonathan was a “much easier child,” suggesting that they did favor him at home. Jonathan made them feel like competent parents, whereas Daniel, partly because he was the first-born, and partly because he was more prone to acting out, made them feel like they were “parental failures”. I worked with the parents to help them see that as they felt like “parental failures”  where it came to Daniel, they then unconsciously encouraged Daniel to be aggressive as a way of denying their role in his behavior. As Daniel got into more trouble at school, the parents felt more relief that Daniel had “issues,” thereby taking away their feeling of “parental failure”. The cycle of parental inadequacy leading to the unconscious wish for Daniel to show that his issues are “organic” and not environmental caused the downward spiral of increasingly difficult behaviors. However, I pointed out to them that although Daniel’s behavior is getting worse, in my office, his behavior is getting better, suggesting that with appropriate limits, Daniel can calm down. Winnicott’s idea of a holding environment comes alive again. Daniel felt “held” in my office, so he did not need to be aggressive in order to feel understood that his emotional needs were not getting met. Daniel’s parents, for complicated reasons, were not able to create this “holding” environment at home. Violence is often a communication tool; a tool to wake up those around that the aggressor needs attention. Sometimes people do not want to be woken up. My work is to find a way to gently nudge a “wake-up” in these parents. I suspect that when I do arouse these parents, Daniel will be “cured”. We will see.

‘I Can’t Believe You Got On The Floor’

Elaine, mom of eight-year old Eli, says to me “I can’t believe you got on the floor with him.” “Isn’t that what you expected?” I asked, thinking that all child therapists want to see how their child patients play and playing with them allows us to enter into their world. “Well, I guess so, but I have taken Eli to so many people and very few people actually try to play with him.” Elaine tells me with tears in her eyes, trying to understand her son. “Eli is a very creative child. I enjoyed joining him in his imaginative play,” I say, marveling at the privilege of being a child psychiatrist. “At the same time, he does seem to have overwhelming sadness centering around the loss of his maternal grandmother,” I say, adding that through his play I could see how this loss has interfered with his ability to enjoy his life. “Yes, I know that,” Elaine says with a look of recognition and relief. She seemed to expect that I was going to give Eli a diagnosis, rather than explain to her what was troubling him. “What happens next?” Elaine asks, as if I might talk about medication. “I think I need to observe Eli at school,” I say, wanting to gather more information since his play was imaginative, but also a bit isolative at the same time. “That is a good idea. You should definitely observe him at recess,” she says, highlighting our mutual concern about his social communication skills. “Getting on the floor really helped me see how he plays,” I repeat, still thinking about Elaine’s opening comment to me. She teared up again, “yes, but I did not expect that.” How sad our world is,  I thought, when people come to child psychiatrists and yet don’t expect the doctor to play with their child. How did we lose our way?

Exciting Times

 

 Glen, twenty-one, comes in, and without a word spoken I feel him vibrating with excitement. I began to think of my previous post https://shirahvollmermd.wordpress.com/2010/01/23/the-nature-of-excitement/. There was something about his facial expression, his body movements and his posture, that made me think about how happy he seemed to be feeling. I say “so you are done with school for this year.” He quickly responds “yea, and I am leaving in eleven days.” I suddenly remember that he has been talking about his summer plans to travel to Brazil with his friends. “Eleven days, wow you sound so excited,” I say. ” “Yea” he responds, with tremendous youthful enthusiasm. In Glen’s mind, he is leaving his troubles behind and he is going to a “stress-free” zone of hanging out and exploring new places. Glen has constructed his summer to be free of “parental nagging” as well as  free from studying for examinations. It is as if Glen feels like he is finally being let out of his cage and explore the world on his own terms. The trip is six weeks, so it is circumscribed play. He is not entering the adult world of responsibilities. He is still dependent on his parents for financial support, but he sees himself free from the phone calls from his mom reminding him what he has to do, either for school or for his family. Glen loves his mom dearly, but he also feels burdened by her prompting him to “call this relative, or buy this one a present.” Glen figured out that travel meant a temporary respite from responsibility. Glen knows that travel can be difficult. He could get sick. He could run into significant travel delays. He could have interpersonal issues with his friends. Knowing this, Glen still feels that the opportunity to explore a new culture, a new country, far outweighs the potential for adversity.

    I saw in Glen the power of his imagination for a positive experience. Even though Glen has never been to South America, he forecasts a fun time. These positive feelings stem from his sense in himself to become excited by new places. In essence, Glen is calling up his positive introjects. https://shirahvollmermd.wordpress.com/2010/04/18/introjects/Glen also loves his friends and as such, he is excited to share a new experience with them. He is confident that his friendships will deepen with this experience. Glen’s internal sense of security translates into excitement for adventure. He knows that he can rely on himself and his friends, in case trouble occurs. His youth means that he has not accumulated terrifying experiences which can damper a sense of excitement.

    Despite the popular belief that therapy is a place to “dump your problems,” therapy is actually a place to share many types of  feelings. Good feelings need to be shared, as do bad ones. As Glen and I talked about Brazil, I could see how he both grew more excited  and he  calmed down.  The excitment mounted as we spoke about the details of his trip. He calmed down as he was in such an up-regulated state that talking with me, brought him back to an equilibrium. The layers of his anticipation were displayed over our session. Once again, I was privileged, and in this case excited, to bear witness.