Hiking and Dying

 

http://graphics.latimes.com/zion-flash-flood/

 

7 hikers died suddenly. I knew some of them. Did they die doing what they love? I don’t think so. I think they died sad and scared. They left families and loved ones who might define their lives by this before and after moment. The question of “should they have known” will never be known, but many people have very strong opinions on both sides. Estimating risk is the discussion of every adventurer. Every step up a mountain could be one’s last, and yet the thrill of the adventure propels people forward. Most people do not die on adventures, and most people do not know people who have died on adventures, and yet, the risk still looms. There is no good way to think about this, except to say, that thinking about these seven people is how we remind ourselves that we matter, and our friends and buddies who share our passion matter too.  Tragedy has no words, only feelings of pain and confusion. Adventure tragedy is no different. Movies are made, stories are told, but the pain does not change. There is no lesson learned. Yes, slot canyons are very dangerous. Yes, flash floods means there is no way out. Skill and experience matter little. Warnings come and go, and getting information out is not always easy given the limitations of cell coverage. The search for someone to be mad at comes up empty. We cannot funnel our feelings into rage and that makes it even harder. The shock and sadness keeps coming, in waves, which feel like an emotional tsunami, similar to the water which killed these  hikers. They were trapped, as we are now, trapped in the mourning and bewilderment of sudden loss. There is one thing to do. Hold hands with people you care about, because you just never know when that won’t be possible. Yes, I have lapsed into cliché. Mourning has emptied out my language, perhaps explaining why clichés come in handy.

Trauma

 

Trauma, a word that is hard to define, in a mental health sense, and yet it appears to be at the root of many mental health issues. The problem with understanding trauma is that the environmental impact varies enormously based on the person’s biology. We return to the gene/environment interface. Genes load the gun, environment pulls the trigger, so to speak. Trauma, broadly speaking, is the upsetting experience, which the average person never has. Trauma, in other words, implies a major diversion from our basic assumptions. Losing a child is traumatic because in this day and age, we assume that parents will die before their children. A reversal of this order leads us to think that the heartbreak is enormous, and yet generations ago, losing a child was a predictable event in that many children did not survive to adulthood. So, trauma is contextual. The child who loses his mother when he is four, may experience a trauma, but at the same time, if that child is raised by a loving father, and perhaps a loving step-mother, then the child may not experience a traumatic loss, but rather a more “ordinary” sense of loss. On the other hand, if we let the patient define the trauma, then do we say that if the patient says that he had tonsillitis at age 6 and had his tonsils removed, then do we yield to him that this was the “traumatic” moment in his life, which now explains his job and marital difficulties. There are therapies which focus on “trauma” without a consistent definition of “trauma” making the therapy less rigorous, in one sense, and yet appealing, in another. The focus on trauma as an explanation for self-sabotaging behavior, lends itself to the reductionist notion that if the therapist and patient can “work through” the trauma, then the subsequent substance abuse and mood problems will resolve. Once again, I return to my thesis. If we can agree that trauma is a complex notion, shouldn’t we also agree that the treatment of trauma is also complex, and not amenable to limited duration cookbook kinds of treatment?

Clint, twenty-two, comes to mind. His mother committed suicide when he was five, on the fourth of July, “ruining my summer,” as he said with dark humor. His father re-married to a woman which Clint says “is OK”. After graduating high school, Clint has lived a life of homelessness and drug abuse. “Do you think that you would not have your current life if your mom did not kill herself?” I ask, wondering if he connects his current despairing life to the tragic death of his mom, sixteen years ago. “How would I ever know that, ” he says instantly, followed by, “probably, that is true.” He says, with tears in his eyes, and then mine too. “I never had anyone that was passionate about me and my development, and I think that really hurt,” Clint says with surprising candor. Suddenly, Clint has come to life for me. He is not the “homeless guy with a drug problem,” as he appears from the exterior, but rather, he is a little boy who really really misses his mom. Clint needs to feel valuable and important, a process which will take mentorship, and a deep therapeutic relationship. Losing his mom was traumatic, but the end result, put into the context of his life, was a deep feeling of worthlessness and hopelessness. Clint needs housing. He needs to live a sober life. Clint needs to feel loved. Short-term treatment is likely to reinforce his sense of hopelessness, as it will create another abandonment, the worst, most anti-therapeutic outcome. The theme, again, is constant. Complex problems require complex solutions. There is no way around that.

 

Sociopathy

 

George Vaillant MD, a Harvard Psychiatry professor, a hero of mine for many years, wrote an article, published in 1975, entitled “Sociopathy as a Human Process.” I have read and studied this article numerous times, but now, as I review for a Journal Club with my Psychiatry Residents tomorrow, I am touched by this article, yet again. Like watching a movie for the fifth time, or listening to a podcast for the second or third time, I am always stunned by what I missed in the first few exposures. The repetition brings new understanding; the hallmark of a good piece. For example, he says “in an outpatient setting the management of these disorders produces therapeutic frustration.” Somehow I did not catch the phrase “therapeutic frustration” but the two words together capture the energy put into a treatment relationship which hits up against apparent walls. Dr. Vaillant helps us to understand that these walls are not a result of the hopelessness of these patients who appear not to have a moral compass, but that these walls are a function of the deeply traumatic experiences of these patients, leading them to need a more intensive intervention than outpatient psychotherapy can provide. In essence, the tool is limited, not the patient. That’s brilliant. It is easy to  lapse into thinking that if I could just listen harder, and more thoughtfully, then I could be helpful, but in point of fact, there are patients who require a more comprehensive treatment program, in that their reluctance to outpatient treatment does not mean that they could not benefit from a therapeutic residential environment. On the one hand this is obvious, but on the other hand, the default assumption is that resistance to outpatient treatment would mean even more resistance to residential treatment. Dr. Vaillant reminds us that if we could provide a benevolent cage for sociopathic individuals, then we could help them learn from their peers about how to grow in the world, with empathy, motivation and a moral compass. His theory is that these patients lacked the family structure which helped them learn delayed gratification, and as such, they never learned to tolerate the anxiety of waiting their turn, or allowing others their point of view. Only a group environment, in which the patient has to get along with their peers will begin to help them to relate, and hence care, about their fellowship. This is brilliant again. Psychotherapy is the wrong tool. Group living, not prison, is the right tool. I do not know where one can find residential treatment for adults where the focus is on forming a functional group, but it strikes me like it is like a wilderness program, where all participants have to chip in, to survive in the woods. This would be a relatively low-cost intervention with a high yield-keeping them out of prison. The point for my residents-sometimes you have to read the old literature to know what to do in the future! Again, an obvious point that is often forgotten.

Crime Vs. Terror

Last night at the Hammer Museum….

THE PRICE OF TERROR AND THE COST OF SECURITY

More than a trillion dollars has been spent on homeland security since 9/11, yet two amateur terrorists—with homemade bombs that cost $100—were able to shut down Boston for a week. John Mueller, author of Terror, Security, and Money: Balancing the Risks, Benefits, and Costs of Homeland Security; Jeffrey Simon, author of Lone Wolf Terrorism: Understanding the Growing Threat; and William Arkin, co-author of Top Secret America: The Rise of the New American Security State, evaluate whether the enormous cost of security is making us any safer.

 

These three gentleman spoke about how fear generated from terrorism has led to billions of dollars being spent on homeland security, under the direction of both democratic and republican governments. Fear gets dollars was how I understood the process, even though, statistically speaking we should be spending our money on more likely threats to our existence, such as motor vehicle accidents. All crime generates fear, so Jeffrey Simon posed the question about the difference between crime and terrorism. This question intrigued me because I think the difference is the extent to which fear is generated. A neighborhood murder creates fear in that area, but the Boston Marathon bombing creates fear in the world. The internet has made terrorism more potent, both in gathering together terrorists, and spreading the fear at rapid clip. Still, Mr. Simon reminded me that antisocial behaviors create a continuum of fear, and as such, terrorism is not so easily defined. The generation of fear gives power, and so fear, seems to be the psychological reward, for terrorist behavior. That said, if we could respond to these crimes without getting scared, then maybe we could diminish the motivation of the perpetrator. Spending a lot of money on a low-likelihood event seems to reward the criminal. This seems to be the world of forensic psychologists, trying to understand the thinking of the evil-doer. Once again, understanding can change how we allocate our resources. So, we have another argument for the value of digging into mental states.

Dissociation

Olivia, twenty-two, comes three times a week, but from session to session, I never know who I am going to see. Sometimes we laugh together, as she amuses me with funny stories. Other times, she rages at me, although I am never quite sure what I did that triggered her upset. Other times, she is profoundly sad, but again, I am never clear about the trigger. If I remind her of how different our dynamic feels to me from session to session, she says “I know, but I can’t help it.” Her knowing, at first made me think that this is not dissociative, but over time, I have begun to wonder that as coping with stress can be so difficult, that for some, developing different personality styles is a way of coping, similar to dissociation where, often because of severe trauma, one has to “leave” oneself in order to cope with the devastation. Olivia’s quickly shifting relating styles makes me wonder about her history of trauma where she might have felt the need to have different senses of herself, with little threads of continuity, in order not to process the pain of disappointment in her important relationships with her early caretakers. Dissociation is taking denial one step further. Bringing her personalities together, helping Olivia develop internal continuity is our work. This internal continuity is critical for self-confidence and trust in oneself. Peter Fonagy in London has said this multiple times in his work on mentalization. One must be able to think about oneself in a cohesive way in order to enjoy one’s life and not chronically suffer from painful confusion. Olivia knows she needs help with her confusion. That is a good first step.

Is Trauma Interpersonal?

The baby growing up in a household who is unwanted and ignored is traumatized by lack of attention and responsiveness. Nomi, twenty-five, was born to a teenage mom, who was too ashamed to get an abortion, or so that is what Nomi has come to believe. Nomi was raised by her mom and her grandmother, both of whom, by Nomi’s report, treated her like a burden which they would have rather not had. Nomi clarifies that she was well fed, and all of her medical and dental needs were attended to. Money was not a problem as the grandmother was well-off and she was generous with her money. The problem, as Nomi has come to believe through our work together, is that neither her mother or her grandmother, was excited about her accomplishments-big or little. She went to Ivy League college, and then on to a prestigious law school. She does not remember hearing a “congratulations.” “Gosh, it sounds like you feel that you were very alone in the world, and I wonder if at some level that makes you very angry and scared to engage with other people on a deep level.” I say, highlighting the notion that trauma can be interpersonal, and as with all trauma, the downstream effect is one of constriction and numbness. “I don’t see myself as having rage, but maybe I do,” Nomi reflects. “Mostly, I see myself as lacking confidence,” she continues. “Well, that may also be a downstream result of not having someone who mirrors your developmental progress.” I say, pointing out that lack of mirroring has a multitude of unpleasant and undesirable outcomes, which often include a lack of self-assuredness and rage. ” I don’t know that I will ever get there,” Nomi says in despair. “The fact that we can talk about it is a large step towards metabolizing your rage and developing a greater sense of your own potential.” I say, trying to help her see that being in psychotherapy, particularly in-depth psychotherapy, takes courage to confront very challenging feelings and experiences. ” I still feel despair,” Nomi insists. “I can understand that your feelings of despair alternate with your feelings of hope in our process.” I say, stating that despair is a part of her experience, but our work together, our persistence in trying to understand her emotional interior, also gives her hope that she can learn to feel better about herself. Trauma can be interpersonal. Trauma, all kinds, can also heal.

The Yoga Intervention

http://www.traumacenter.org/about/..\clients\MagInside.Su09.p12-13.pdf

This article, by a well-respected expert, asserts that yoga heals the mind by working with the body. That makes sense to me.

The Car Accident

Louise and her dad come in for their weekly visit with looks on their faces which speaks to a traumatic event. Louise, age six, says “we have been through a lot,” in a way that conveys she does not want to tell me all of her news in one sentence. Although only six, she seems to want me to guess as to what might have happened to her. She is teasing me, in a playful way. Larry, her fifty-year old dad, chimes in, “we had a car accident.” Larry’s tone and body movements are different than usual; he is more tense and uptight. Louise jumps in, “we got to ride in a big truck,” she says with excitement for the novelty of riding in a tow truck. Larry, who is not the focus of the treatment, concerns me in his demeanor. He has the appearance of “shell shock,” I tell him. It is the look of stiffness and detachment. Louise, on the other hand, appears relaxed and happy. Louise has some behavioral problems at school, but through our work together, as Larry tells me, she has calmed down quite a bit. “I have to say I am concerned about you, Larry,” I say, trying to walk the fine line of expressing a clinical judgment to someone who has not consented to be my patient. “Yea, it was pretty scary. I had Louise in the car and I just can’t believe how close we were,” stopping his sentence right before he seemed about to say how close they were to dying. “I can certainly imagine how terrifying that is,” I say, understanding that the motor vehicle accident broke through Larry’s denial about the finite quality to our lives. I know the accident was recent and that with time, Larry is likely to restore his old defense mechanisms, but I want to tell him that if this “shell shock” quality does not go away, then he should seek professional consultation. I am not exactly sure how to say this, so I end up saying, “let’s meet next week without Louise and see where we are.” Traumas are openings for the re-working of internal structure, but first they create a numbness that speaks to future suffering when the numbness wears off. “I am glad Louise is doing better,” I say refocusing our work back to Louise, but still concerned about Larry. “Yea,” Larry says with a flatness that is uncharacteristic for him. We stop on that heavy note of flatness.

Hurt People, Hurt People

Wounded adults become wounded parents who then wound their children and the intergenerational transmission of trauma continues. Psychotherapy hopes to interrupt this pattern and thereby not only help the patient, but future generations to come. Leah, thirty-seven, has a thirteen-year old daughter Sophie, and no husband. Leah is divorced, but her daughter is the product of artificial insemination which occurred after her break-up with her husband. Leah constantly “worries” about Sophie in the same way that Leah’s mom hovered over Leah. Leah understands this, but she feels she can’t help herself. She comes to me with the hope that she will be a better parent than her mom, along with the hope that she will feel more relaxed around Sophie. Together, over many years, Leah and I explore her identification with her mom, along with her inability to separate from her. We also explore Leah’s relationship with me, and particularly how Leah has unconsciously assumed that I am judging and evaluating Leah in the same way that her mom has over the years. “OK, to get psychoanalytic about this,” Leah says, “I think I have always thought of you as my mom and I have always thought that you were judging everything about me: my clothes, my hair, my interpersonal skills. It is only recently that I have come to see that I am assuming that, and that maybe that is not true.” Leah explains to me with a sense of contentment that I rarely see her exhibit. I sit there listening attentively, but feeling no need to respond, as Leah has taken over the work of our psychotherapy/psychoanalysis. She has begun to develop an observing ego such that she can appreciate how her dynamics, her assumptions about other people,  are getting in the way of enjoying her life. “Hurt people, hurt people when they do not develop distance from themselves,” I say, reminding Leah that she is beginning to break the chain.