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An Unforgettable Patient: The “Meerkat Boy”

An Unforgettable Patient

An unforgettable patient was a child I will refer to as the “Meerkat Boy.” He was only 4 ½ years old. His father had mentioned to his own therapist that the child had rarely (if ever) spoken, was reclusive, and was defecating in the corners of rooms. The therapist recommended that the child be evaluated. Hence, my first meeting with the boy.

The child entered my office alone, apparently uninterested in having his parents join him. His skittish movements reminded me of a Meerkat, on the lookout for danger but nevertheless engrossed in exploring his environment. He moved through the room quickly and with curiosity, gently opening and poking through drawers. What was he searching for?

Suddenly, he stood straight up and beamed a broad, excited smile. He had found a treasure! He swung around and motioned for me to sit down in a nearby chair, positioning me so my face was at his level. He was about to share his treasure with me! He held out a roll of transparent tape. What next? He gently approached me, but no longer with caution. He took my head and began to wrap it in the tape.

Should I stop him? Should I be using this as an educational opportunity to teach him about boundaries? Should I insist that he put into words what he was demonstrating in action? The next 10 minutes were painfully long as I wrestled with how to be most helpful to him. But we’d only just met… So I said nothing. And, with both care and determination, he wrapped my head until the entire roll of tape was gone.

With that, he stood back examining his work with pride, and pronounced, “I wish I could do that to Mommy!”

I soon came to know that he was not on the Autism Spectrum or struggling with intellectual developmental delays, as others outside his family had suspected. The boy was a bright and curious child, coping with extraordinarily odd and intellectually disabled, although well-meaning, parents. His parents, after all, had not recognized anything unusual about his lack of language and odd behaviors, but had willingly brought him for therapy when this was suggested by a professional.

In meeting with the child’s mother, I learned that she also had some unusual interests that challenged normal boundaries. (“I wish I could do this to Mommy!”—that is, containing her with tape.) Whenever a family member used the bathroom, she would call all others to view the “product” before flushing. She had also removed all bathroom doors, purportedly due to a fear that her son might drown if allowed to be alone in the bathroom. The child’s preference to defecate privately in the corners of rooms now made sense to me. When his need for some privacy was explained to her as developmentally appropriate, she willingly returned the doors and stopped calling for audiences. He responded positively.

With my encouragement, she also enrolled him in a nearby preschool. Teachers responded to his intelligence and curiosity, and he thrived. More clues to his concerns about boundaries came with his first “show and tell” at school. Children were to bring something from home to share with the class. The day before the event, the boy came bounding into my office, both excited and anxious, to show me what his mother had prepared for the event. He pulled a clear plastic bag from his pocket and laid it on the ottoman. The baggie revealed a multi-year supply of cotton swabs dripping in ear wax. He announced that his mother had been saving it from before he was born. I worked hard to maintain my composure (and breakfast) and agreed that this was indeed something the other kids might find really interesting. Knowing though that some children (and the teacher) might not respond positively, I wondered out loud whether he might want to take something a little less unusual for this first share. His body language showed great relief and he proceeded to explore my office for something he could take instead. He decided on some paper clips, which he linked together into a long chain.

I passed the change in plans on to his mother and, although confused that there could be potential controversy, she complied. The linked paper clips also appeared to gain special meaning for the child, as thereafter he would ask if he could take two for his pocket whenever there was to be a break between our sessions.

I have had the great fortune to work with this young man periodically through the years, as various issues have arisen for him. I’m so glad that I’d chosen to observe and listen. He will always be an unforgettable patient.

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Thumb Sucking: Orthodonture or Psychotherapy?

Thumb Sucking

Thumb sucking can become a heated issue for parents. “How can I get my child to stop sucking her thumb?” is a common question asked by parents. And there are so many “remedies” on the market to help achieve this goal—bitter nail solutions, thumb wraps, children’s books to coax a child away from the act, and parenting books with numerous strategies. I rarely hear the question, “Why is my child sucking her thumb?” As a psychologist, I wish we would start there.

Yes, I too have heard from pediatric dentists that constant thumb sucking may impact the teeth, jaws, or roof of the mouth. But I’ve also read sources (e.g., American Dental Association, 2016) that suggest that we shouldn’t be too worried for a young child. And, as noted by the American Dental Association (2016), excessive pressure to halt thumb-sucking can in fact do more harm than good.

Children can be seen sucking their thumbs even before birth in the womb. It is a natural way to self-soothe and relax, and may build a sense of comfort and security in times of stress. Some children gradually develop other modes of self-soothing by the time they reach 4 years of age, especially when they learn to express themselves and connect to others with words and other activities.

But children are not all built the same. Temperaments differ. Some children are born with more intense feelings that are harder to manage. And environments do not have the same impact on all children. Some children relish being surrounded by activity and sounds, while these can overwhelm others. Of course, an especially stressful environment can cause problems for a child, but even a normal level of stress may overwhelm the coping mechanisms of some children.

If a child is over 4 and still wishing to suck her thumb, rather than jumping to eliminate this potentially important source of comfort, I would encourage parents to consider the needs of their individual child.

• Is the thumb sucking merely a habit which is no longer important as a source of calming?
• Is there something they can modify in the child’s environment to reduce stress?
• Can they help her develop other coping strategies?
• Or should they allow the child to continue sucking the thumb until she is ready to move on?

In some cases, future orthodonture may be a more desirable alternative than years of psychotherapy as an adult.

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What a T-Shirt and Ticklish Gorilla Can Teach a Psychotherapist About Building a Life That’s True to the Self

Identity Development

I’ve learned much from both my favorite t-shirt and a ticklish gorilla about identity development, self-awareness, and building a life that’s likely to be fulfilling.

First, for the t-shirt. My favorite t-shirt has a little label sewn on it that says, “Do what you like, like what you do.” I’ve thought a lot about this. How is it that we can come to know what we’ll like to do? It’s a question that I believe is related to identity development and self-awareness—areas that I’ve long been interested in as a psychologist, psychotherapist, and college professor.

How can we come to know who we are and what we’ll like?

Can we think our way there? Can we read about options on the internet, consider our intellectual strengths and temperament, select a path, and live happily ever after? Or is there benefit to meandering along unplanned trails, getting dusty and sweaty, and feeling the warm sun on our face? Which approach will provide us with a more fulfilling journey as we proceed through life?

I spent the entire summer after graduating from high school, thinking about exactly what college would be like. I read about it, dreamed about it, and had long discussions about it with my dog Louis, until I thought I had it all planned out. I would be a French major and then go on to Law School. And I would establish a law practice in Paris. It all made perfect sense. I loved French poetry and had taken French since the 3^rd grade—something not uncommon on the east coast—and so was pretty good with the language. I was analytical. And I thought Paris was a beautiful city. And so, here I am, today, a lawyer in Paris… My point is that I really had no idea what would be in store for me over the next few years.

So, I began my first year in college as a language major. The only field I’d ruled out was psychology—I thought that psychologists must be, by and large, strange people and kind of scary. But then, one day as I was stumbling through the halls on my way to a class, a psychology professor stopped me and asked if I’d like to run a study with him. What kind of study could one run in psychology anyway, I thought? Fortunately, I said, “Sure,” thinking of it as an opportunity to try something strange—strange, like eating chocolate-covered ants might be strange. But he soon had me researching in the library, constructing questionnaires, running all across campus to collect participants, learning about stats so I could analyze the findings… If I’d stopped and reflected on what he’d have me doing before I jumped in, I never would have said yes. I never would have considered psychology—a field that I’ve now been very happily working in for most of my life—if a professor hadn’t encouraged me to “try it on.”

Now for the ticklish gorilla. A delightful article by Bering (2010) was published in Scientific American several years ago. It was about evidence that animals have a sense of humor. I’d like to share this excerpt from the article:

When I was 20, and he was 27, I spent much of the summer of 1996 with my toothless friend King (a 450-pound Western Lowland gorilla, with calcified gums), listening to Frank Sinatra…, playing chase from one side of his exhibit to the other, and tickling his toes. He’d lean back…, stick out one huge ashen grey foot through the bars of his cage and leave it dangling there in anticipation, erupting in shoulder-heaving guttural “laughter” as I’d grab hold of one of his toes and gently give it a palpable squeeze. He almost couldn’t control himself when, one day, I leaned down to act as though I was going to bite on that plump digit. If you’ve never seen a gorilla in a fit of laughter, I’d recommend searching out such a sight before you pass from this world. (para. 2)

Now, a lot has been written in the field of psychology about identity development. And, with the help of neuroscience, a helpful distinction is starting to be made between identity and self, putting words to elements that are related but actually quite distinct (Gerson, 2014). Identity refers to a self-reflective third-person understanding of oneself, whereas self is a more primitive and core first-person sense or experience of oneself. Early on, we move from a purely personal experience as and become more reflective, as we become socialized and develop language (Gerson, 2014). We no longer merely experience with our senses, as we develop tools to reflect on and think about our experiences. We become our own observers. This development represents identity (me), as opposed to self, which involves our personal experience as an I. Our gorilla friend probably experienced more self-ness than clarity about his identity—but that’s for ethologists to verify. Human adults, on the other hand, often lose touch with their basic self.

If I asked you who you are, I might get a variety of answers. You might say “an adult,” “a generous person,” “a teacher,” “a psychotherapist,” and so on. These would tell me a little bit about your identity—descriptions that derive from observations of or reflections about yourself. But, now take a moment, and think back to your earliest remembered experiences. Try to experience what it felt like being you at the time, not as an observer, but as a participant. Did you feel excited, timid, curious? Now, you could probably tell me something about your self. Probably something our gorilla friend was acutely aware of during the play experience.

My experiences with my psychology professor had transformed both elements. They had changed not only how I thought about who I was, but also how I experienced my self, in the first person—I. And redirected me down a path that has allowed me to build a life doing what I really love.

Erikson (1959) (who did not distinguish in his writings between self and identity) wrote about the value of moratoria in identity development. I believe first-hand experiences are important for becoming aware of the paths that will be consistent with the self and lead to an optimally satisfying life.

References

Bering, J. (August, 2010). Laughing rats and ticklish gorillas: Joy and mirth in humans and other animals. Scientific American. https://blogs.scientificamerican.com/bering-in-mind/laughing-rats-and-ticklish-gorillas-joy-and-mirth-in-humans-and-other-animals/

Erikson, E. H. (1959). Identity and the life cycle: Selected papers. Psychological Issues, 1, 1-171.

Gerson, M. J. (2014). Reconsidering self and identity through a dialogue between neuroscience and psychoanalytic theory. Psychoanalytic Dialogues, 24(2).

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Facing Dreaded Projects (How to Make a Mole Hill Out of a Mountain)

Facing Big Projects

We’ve all had to face that project that we’ve dreaded. A paper, a speech, preparing an event. Maybe we don’t feel that we have enough background or the skills needed to do the project well or even to do it at all. Or maybe it’s just that it’s so big—like a mountain we’ll have to climb, with its peak so tall that it’s obscured by the clouds. Or maybe both—we’ll have to climb it barefoot and it could erupt with lava at any moment… Clearly, I have personal experience with such trepidations.

To be efficient in tackling such projects, we need to consider both the emotions that may be involved and how to tackle the project in a problem-solving mode.

Diffusing or Managing the Emotions

Over a century of research shows that it’s really hard to think and plan when our emotions are intense. Some degree of anxiety can be motivating, but when we’re too aroused, our minds shut down (Yerkes & Dodson, 1908). Even trauma research supports the importance of moving beyond an emotion-focused coping style to one that works on problem solving (Penley, Tomaka, & Wiebe, 2002).

Plan A: Consider what you might be so worried about. What meanings do the project, its accomplishment, or its failure have for you? They may be as simple as concerns about increased expectations for the future or not wanting to appear foolish to one’s peers. Sometimes the meanings are less apparent. In helping doctoral students, I’ve been struck by the number of times a student couldn’t complete their dissertation until a revered parent passed away. Only then did it become clear that the resistance had been rooted in less obvious fears, stemming from prohibitions against competing with the parent, anxiety about incurring the parent’s envy, or symbolically becoming an independent adult.

If you’re stumped about the meanings, it may be helpful to ask yourself the question immediately before going to sleep: “What meanings does this project have for me?” I’m a big believer in our problem-solving abilities during sleep. With the decreased censoring by the prefrontal cortex during sleep, you may gain some insights (Barrett, 1993). Hopefully, you’ll discover some meanings that you can recognize as survivable and so will no longer be incapacitating.

But if you can’t figure the meanings out or otherwise diffuse them, go to Plan B: work around them by delving full-force into the next step.

Tackling the Problem

From here, no more keeping things in your head—put everything on paper (or its technological equivalent). This will not only help with constructing a reasonable plan and monitoring its progress, but can also reduce the emotionality of the task.

Get out or access a calendar. When must you reach the top of the mountain? How much time does that give you? Be very concrete — “3 weeks,” rather than “frighteningly little.”

Say you have 3 weeks. Is there an event (e.g., Thanksgiving, your daughter’s 16^th birthday, etc.) that will interfere? How many days does that now leave? How much can you reasonably expect yourself to accomplish each week? Each day?

Now, chop the project up into do-able pieces. Small pieces–pieces that can be accomplished within no more than 1-2 hours each. Do you need to consult with someone for guidance to help you know what all of the pieces are? Include that as a piece. Don’t freeze in fear; problem-solve.

List all of the pieces in an order. If some must follow others, number these (1, 2, 3, …). If some are interchangeable, follow their numbers by letters (e.g., 1a, 1b, 1c, …). Allow yourself to move between the letters. For example, if you don’t feel like working on 1a at the moment, you can start with 1c. I find that this flexibility helps give at least an illusion of choice. You may not have a choice about whether to do the project, but you may have some in freedom in how to proceed from hour to hour. This can relieve boredom (and any rebellion that may be lurking in the wings).

All aspects of your life probably can’t be put on hold during this period. Make a list of any other noteworthy things that must also get done during this period—appointments to keep, classes to teach or attend, bills to pay. Put off nonessentials until after the 3 weeks are over (or do them during breaks of non-thinking down-time)—polishing shoes, looking into new window treatments or car detailing, a monthly call to Aunt Sue, bills not due for a while, etc.

Consider what windows of time may be least disruptive to your life and/or best for a clear mind. Early morning before others are awake? Late at night when things are quiet?

Also consider how you work best. Short bursts interspersed by other activities? Long, uninterrupted periods of focus? Schedule your day so it works most efficiently for you.

But, however you plan your day, be sure to schedule periods of sacred time dedicated only to the project. Do NOT just tell yourself that you’ll “work some time in” for the project—chances are, other obligations will edge it out. Years ago, a colleague said something that had, oddly, never occurred to me but has worked out well—a person can always get up earlier. I was never an “early bird,” but I’m also not a “night owl” (if you are, this may not work for you). But I find it best for me to hobble over to my desk every morning, before I’m awake enough to talk myself out of it, to put some time into a project I’m needing to accomplish. Of course, my desk must be ready for me so I can plunge right in (Achor, 2011).

Each morning (or evening), reevaluate your schedule, check the number of remaining days, and modify your list accordingly. Modifications are part of the process.

Happy mountain climbing!

References

Achor, S. (2011). The happiness advantage: The seven principles of positive psychology that fuel success and performance at work. Virgin Books. ISBN-13:9780753539477

Barrett, D. (1993). The “committee of sleep”: A study of dream incubation for problem-solving. Dreaming, 3(2), 115-123.

Penley, J. A., Tomaka, J., & Wiebe, J. S. (2002). The association of coping to physical and psychological health outcomes: A meta-analytic review. Journal of Behavioral Medicine, 25(6), 551-603.

Yerkes, R. M., & Dodson, J. D. (1908). The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology, 18, 459–482. doi:10.1002/cne.920180503.

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New Year’s Resolutions Get a “Bum Rap”!

New Year’s Resolutions

New Year’s Resolutions get a “bum rap.” They’re often derided as deluded wishful thinking and as rarely successful. But I think they provide us with a wonderful opportunity to reflect and reevaluate, to engage in self-forgiveness and acceptance, and to rekindle hope and commitment to important goals—and, if approached carefully, they can be very successful.

Resolutions often involve things we know are good to do, but which either get lost in the mire of our daily obligations—like spending more time with loved ones or dedicating time to charitable work, or which are downright unpleasant—like controlling overeating or spending responsibly.

New Year’s Resolutions can serve as a reminder about our values and priorities. Each day is filled with obligations and stuff that has to get done. A special date, like New Year’s Day, can remind us to step back and take a look at where we are and where we’d like to go in life.

Even more importantly, resolutions provide us with a chance for a “fresh start.” Renewed hope. A chance for a “do-over.” We stop to reflect on what we should be doing—and haven’t done. We have an opportunity for self-forgiveness for our failings and acceptance of our selves, as we strive to do better. We can be empowered and reenergized.

How to Make Them Successful

But we can’t just wish something to be and expect it to happen. We must develop strategies to ensure that we can accomplish these goals.

Having a significant marker—a clear and special start date—is a good start. We share New Year’s as a culturally recognized “new beginning.” Social psychology notes the importance of culturally prescribed “rites of passage”—as in weddings, Bar and Bat Mitzvahs, Confirmations, etc.—to help mark new beginnings and to solidify new roles. New Year’s celebrations occur annually and are certainly not as profound as these other rites, but can provide a boost for starting a new journey.

But the excitement that comes from renewed hope is likely to wane as the year progresses. Identifying other motivators is important. We need to identify exactly why we want to pursue this goal. So family members will be happier? Which ones? So we’ll feel more connected to humanity? In what ways? So we’ll feel healthier and more comfortable? How will we experience this? It’s important to be as specific as possible in answering this question.

And then we must visualize these positive outcomes—as clearly as if we were watching them occurring on a video. Research on procrastination tells us that we relate to our “future self” as if it were someone else (Pychyl, 2013). Eating the cheesecake brings us immediate pleasure—that unfortunate “other person” can deal with the consequences in the future. So, it’s helpful to look for ways to make our future self salient in the present. We must visualize ourselves as that fit person, published author, or runner in a marathon.

We must also identify reasonable, realistic, and concrete steps to achieving the goal. If we wish to lose 20 pounds, write a book, prepare for a marathon, etc., we’ll need to identify the steps on the way to the goal, translated in behavioral terms. What would one have to do to lose 20 pounds, for example? On Week 1? On Week 2? Again, small steps, defined in terms of behaviors.

Of course we’ll lose track of our goal—“fall off the wagon”—from time to time. So we also need to establish regular times to reevaluate and reconnect to the goal. Maybe a weekly time, marked in our calendar, to see how we’ve been doing and the next steps to take.

The “20-second rule” (Acher, 2010) is also very helpful. We need to create an environment where it will take no more than 20 seconds to begin doing the behavior. If we want to go for a run every morning, we need to have our running clothes ready and set out so that we can get out of the door before getting distracted from (or talking ourselves out of) the activity. If we want to be sure we eat more fruits and vegetables, we should have them all washed, prepared, and visible in the refrigerator.

Finally, research tells us the positive impact of social support, both on well-being and on attaining goals. We should declare our resolution to others. Perhaps others can be supportive of our journey and maybe even join in.

You can find more on making even dreaded tasks work in Facing Dreaded Projects.

References

Acher, S. (2010). The happiness advantage. NY: Crown Business.

Pychyl, T. A. (2013). Solving the procrastination puzzle. LLC Gildan Media.

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Why Can’t We Simply Choose Happiness?

Happiness

Can’t we simply choose happiness? As a psychologist and psychotherapist, I’ve spent the last 30 years listening to people struggle with anxieties, depression, and loneliness, in search of ways to alleviate unhappiness. And as a professor, I’ve spent as many years researching ways to build resilience—hoping to find ways to prevent people from “succumbing” to unhappiness. The more I explore these issues, however, the more I’m convinced that Freud was on the right track. We are extraordinarily complex creatures who, by nature, are probably not headed toward tranquility or happiness. If we wish to build a happy life, we’ll have a darned hard fight on our hands.

Brain Research On Neurophysiology of Experiences

I keep returning to a delightful article by Hiss (2014) on the human brain published in the Reader’s Digest a couple of years ago. Hiss reviews fascinating research on the neurophysiology of such experiences as love, procrastination, reactions to criticism, and road rage, and the basis for many of our emotional struggles.

We like to think that our intellectual abilities accorded to us by the magnificent cortex provide us with the tools needed to control unpleasant emotions and primitive urges. But why, then, do we feel our blood pressure rise and rage take over when someone “waves” to us with a single finger from their car? What just happened?

As Hiss notes, the cortex is a relative newcomer to the brain party. It’s built on a more primitive mammalian, emotional part of the brain, which is built on an even more primitive reptilian part. How peaceful—or cooperative—a party should we expect?

Our Expectations On Handling Life And Emotions

She draws an analogy to a speed boat that’s been built on a row boat base. We expect to zip through life’s rough waters with ease—something our rickety base may not be able to manage. It’s amazing that our brains aren’t out of service more often!

So when I hear patients question what’s wrong with them that they can’t seem to manage their emotions or just “choose” to be happy, I remind them that they’re not a Golden Retriever. And some days, their lizard is active. Why can’t we simply choose happiness? Our brains may not be wired that way.

Mindfulness exercises may help. To learn more about mindfulness, see Mindfulness Training: Introduction and Mindfulness Training: Body Scan Meditation and Informal Mindfulness Practices.

References

Hiss, K. (Sept. 2014). The beautiful life of your brain. Reader’s Digest.

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The Importance of Consultation Among Psychotherapists

Consultation for Psychotherapists

I tell my graduate students that beyond all the academic exercises of reading, writing, and research, the two most important skills for a competent psychotherapist to master are the capacities for being alone and the tolerance of not knowing.

Ironically, even though a psychotherapist spends many hours listening and talking with patients about the most intimate details of their lives, the therapist is a virtual stranger who assumes a role that is temporary and transient. The therapist certainly is drawn into an intense emotional experience, but, ultimately, as a visitor.

When the sessions end, any residual effects must be contained or resolved so as not to contaminate his/her role for the next patient or to be brought home to one’s family and friends. Our commitment to confidentiality is also a commitment to a private and personal aloneness.

Very few occupations require a person to remain as silent about one’s life as does the psychotherapist, except perhaps, for the profession from which it is derived—the priesthood. We do, however, have the option of seeking consultation and/or supervision where, under a similar cloak of privacy, we can admit to our confusion and find refuge from our isolation.

The education of a psychotherapist is continuous, yet no amount of reading or research is sufficient preparation for a suicidal adolescent, the abused child, or the dying elderly. In the aloneness of these challenges, the therapist faces the limits of one’s potency in the task of helping a fellow human survive.

Connecting with a colleague is a service, I believe, that is owed by every member of this profession, to every member. The remarkable technology we have can allow us to form affiliations with relative ease and unlimited potentials.

I invite any mental health practitioner who reads this blog to consider reaching out and forming connections, starting study groups and peer supervision circles.

For more on the complexities of the therapeutic relationship, see Psychodynamics of the Therapeutic Relationship.

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A Commentary on the State of Mental Illness in Contemporary Society

Psychiatric Medication

Television advertising for psychiatric medications seems to have become as regular as commercials for automobiles, miracle cookware, or cosmetics. We are shown beautiful young men and women enjoying their friends and family, as we are also told that they have major depressions, bipolar moods, insomnia, and other potentially debilitating conditions.

Certainly these ads help de-stigmatize mental illness by showing that anyone can suffer from psychiatric problems. They present an optimistic view of successful treatment, a healthy productive life, and the assurance of better living through chemistry. Appropriately, they provide the legal disclaimers that these medications might cause some side effects and are potentially life threatening, but the likelihood is probably small and the image of a potential cure is obviously seductive.

The Motivation Behind Psychiatric Medication Ads

But also consider what else may be motivating these ads. These are not products that anyone can go out and buy like a car, a non-stick pan, or anti-wrinkle cream. These are products carefully controlled by the FDA to be dispensed only by licensed medical providers with an expertise in psychiatric disorders.

The target audience is presumably people who are suffering from serious mental health complications and/or their family members. If the intent of the advertisers were to help people seek psychiatric care, they would be promoting clinics, counseling centers, healthy lifestyle choices, and sources of information, as seen in public service announcements. Instead, they are targeting a vulnerable population with an implied promise of a cure that is not really supported by scientific research.

This is not to say that psychiatric medications are not helpful–they clearly are. But they are not curative. The ads promote the theory that psychiatric disorders have been proven to be medical illnesses, which is not exactly true. The ads further assert that the cause of these conditions is specifically known and that these medications will correct the imbalance or deficiency the person is plagued with—also not exactly true!

In my 30+ years as a clinical psychologist I have seem many patients benefit from the use of medications, but I have never seen a patient cured by medication. The combination of medication, psychotherapy, and lifestyle change has the best likelihood of helping people survive and thrive, so why isn’t that being made more explicit?

What Are Psychiatric Medication Ads Really Promoting?

I believe that the subtext to psychiatric medication ads is the promoting of helplessness and dependency in the public. That is, the ads promote the position of the patient as defective, damaged, or victimized.

There is no question that people are biological creatures constituted by a remarkably complex physiology and neuroanatomy. People are also creative, imaginative, and intelligent creatures who experience life with a remarkable capacity for change and adaptation. Everything we do or think or feel is accompanied by changes in our physiology, biochemistry, and neuroanatomy, but that does not mean that these processes determine us. Rather, biological processes are descriptions of how we function.

An increase in neurotransmitter levels may enhance a mood, whether by ingesting a medication, or by engaging in meditative or pleasurable activities. The causal relationship between biochemistry and mental states goes in both directions. By taking active roles in improving their lives, people can foster a healing that extends to the deepest levels of their physical existence.

To equate the effects of a medication with the definition of a mental experience would be like saying that a headache is caused by an aspirin deficiency. The aspirin can help, but its absence is not the reason for the headache any more than lowered serotonin level is the reason for depression. For those people who may have a genetic, or otherwise inborn tendency toward a depressive way of being, medications may prove to be a godsend. These people will also greatly benefit from being helped to reconsider how they manage their lives, relate to others, and pursue their dreams.

Our Potential In the World

Mental illness may be an inevitable consequence of the human endeavor to redesign nature into a world that is safe, fair, and rewarding. We cannot eliminate the reality of nature’s forces or its occasional cruelty and tragedy. As humans, we face the disappointments of elusive ideals and the limitations of our ability to control our destiny. We must also consider the extent to which the world we have created for ourselves may be responsible for eliciting what we call mental illness. We are not the world, only participants in it who have a potential to think, choose, and survive with the help of others.

Mindfulness meditation practices and psychotherapy provide alternatives that can improve well-being, without diverting attention from the individual’s role in defining his or her life’s journey.

To find online courses for continuing professional development in psychoanalysis and other areas of psychology, see our list of courses on promoting diversity, modern systems theory, psychodynamics, mindfulness, and more.

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Are We Over Diagnosing Children With Mental Illnesses?

Over Diagnosing Children

I once read an article by Jordan Smoller called, “The Etiology and Treatment of Childhood.”[1] It was a satirical article that described childhood as a mental disorder. He noted that childhood is congenital, is characterized by temporary dwarfism, is marked by emotional instability and immaturity, and that children have knowledge deficits and legume anorexia. Mercifully, most children recover from this condition over time.

While clearly the article was meant as a spoof on the Diagnostic and Statistical Manual of Mental Disorders (DSM), the standard reference guide for mental health providers in the U.S., the implications of this article are quite serious. Children are being diagnosed with mental illnesses at an alarming rate and being medicated for those conditions with increasing regularity.

Over Diagnosing of Attention Deficit/Hyperactivity Disorder

Consider the case of Attention Deficit/Hyperactivity Disorder. This is a condition where a child is unable to constrain his/her behavior to the requirements of a given social context. We are not talking about criminal or psychopathic behavior, but rather the inability to sit still in a classroom, restaurant, doctor’s office, or other such environment where conformity is expected.

Fifty years ago this condition was called Minimal Brain Dysfunction (for extreme cases) and was thought to be the result of a mild form of brain compromise that was not explicitly evident but could be assumed. The term fell into disrepute when parents resisted having their children stigmatized as damaged goods.

Then, sometime in the 1980’s, the atmosphere changed and the former stigma became, for some parents, an embraced diagnosis of ADD (then called Attention Deficit Disorder, with hyperactivity as a sub-type).

Why the change? ADD was classified as a learning disability that entitled children to special accommodations in the classroom and on standardized tests. Not only were schools required by federal law to provide preferential seating in the classroom, but the students could also have less, or no, homework, extra time on exams, less rigorous exam standards, and counseling and tutoring services (also subsidized by federal funds).

I am not suggesting that all children and parents took unfair advantage of the system. Many children needed these services and greatly benefitted from them. Some students also received these services in order to give them a competitive advantage for college placements.

I am not faulting parents for trying to get what they can to make their child’s life better and their future more promising. In fact, as a psychologist, my profession has profited greatly from this boon, as have college guidance counselors, and educational therapists. No one has profited more, however, than the pharmaceutical industry, which supplies medications to enhance focus, concentration, and task performance. In my view, the issue of ADHD is only the beginning of a much larger problem—the pathologizing of children.

Over the past few decades we have seen enormous rises in the diagnosis of autistic spectrum disorders, bipolar disorders, depression, and obsessive-compulsive disorders in children and adolescents. It is possible that the mental health of this population is deteriorating at an epidemic rate. It is also possible that children are being dangerously over-diagnosed. Note also, that the rates of diagnosis are unique to the U.S. and disproportionately represented in middle and upper-middle class families.[2]

What Can Parents Do If They Think Their Child’s Behavior Is Questioned?

So what can be done?

First, parents need to step back and question the basis for a child’s diagnosis. If a child’s behavior is being called “pathological,” what is the normal standard for a child of the same age and sex? Nowhere in the DSM is there a guide for determining at what point a child’s restlessness, for instance, exceeds normal standards. The diagnostic criteria instead say “often.” Not how often, or too often, just “often.”

Second, parents and doctors need to consider the context of the child’s life. If the parents are divorced and the child lives alternatively in either home, how might that stress affect concentration and attention? Or how interesting is the classroom for the child? Maybe a different teacher or school would be a better fit for the child.

Third, how much sleep is the child getting each night? Half of the children I have assessed for “inattentiveness” were sleep deprived. The child may be going to bed at 8:00, but may be on a smartphone, iPad, or computer until late in the evening. Furthermore, a sleep-deprived child may be depressed or anxious, not necessarily “suffering” from ADHD.

Fourth, doctors, psychologists, and teachers often base their diagnosis on checklists. This can be a somewhat useful starting point, but is irresponsible as a stand-alone assessment. No checklist is a substitute for knowing the person of the child. Consider that chest pain could be a heart attack or it could be indigestion! A restless, inattentive child may be lonely, sad, afraid, etc. While these conflicts and challenges are difficult and distressing, they are not necessarily signs of mental illness.

Finally, if there is a reasonable suspicion of some mental health issue, a competent specialist should be involved to thoroughly assess the child, the family, and the surrounding circumstances. What diagnoses have been explored, evaluated, and ruled out? A range of possible interventions should be considered, with priority given to those that are the safest, least invasive, and most likely to be helpful. A child’s mental health is not the place to shop for bargains or quick fixes.

I constantly remind my graduate students that diagnosis is more about the person than the illness and that children are people, not disorders.

Professionals who want to learn more about psychoanalysis, developing an analytic mindset, and more topics for continuing education in mental health counseling, see a list of our online courses.

[1] Published in the book by G. Ellenbogen (1982), Oral Sadism and the Vegetarian Personality, a collection of satirical psychological articles.

[2] Hastings Center, Washington, D.C. (2008) found a 20% increase in prescriptions for behavioral drugs between 2000 and 2003 and a 73% increase in prescriptions for antipsychotic drugs between 2001 and 2005.

Uncategorized

Are There Really No Psychological Accidents?

Psychological Determinism

Perhaps the single most representative concept of psychoanalysis is that of psychological determinism. By this I mean a fundamental belief that human behavior, consciousness, and experience are determined or explainable. Freud followed in a scientific tradition that was dedicated to uncovering the laws and mysteries of life, hopefully to lead to a comprehensive theory of the mind.

Is Action Accidental or Random?

Such an approach would never be satisfied with a conclusion that suggested that a certain action was “accidental” or “random” or that a thought occurred strictly from a spontaneous, meaningless neurochemical action. Unlike radical behaviorism or even social learning theory, which propose to account for some behaviors as incidental contingencies or fortuitous accidents, psychoanalytic thinking would tend to view such explanations as naïve, simplistic, or superficial.

What Does Psychoanalysis Tell Us About Action?

Psychoanalysis proposes to describe mind and behavior as meaningful and understandable. Thus, our lives are the products of our being. Our intentions, as well as our accidents, are worthy of understanding. While critics may argue that psychoanalytic theories make too much out of too little, the supposed error is committed in the pursuit of knowledge, with an implicit expectation and respect for the complexity of life. It should also be noted that such an attitude is reflective of an appreciation for the humanism of psychology, not its mechanization or reduction to biochemistry.

What is the Focus of Psychoanalytic Explanation?

Even if one could demonstrate, once and for all, that the universe and life are random, nonsensical phenomena, this would not contradict the view of determinism. The focus of psychoanalytic explanation is on the human experience of life. What is characteristically human is our mind’s proclivity for making sense out of nonsense. We cannot tolerate being in a state of uncertainty or confusion. Psychological determinism addresses this characteristic of being human by suggesting that all human knowledge, no matter how sophisticated, abstract, or profound, is always, ultimately, human.

Freud and Breuer’s Studies in Hysteria

Freud’s and Breuer’s Studies in Hysteria are classic examples of the humanity inherent in a view of psychological determinism. In their investigation and treatment of hysteria, they stressed how patients’ peculiar behaviors stemmed from important but forgotten episodes of their lives. Hysteria, understood in the context of a person’s life, represents a meaningful continuity of being, such that the mental life of the patient is respected as relevant and the patient is further accepted as exhibiting psychological processes common to humankind. The “logic” of symptoms soon led to an appreciation for the logic of dreams, mistakes, jokes, and slips of the tongue. With acceptance of determinism, we can never take life’s events for granted again!

For more on psychological determinism and other psychoanalytic concepts, see the course Classical Psychoanalytic Theory. If you would like to receive a specialization Certificate in Psychoanalytic Psychotherapy and learn more about issues of interest, please see our home study psychology continuing education courses, available online.

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An Unforgettable Patient

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Facing Big Projects

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Over Diagnosing Children

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Is Action Accidental or Random?

What Does Psychoanalysis Tell Us About Action?

What is the Focus of Psychoanalytic Explanation?

Freud and Breuer’s Studies in Hysteria

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