Tuesday, October 29, 2013

Why We Have Sex

We're always saying it around here, sex is marital glue. But it isn't always.

New study, University of Toronto, published in the Personality and Social Psychology Bulletin, summed up in last week's WSJ. Worth a look.  What you learn:

We have two ways of dealing with this particular bodily function, sex.  We participate because either:
(1) we want to feel good, make our partner feel good, or
(2) we want to avoid a bad feeling about ourselves or about our partner or relationship-- the negative consequences of not participating.

Whereas it might seem that our motivations to approach or avoid are relatively circumscribed and few, a previous study at the University of Texas (2007) found 237!!! motives to have sex, everything from spiritual closeness to the Old Mighty to retaliation for a partner's affair. That retaliation could be sex with the partner, or with someone else. These are mind-boggling motives no matter how they shake out, and great fodder in therapy, they reveal so much about us.

There probably really are precisely 237 reasons to have sex because the Texas inquiry had to be qualitative, meaning social scientists interviewed enough people for a long enough period of time to literally saturate the category, reasons to have sex.

And we're not even talking about the reasons for not even bothering with sex, another study altogether which surely would include the intimacy fears-- those fears of exposure, annihilation, suffocation, rejection, etc.,-- as well as our personal mental status problems, i.e., depression, and let's not forget our physical laments, marvelous, valid, at least for awhile, excuses-- as in menopause, peri-menopause, pain, fatigue, hunger, etc. Such are among the reasons we literally, physically, but mentally, too, avoid having sex.

But avoidance in the University of Toronto and Texas studies is about avoiding psychological thoughts and feelings by having sex, not physically avoiding it.
See how confusing it is to be an academic?
The University of Toronto team divided responses into two categories. Self-motivated or partner motivated reasons for having sex. (Interesting that sex becomes the object of a preposition, not a verb here, and we're always saying that love is a verb.  Self-motivated and partner motivated reasons look like this. Try to figure out which are which:
If I do it, I'll start my day out right.
If I don't do it, he might find someone else and I'll be alone.
If I do it, he'll start his day right, and I want him to feel good.    
If I don't do it, he might think I don't really love him, might even look for someone else.
It isn't easy, sorting all of this out.

And yet, two basic, important findings:

(a) Partner motivated approaches are the most telling predictors of couple satisfaction. So it's okay, you see, to be selfless to a point.
(b) Whether or not it is for me or for my partner, if the reason is positive, there is higher relationship satisfaction overall. You feel like a better team.

That's the marital glue we're talking about.

It also means we shouldn't be having sex for negative reasons. (Obviously, the reasons are always wrong in any type of sexual abuse that isn't consensual or in which consent is coerced). But to make a seemingly good relationship (we have sex!) truly good, much better, the job would be to work out the negative reasons. Work them out and the relationship is more emotionally intimate.

And when that's how it is defined, truly emotionally intimate, it likely that sex will be marital glue. I would go so far as to say, only then.

I'm truly grateful for that study, because it makes it much easier to explain to my patients.  I mean it.


Sunday, October 20, 2013

Bullying and Suicide

Rebecca Sedwick, suicide victim of bullying

People are pretty disgusted by the news of twelve year-old Rebecca Ann Sedwick's suicide jump from a tower at an abandoned concrete plant in Florida last month.

On Monday, the county sheriff, Grady Judd took a hard stand and charged two Lakeland teenage girls, 12 and 14 (12 and 14!) with felony aggravated stalking. Bullying, technically, isn't a crime; it is something kids do. But aggravated stalking is an adult crime across the nation, and juveniles can be just as guilty as adults.

Who stalks? There are many reasons, and we'll discuss them below, but the behavior seems to be generated by either insecurity or sociopathy.  Those fearful of abandonment take matters into their own hands and punish the ones who try to leave. The sociopaths or almost sociopaths, are criminal-- they have no remorse, no guilt for the harm they cause. Sociopaths (legal determinations) are often diagnosed with personality disorders, antisocial personality disorder at the top of the list. Some are children.

Even after the suicide, the older of the two young adolescents continued to write cruel things about Rebecca on Facebook.

"Yes ik [I know] I bullied REBECCA nd she killed her self but IDGAF [I don't give a f***]"

That threw the sheriff over the top, determined the felony charges.

Heartless. How does a kid write such a thing!? Does this kid need therapy? Undoubtedly.

And to think I just told a mother of a bullied child last week, "I like working with kids like yours, with the victims. The kids seem to like therapy."

What I don't mention is that victims are easier than the perpetrators because they don't have the attitude, the resistance, the disdain for authority. So they are easier clients. Merely depressed as hell.

Now I feel bad for implying I don't even want to work with the bullies and cyber stalkers. It isn't all their fault. Aggression doesn't happen in a vacuum.  Bullies are usually victims, displacing their own anger, no matter the cause, often unconsciously, onto someone else.  Displacement is a psychological defense, protects our fragile egos. Being young, these kids have time to work on their identities.* It's what we do in therapy.

Most of the time, too, aggressive behavior is easy to reverse -- a little anger management and family therapy and the kids are giving workshops to their friends. That has to be woven into the new bullying laws, the family therapy part.

When it isn't displacement, aggression is likely to be transgenerational, passed down generation to generation under the guise of domestic violence or child abuse. It is usually learned, and in some families considered normal.  They all have tempers in our family.  Every therapist has heard that one.

There's research that tells us a predilection toward violence might be caused by a birth accident or the lack of the empathy gene.  Wonderful people have difficult kids, and their parenting doesn't necessarily pay off.  We need more specialists, more research to help them.

This new sociological darling, bullying, or cyber bullying, cyber stalking, concerns us because now, more than ever before, suicides are mounting. We don't know which causes are the most likely, but in Rebecca's case the lead tormentor apparently learned the behavior.

Caught on camera, Vivian Vosberg, the step-mother of the "bully ringleader," is pummeling a boy in her home. A group of children laugh, push. Chaos ensues, noise, a scuffle, and all the while, someone is manning the cell, the video cam.

She's been arrested on child abuse charges, sent to jail, and her daughter, the cyber stalker quoted above, is supposedly in state custody. Ms. Vosberg claims she was merely breaking up a fight.

She is only thirty years old, looks like a teenager herself, and her neighbors are talking about her as a bad role model, blaming her for her step-daughter's behavior, no matter what really happened or what triggered her behavior on tape. It would be nice if Ms. Vosberg would tell the press more about her stress, more about why she hit that kid, and more about her trouble with her step-daughter. As it is, she denies the child's role as a cyber stalker. She needs to become a part of the solution. We need one.

If she won't own her part, the lesson for her step-daughter is that old adage, See one, do one, teach one. Many children joined in the stalking but they didn't have the audacity to continue the abuse after Rebecca's death. This kid, Vosberg's step-daughter, needs more attention, more of an intervention than the rest.

Meanwhile, Rebecca's mother, Tricia Norman, knew there was a problem, tried to help, but laments that she couldn't do enough. She pulled her daughter out of school, home-school her, then arranged a transfer. Still she couldn't protect Rebecca.

Probably because cyber stalking is a crime without walls, and continues even after the stalker stops talking. What is written on the Internet is permanent. The tragedy is that Rebecca believed herself worthless. She believed what those young girls wrote on her wall.

Her mother told reporters:

"She would come home every day saying she's not worth anything, she was ugly and stupid," 

Rebecca heard it from ten or more children, was verbally taunted, physically abused, beat up. Repetition makes its mark. It's hypnotizing.

Her mother made her delete her Facebook account but after Rebecca's death found messages on the child's phone: "Nobody cares about you," "I hate u," "You seriously deserve to die."

Mother tells reporters:
The effect of such abuse?  She started cutting, left pics of cuts on her thighs, cuts her mother had never seen, and pictures of herself lying on the railroad tracks, waiting for the train. 
Tricia Norman blames herself for not doing more to help her daughter. I want to tell her not to, that the problem is epidemic. The violence in our culture defines our culture (see Saturday's WSJ, Are the Streets Really Paved with Gore). When kids witness violence in the home it reinforces what is seen in the movies and on television, YouTube, everywhere.

Therapy might have helped, for sure, but a socially isolated child is at risk, even while in therapy, when systematic, repeated, mental, verbal, and physical abuse has torn down, whittled away at the will to live. Without friends, at any age, we're miserable, feel we're better off dead.

Just one more jab will do the job.  And we can't control all of the jabbers.  Children, the old saying goes, are mean. They have their reasons.

What to do?  Identify them early. Intervene early. Call the parents of your kids' friends, the ones who hurt them. Programs in schools have work to do, and should include discussions of the media, the lessons learned watching.

We need to establish interventions for bullies-- suspensions, amends to the victim, group therapy in the school, family therapy at a local agency, and legal proceedings to add some teeth to the solution. Keep that therapy alive for at least a year, make that two.
Then maybe we'll find out what young people like Rebecca Sedwick have to contribute to our society. My guess is, something special, given the chance.


*We're starting to see that intractable, violent personalities, kids without empathy, are recognized in early childhood. They are a minority. Most of us take quite awhile to decide who we are, who we want to be, and may be well into our twenties before we begin to really become the people we hope to be.

Monday, October 07, 2013

Celestial and Cerebral Reunions

When patients come to me distressed about a recent loss, we go through the process of differential diagnosis because there are many types of depression associated with grief.  At some point we get right down to facts:

How we grieve, or bereavement, is beyond our control. We're powerless for the most part.  Crying, tearing up, feeling adrift, lost, disengaged from the rest of humanity-- is a natural response to having lost something of tremendous value, something, someone, that we cannot see anymore, can't feel, touch, hug, cherish, even care for anytime soon, maybe ever.  It is especially natural when the object of grief was complicated, difficult to grasp, or the relationship suffered strain and miscommunication.

I received email yesterday from Mario Trucillo, a doctor under the assumption that I'm a caregiver by trade. He asked for a link to his blog, The American Recall Center It's about FDA recalls

I'm put in the context of caregiver (maybe he didn't read very carefully) because for the past few years, before my parents passed away, I lived closer to them than my brother and could drive here-there-and everywhere, take care of a few daily needs. But technically, I'm not a caregiver.  Even while performing some of the tasks of that job, I always considered myself a daughter, my brother, a son. Caregivers are people on a much higher level.
Proof of Heaven? Maybe

But let's get back to bereavement and tears. It may be American Health Literacy month (according to Dr. Trucillo) but we don't have to stick to what has been found empirically evident.  We can hypothesize, too.

Some people cope with loss by assuming there is an afterlife complete with heavenly reunions.  Sci fi, to me, but my cousin in Israel, hearing about the loss of my mom, wrote:
"Now all of the cousins are together." 
I have to write to her, now that I'm finally getting to thank you notes. It is comforting to her, the thought that our mothers are together now. Just hearing from her is a comfort to me.

Lesson learned: always reach out to your friends, even to random people you know who have suffered a loss.

But something may have been lost in the translation. The thought of heavenly reunions unfortunately, doesn't work yet. A close friend advised a book,  Proof of Heaven: a Neurosurgeon's Journey into the Afterlife by Eben Alexander. I started it yesterday. So I'll let you know.

Moving right along. The DSM V, that new edition, is a wiser 941 page tome of diagnosis than the last.  It required much more concentration than I've had, lately, but it seems, that like its predecessor, bereavement is still a differential diagnosis.  Clinicians are encouraged to especially whether or not a diagnosis of major depressive episode ought not be considered, depending upon the circumstances. We're to take weight loss, insomnia, intense sadness and rumination over a loss very seriously.  Not necessarily just bereavement, in other words.

I don't know if I've said this or not, but I never expected to be grieving my mother, not this much. Denial, obviously.  But I felt that my mother and I had such a good relationship, that there was nothing unresolved, nothing to make a simple matter like loss so difficult.

What happens is that the brain has so much of our lives packed into our central processor,, amygdala and hippocampus, not to mention the cerebellum, basil ganglia and motor cortex, that we can't begin to predict such luck.  What we can predict is that when we have been ultra-involved with our parents, their go-to people as they age, memories will be vivid.   The flashbacks accessible, palpable, real, we become aware of all of the things we could have done to make them more comfortable. And the guilt-- what we should have done for them, as opposed to the little we did by comparison, is unrelenting, as are the thoughts.

Air them, naturally, and they do relent, recede. This is what friends are for.

We can always be a better . . . A nice little PhD thesis for one of you:
The degree of our involvement with a loved one before death will predict the intensity of memories and magnitude and frequency of flashbacks in the first months after death. 
You could use a hired caregiver group as a control, make up your own hypotheses. Other variables matter, too, type of relationship, cultural expectations, external support, income. It is likely, no matter, that if we're a go-to person, almost anything will remind us of the person we lost.

Major Affective Disorder with Depression, sure.  But repeated exposure and the trauma at the end of life, depending upon those other variables, is likely to be associated with Acute Stress Disorder (308.3), too. We consider it anytime there is exposure to actual or threatened death, serious injury, or sexual violation, when a patient has witnessed a disturbing or violent image, say a serious car accident (blood, dismemberment, etc.).

Memories of coma, a parent's eyes pleading for help, those last moments of life, even if they are good, are snapshots that are recorded, indelible. The DSM 5 calls this an acute grief reaction and suggests the adjustment disorders be ruled out, too. We're seeing that no matter the diagnosis, it takes work to put such memories into safe files in our brains, lick those envelopes and put them away.

I had heard about something else, this from an enmeshed patient (she described herself this way) but didn't expect it would happen to me.  Sometimes everything is vetted through thoughts of the deceased.  Nothing is interpreted without an unconscious, non-intentional, surprising, mother-coated lens . She is everywhere.


I get my nails done, first time in three months. The manicurist is a little rough and I think, Good thing I didn't bring Mom here. She might have hurt her.

My 8-month old grandson tends to draw out one note and sing, not say words. He is a little young, we'll cut him some slack, and this is probably how we should all communicate. But he latches onto one note and holds onto it for as long as he can.  The note is loud and clear and beautiful, and I remember that his father did the same thing as a baby and that in the car I would play him tapes of Luciano Paveratti and Placido Domingo. (Today he is a part-time cantor). This thought immediately blends to the anniversary card with the crisp one-hundred dollar bill that my mom would give to me and FD each year for the opera.

I am sitting with a friend and notice her slim hands for the first time. My mind's eye jumps to watching my mother's hands and how they alternatively swelled to purple and blue, sometimes responding to cold or heat, sometimes merely her crazy electrons, completely out of whack.

On those Jewish holidays, just last month, on the holiest day of the year, when the liturgy is especially beautiful, I hear her voice in my head as if she is on my right side, singing in my ear as she did when I was seven!

Last week FD and I visited our kids and grandkids in Atlanta, and waiting on the curb for our ride to the house I think, I have to call my Mom, tell her we're here, arrived safely.  What used to be an obligation, and I think this is the real kicker, is something I wish I could do but no longer can.  My solution is to talk to her anyway, the mock call, an intervention suggested to others.
Hey Mom, we arrived, how ya' doin'?   No, waiting for them to come and get us.  Sure, will call you tomorrow.
Not to mention that one of her great-grandchildren looks like she did as a child.

I find it hard, a one-way call.

Then, on the return to Ohare, in the terminal waiting for FD to deplane I think, Well, that was a nice trip.  Haven't flown since (my son)'s wedding in May.  And this immediately signals the thought that she wanted so badly to go to the wedding and couldn't. And although we set up FaceTime for the ceremony, and she spoke (via an Iphone recording) to the 200 plus guests at dinner, it wasn't enough. She was angry, upset about missing it.

But if you were to ask me how I'm doing I would have to say, Fine.  This isn't a bad thing. The real diagnostic data that matters is functioning, and fortunately, robot that I am, that many of us are when it comes to work, that's still there. Focusing upon others is a natural distraction.  As is Modern Family.

However, if you're taking out a friend who is going through this sort of thing, stages of grieving, just saying, maybe you are going to lunch or to the cemetery, wherever, you might want to be the one behind the wheel of the car.


Empty Spaces