Monday, August 18, 2014

The Year of Mourning

We've talked about it before, ritualized grief. It is healing, if executed well. And at the end of an official year (especially if you do it the Jewish way) one feels different, as if a millennium has passed.

We're returning from Ruby Falls, a tourist trap in Tennessee. I had the front seat of the van on the way out, but am in the back now, hosting three very little, dirty and exhausted children. They are engrossed in movies. I can stretch out my legs. Not a bad way to travel. Gazing out the window, road trip lyrics come to mind:
Let us be lovers,
We'll marry our fortunes together.
I've got some real estate here in my bag.
So we bought a pack of cigarets.
And Mrs. Wagner pies,
And we walked off to look for America.
America, the Bookends Album
Hard to get the Bookends song out of my head. Now you've got it. That's what we do in my family, pass off songs.

My son asked if we could take a short vacation, come for a visit this summer. So just before the year of mourning ended, FD and I got on an American Eagle jet and took photos of clouds, seeing clouds from both sides now, obviously. Changing the song works, too.

But only one  emotional snapshot stands out from that vacation.

The children have personal entertainment consoles;  The Lego Movie and Lilo and Stitch play on and on. I look out the window and watch the landscape, hoping for an occasional rooster or horse. The Paul Simon song attacks and I want to sing but can't remember the words, immediately Google them on my phone.

A patient had just complained about her niece and an internet addiction. More accurately, a media addiction. And I think: My grandchildren will have to wait until they have children of their own to even  begin to look for America, feel the sensory joy of looking beyond their phones, their tablets. They will have to take their kids on road trips. Drive.

But maybe not. My kids are pretty conservative, don't even let the little ones have email accounts. I understand you get one now at your bris.

So I sing softly to myself, thinking it odd that during the first year of mourning, if you observe those Jewish rituals, singing is permitted, but not listening to music. Certainly not live music. Recorded music is discouraged, too, really. Paul Simon whispers in my brain and there's no need to adjust the volume, no headset.

So I looked at the scenery, she read her magazine, and the moon rose over an open field.

Ruby Falls at Lookout Mountain
Why forbid music during a year of mourning?

Too happy, maybe. But until it ends we don't understand the real reason. After a year of sensory deprivation, at the end of that season of grief, the anticipation, the desire, the need to live is indescribable. And when you finally hear the sound of music, you cry.  It is as if life begins again.

As it should. That is the point. (We only grieve this long for parents, by the way).

So picture me the last evening of that season, a Thursday night. I have invited guests for a Friday night dinner, cooked a few hours. It is finally dark. Pitch black. FD comes home, has a quick bite to eat. I am in a chair, exhausted, feet up, watching my fish swim in the aquarium. He asks me if I want to hear what he's been working on. (He is a classical pianist). I thought you would never ask.

For a year he practiced on a keyboard, headphones on, and all I heard was the banging of keys, no notes. So now he plays the scherzos so that I can hear them loud and clear, explains each one. Then we listen to yet another on YouTube, one that he hasn't learned because it hasn't been transcribed for piano. He's working on the transcription. He tells me that a scherzo is a musical joke. The thought makes me smile. Weird Al has nothing on a scherzo.

The next day I am texting the kids, asking them for the names of popular songs that I missed during the year. I use itunes (forgetting all about Pandora) and listen, wondering if I even like the choices. As I dice onions, the enormity of it all, the trance-like feel of transition, works its effect. Guests! Fun! Friends. For a year socializing has been limited to family, primarily, and a few couples, one at a time, let's not over do it, very few. Certainly nothing remotely like a party. Tears applaud this moment, make it memorable.

My grandson would videotape the scene: An aging female seeking show tunes on her iphone, crying as she dices onions. Funny, no?

But it is sad. Setting the table, it is clear to me that my mother would love the china, the silver, the royalty of this Sabbath meal especially, for her touches are on everything. She is everywhere.
Waterford rose bowl


Then at night, after the dinner, a dream, a disturbing dream. She is alive, but not really alive, wearing a pale green dress that I don't remember, but her style (and green is a good color on her, but not this time). She is thin and disabled, and it is my son's wedding, which she missed due to her illness. But she's there now, and I have lost her and am in a panic trying to reconnect. She is in a carriage, or a rickshaw, on her way to the synagogue where we are hosting a huge celebration after services, the occasion of the day. I miss the whole thing trying to find her a lemonade.

Not a good dream, and it cast a pall over the weekend. We don't lose bad dreams easily, and even though it was nice to see her, it wasn't a picnic. I blame the short glass of excellent red wine, a Gallil Mountain, Yiron 2010. My guests chose well, but wine can be dangerous, even in small quantities.

The next night we dress up again. FD has tickets for Brigadoon at the Goodman Theater downtown, and from the very first note, the voices so clear and high, so strong and powerful; the scenery, brilliant; the story, fanciful, I am lifted there, to Brigadoon. A musical is surreal under any circumstances, which is why we love them, but to hear the songs that Andrew Lloyd Webber pirated (you're undoubtedly familiar with Phantom), and gaze closely at classically trained dancers up on their toes, stepping, twirling, skirts flowing, everyone smiling on stage, in the audience, everywhere.

Quite a sensory whirl.

We meet a few friends at the theater, too, also odd, because who goes to see Brigadoon? (People a bit older, that's who). Our friends go to the theater often and suggest we try the Lincolnshire if we haven't already. Very reasonable, wonderful productions. My parents had season tickets, I say, but we never took them up on their offer to go; the drive is a little far. Now I want to go. I am becoming my mother, I laugh.

Brigadoon-Goodman Theater
One of the women notices and compliments my beaded bag.  She has one like it, her grandmother's. She is nostalgic, her eyes look up and to the left, remembering.

My bag was my mothers, naturally.

therapydoc


Tuesday, August 12, 2014

Robin Williams and Bipolar Disorder

Robin Williams
I know he denied it, but it does seem that Robin Williams had bipolar disorder. So based upon the presentation, at the very least I'm going with a Bipolar II. You only need one manic episode for that one.  A depressive episode took his life.

I get my first world news updates from Robin Meade's early morning show. Her voice is calming. In therapy, people who work on a morning news show are at work at one a.m. They will tell you that to get through that shift: You drink a lot of caffeine.

Many of us do, too, drink a lot of caffeine, if only in the morning, and it makes us a little  manic (I am typing fast) and we wouldn't trade the feeling. Half-caf is a suitable alternative. 

There is a world of difference, however, between the manic feeling associated with two cups of coffee and the "manic" in manic-depressive, or bipolar disorder. We now really only use the term, bipolar disorder. I don't know why.

One of my first posts on this blog, back in June, 2006, hosts a long list of celebrity sufferers, including Mark Twain, Agatha Christie, Abraham Lincoln, Plato, Graham Greene, and Sir Isaac Newton. Dozens of Hollywood stars rate inclusion, celebrities gone public about their disease.

We have to add Robin Williams, now. He killed himself to escape the disease. He was in Hazeldon for rehab only last month and had treatment for depression, too, fairly recently. His daughter Zelda just turned twenty-five. Susan Schneider, his loving wife, is "utterly heartbroken." Millions of fans, everyone, mourns with the family. It is a dark day, and it isn't just the weather.

When I see the montage of photographs it seems as if the actor is crying in most of them. The editors on television shows know how to relate, convey empathy. There is a sadness in Mr. Williams, a sadness in his eyes.

It is not the sadness of Lesley McSpadden who lost her son, Michael Brown, on the same day, although her eyes are sad, too. A policeman in Ferguson, Missouri shot the boy down; Michael's hands up in surrender. A riot ensued, teargas to contain the mob. Ms. McSpadden shouts to police:
"You took my son away from me."
The shooting, racially motivated. Had it been a white teen on the street, it is unlikely this would have happened. So Ms. McSpadden has fellow mourners, millions, too.

It is not the sadness of the family and friends of Rabbi Joseph Raksin:
Rabbi Raksin: Victim of hate crime
In cold blood.

Homicide victims, symbolic of the racial tensions of the day, are now common. And we haven't even discussed Knockout, a video game encouraging players to take to the sidewalks. One rolls the camera while the other casually knocks out an innocent pedestrian. Victims happen to be Jewish in New York. It is rumored to have happened a few weeks ago in Chicago, and the victim died. So scary that some of us think, "I should buy a gun and learn how to use it."

Then there is Robin Williams, who died with a belt around his neck, a man who brought the world happiness and tears, the tears we love to cry at the movies. It feels like a crime, too, his suicide. He describes his quiet childhood, and tells NPR that he certainly suffered sadness, but everyone does. Yet others speak of disabling depression. A person can take only so much. He probably thought he had tried everything. 

But he hadn't. We know that because he's gone.

To "treat" his disease, among other interventions, he used alcohol and drugs as "controllers." He suffered a dual-diagnosis, most likely: bipolar disease and poly-drug dependence, hence the stay in Hazeldon, a popular, effective, addiction treatment center. Following his release, clearly, he should have been evaluated to be sure he didn't kill himself, to see exactly where he might be falling, alcohol-free, on the depressive continuum. For those with dual-diagnoses, treating one and not the other is futile. Easy to see this with hindsight, but Mr. Williams should have been admitted for a long stay in a psychiatric facility, a nice one, of course, for observation. He could afford it.

We can assume he had been there and done that in the past, probably plenty of it. It is a cyclical disease, however, and a cycle can last. A depressive cycle can be so painful that the patient wants to make it stop lasting. We might say Mr. Williams needed a much longer inpatient stay, longer than he had ever had before. Again, twenty-twenty hindsight, but we're talking about a legendary actor, and there are other legendary actors who suffer, much like Abraham Lincoln, Sir Isaac Newton, Mark Twain. . . Not that they all killed themselves, maybe none of them did, but one in ten with bipolar disorder do. We have to learn from these suicides, don't we?

therapydoc

Wednesday, August 06, 2014

Enmeshment and a Proper Ending

We haven't talked about family of origin in awhile, so why not get back to it. I was going to write about guilt, anyway.

I have an optometrist who made me a pair of rimless glasses about fifteen years ago, glass.  "Treat these like jewelry," he warned. "They are very fragile."


Random building, random car, not the car
or building in the story
.
The Story:
Five or six days out of the week I swim. At the same time, as I walk into the looming multi-unit building, a frail older man in a white shirt and tie, black suit and hat, is leaving. A large SUV waits at the curb. The gentleman struggles with the passenger front door, steps up carefully into the car. He and his driver are likely off to morning prayers.

The windows are dark, but I assume the driver is his son. I can picture the older man tossing the cane into the back seat.

Hating myself for judging, it bothers me that whoever it is picking him up, for whatever reason, hasn't popped out of the car to help. It is what I did for my mother at any opportunity, pop out, although she complained.
"I can do it."
She couldn't.

My bad for that? Should I have respected her need, her desire for independence, the very thing we crave most of our lives, especially in the more traditional marriages, marriages like hers, as in, serving-is-just-what-we-do? But I wouldn't have dreamed of letting her risk a fall while struggling with a car door. Any fall at that age is critical. The recollection of her broken pelvis as a younger woman is enough.

But giving the benefit of the doubt, the resident is a man, after all, if an older man, less brittle perhaps. Maybe the passenger sternly warned the driver:
 "I am not an invalid. Do not insult me. I can get into an automobile." 
Said with feeling, spoken with intensity, the lasting affect of a more youthful personality. And obviously, he can. The son shows respect. The father, surely at one time a person who drove his own automobile, has his autonomy. What choice is there?

And inside the car it feels intimate, it has to. Because as we lose height and balance, we suffer fewer niceties, fewer formalities. Less tip-toeing around feelings because there's no denying the need for doctors, medicines, help. Aging, accompanied by aches and pains as a rule, begs to be expressed. "How do you feel?" and the cork is popped. The answer, in a whisper or a roar, will be better in Yiddish.
Elaine Stritch on NPR's Song Travels

Elaine Stritch recently died, but worked well into her last years. Even before reaching a certain age her style was direct, honest. Comedians get their laughs precisely for that, their honesty and self-disclosure. Even their memoirs are intimate. Watch famous younger actors fawn over Ms. Stritch in Shoot Me. The actors want a relationship with her, want her time. It is more meaningful than a random act of kindness to a stranger, not that helping someone across the street feels bad.

So fellow actors, make-up artists, coffee fetchers and valets will grieve an actress like that.

Of course, they aren't family.And let's not forget, there are old people, and there are old people. Generalizations about intimacy are meaningless when people age mean and difficult.

Which brings us to a few dissertation questions for the graduate student's consideration.

Long-term outcomes of childhood enmeshment

(1) Does childhood enmeshment predict a good result for the aging parent?

We assume it is bad for the child, especially toxic for a teenager who is denied a life, who cannot run with friends, socialize or leave home for college,individuate, become his own person. And it is bad for younger children, too, never having play-dates, missing school to stay home with a needy parent. All because of a psychological (and sometimes physical) need for control and attention.

But does it work for that parent during those senior years? Or is it payback time.

(2) Does childhood enmeshment predict depression, anxiety, substance abuse, etc.? Fill in the blank.

Does an enmeshed child's mental health fare that badly over the course of a lifetime?

Studies would have to control for confounding variables, like the degree of enmeshment, degree of psychopathology, characteristics of the adult child, the parent. Keep it simple for a dissertation.

In some cultures enmeshment is an emotional death sentence for the oldest or youngest daughter, destined to care for her parents, not to marry and move on. But usually enmeshment is less formal, isn't reserved by birth order. It is the coddled son who never marries, who is still living with his parents well into middle-age and is drinking with them on the couch in front of Dancing With the Stars.Or a family like we see on Everyone Loves Raymond. 

Logically, over-involvement, interference, should predict anger, but it might not. (Alcohol keeps it in check, and humor can, too). But the guilt associated with the very thought of leaving home has its own sedating effect, is my thinking.

For those of us who treat family problems, who see the way the family operates as a having an impact upon mental health, another question is relevant. What can we do? There is a field of outcome research that evaluates the efficacy of our interventions. I'm proposing one here. Call it, the future tripping intervention. A more professional term would be
  projecting into the future  
A final research question then,

3) Does projecting into the future function to dis-enmesh families that have problems with one generation respecting the physical and psychological boundaries of another? Narrow this down, of course, focus and study in-laws and their adult children.

It is the adult child who comes to therapy, generally, alone or with a partner, and many therapists leave the invasive in-laws out of the treatment intentionally, assume that it is healing for the patient to buck up, assert. The asserting is scripted, sometimes as an unimaginative ultimatum to the parent:
"If you can't stop . . . then. . . we'll move away." Or more typically, "won't answer your calls."  Fill in the blank.
The famous moratorium. Sometimes it works, but it is painful for everyone, and feels like over-kill. Parents with personality disorders will find ways to make the child feel even worse, will sabotage or retaliate. Parents who are less disordered might miss the entire part about the family's overall mental health.

Include them in therapy and it is another situation entirely. The therapist is a witness, one that will validate, certainly to a degree, rather than an attack the older generation, the one that ostensibly is responsible for the enmeshment. They need help, after all, do they not? Therapy should feel like an unanticipated benefit, enacted well. Add the projecting into the future, what it will be like when these people will really need attention, and the thought that by that time their children may resent the inconvenience (not that they do now, but in the future. . .) and you have a winning hand.

Nobody wants their children to have a mid-life crisis and abandon them at the worst possible time, about the time they can't find their reading eye-glasses.

Always use abandonment fears in therapy when you can.

Projecting into the future isn't an intervention only for enmeshment, but a natural technique in any type of multi-generational family therapy. Any family-inspired mental distress will do. It is useful, especially, when the parents have been abusive. Abused adult children often still seek the love, want it, which explains why many take care of their parents at the end, no family therapist need apply. But it is a gamble for the abuser to depend upon that.

So to me, seeing that SUV, the father-son relationship played out in the early morning, is a snapshot full of possibilities. I want to know how they got there, how he got to be the good son. Or was he always that way.

therapydoc