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Monday, October 20, 2014

How to Cope When the Status Changes

If it had only been one patient, I would have thought it idiosyncratic. But people are finding out on Facebook that their ex's are married, or engaged to be married, sometimes only months after they broke up. It can be a more than a moment of reckoning.
Marshall and Lily Got Married

Not judging the announcements, especially the videos. Who wouldn't post an incredible engagement/proposal video on Facebook? Isn't that the purpose of the video? These are works of art. A sixty to ninety minute montage entirely composed of five or six How I Asked ___ to Marry Me's couldn't be dull. After all, she might say no if it is.

Hearing that someone you know recently changed relationship status to become engaged or married, can be upsetting, no matter how we find out. Marshall and Lily, the token couple to take the plunge in How I Met Your Mother illustrate that marriage can be intimate and passionate, if you do it right. And it need not herald the end of relationships with single friends. A bar in common below your apartment helps. 

But I'm only on Season 3 and skip through most episodes, and confess to not having even made it past the first few seasons of Orange is the New Black or West Wing, now that Scandal is on the radar and that is getting boring, too. For for all I know, by the end of Season 9, Lily and Marshall are divorced, fighting over who gets to keep the teddy bear, a favorite blanket, or a child. That would be sad, their break-up, so don't tell me, not on Facebook, not here. I may skip to Season 9 one day soon.

It is subtle, the sudden death, the moment a person hears about an ex settling down with someone else. It can be as simple as a "Like" to a comment about something random.  But the Liker has a new name.

Or in a vulnerable moment, you might actually look to see who Facebook suggests as new friends. There she is, your ex, with another name, or an additional name, and it isn't the name her parents gave her.

Or the new profile pic is one of her with another person in a loving embrace, beatific smiles.

And here I thought nobody changed their name anymore, but that's not so.

Discussing this at a kiddish (food and drinks after prayers if you're Jewish), someone who knows these things informed me that it's an in your face thing, bragging about the new status, the new name.  But that's paranoid, I think. The in your face part is paranoid, not the bragging, telling the world. People do tend to want to tell the world, although many use discretion, when they are connecting with another for whole-life, not buying a term policy. This feel good, for many, if not most, is the first real feel good in a long time, and it is often about security, being a couple. Power in numbers.

So when we're faced with being alone again, naturally, as Gilbert O'Sullivan croons so well, and panic ensues. It is the original abandonment anxiety, one that therapists refer to when talking of any loss, especially death. 

The new status marks the death of the relationship. Thoughts escalate, become irrational. A person begins to think that she is the oldest person on earth not attached legally to another, not in an intimate way, one that scores showers and parties, insurance. We begin to think we really are old, in our 30's or 40's, which is not old. We'll let you know when you're old.

You begin to think that you were at fault for the break up. It must have been your fault, because she has found someone who clearly finds her wonderful. Why couldn't you do that, find her wonderful?  She went ahead and took the advice of a rock star.  She made him put a ring on it. She couldn't make you. Yeah, you had issues.

This self-castigation gets worse, becomes an obsession. One begins to self-blame constantly, for what went wrong in the relationship, well beyond not having committed to it. For the first time, perhaps, there is a serious look deep down, not at her, where the blame once rested. And when we look at ourselves, our faults, our personality, our petty ways, for we all have them, we come up short.

You go to therapy and ask, "What is wrong with me?  Why couldn't I commit?  Or in the case of a previous self-initiated divorce, Why couldn't I stay?! Why couldn't I be that guy, or that girl, the one who gives, the one who gets the ring."  And you discuss fears of intimacy ad nauseum perhaps stretched out on one of those safe pieces of furniture, the therapist's sofa, a box of Kleenex to your left or right (we buy in bulk), discuss the fears of exposure, merger, suffocation,and yes, abandonment,all those fears brought to the dim light of day in that office. You don't leave out how badly your parents got along, how much trauma you yourself suffered in relationships in those short thirty or forty years that make you feel so old.

And the rational side comes out and you get your act together to defend yourself and ask the doc: "Why would I risk spending the rest of my life with someone who made me miserable and threatened to do so for the next fifty years? I am perfectly fine as is, now that you mention it, and did I tell you?  I like my space." Amen.

The therapist confirms, probably, and brings things back to affirming that you are on track, thinking systems, staying rational, remembering the times she was so mean. Or the time she ignored what you had agreed upon, or so you thought. . .that was truly horrible. Yet you forgave, swept it to the pile with the rest of the disappointments, until it all got too difficult, too many tears, too little laughter, and you simply had to say: Enough is enough. We're over.

So why be upset when she moves on, right? Because it really is over now, no turning back. And although it feels like rejection, an in your face, and it feels like you'll never find someone now, for sure not, you can bet on it, you really don't wear a sign that shouts out: Damaged. You don't.

She wasn't the first, although now she might be the last to refuse to give you the job, and you are, now, an amazing candidate, better off without her. You knew that in your gut, you know.

So don't say, although you could, that she will probably never stay married, and that this guy is in for more than he bargained for. No sour grapes.

Be happy for her.


Gilbert O'Sullivan - Alone Again (original version)

We talk about this one all the time.

Wednesday, October 01, 2014

Snapshots:September, 2014

With so many horrible things in the news, I say we take a vacation from it all.

(1)  With Feeling
Dunkin Donuts, Kosher in Chicago on Devon

A grandson has a 10:30 orthodontist appointment on a school day, and I have the honors. The rain is coming down hard and he holds the umbrella over me while I unlock the car. Once inside, the fellow shoots me a sideways glance. I turn my head, raise an eyebrow, speak our first words since leaving school.  

“I’m starving.”

“Me, too!” he exclaims.

We work out the details of taking out from Dunkin Donuts. He will sit and get his braces tightened, change hues, and I'll run in. There isn’t a minute to lose because office hours begin in the early afternoon and I can’t be late. 

Our timing executed perfectly, he is at the curb, ready for me after the procedure. Overjoyed with the egg-and-cheese croissant (with fake bacon bits), hash browns, and a blue berry muffin, he eats faster than my Airedale. He can’t thank me enough.

Three years ago, at 9 years old, a Thanks! might have stuck in his throat. But he has it down now, smiles with gratitude and the words gush out uncontrollably. Thanks SO much!!!

For this reason alone, and there are many others, parents have to think: There's no hurrying psychological development.

The tests of our children are really our own.

(2) Our Unfamiliarity with War (Details about patients in this story, and all of them on this blog, are pure fiction.)
Montfort Castle in Israel

This profession can be quite intimate, and although most therapists share about themselves, we don’t share all that much. We may share more, even share less if we have been seeing the patient for several years. I know I do.

It all depends upon the person getting the therapy. But over the years there is more depth to a relationship, and confidence that what we do share will be absorbed for the good. Otherwise why say anything at all? It is not a friendship, not by any stretch of the imagination, but both the therapeutic relationship and friendship are defined by mutual trust emotional safety.

Still, whereas the patient can never say too much, for what he says is all relevant and diagnostic data, we can.
Just prior to leaving for this vacation, the first real time away from work for longer than a few days-- in years, I let the destination slip a few times. It happened when rescheduling proved challenging. Frustrated with the perceived long wait, the patient would ask:
 “Going on vacation, are you?” 
”Well, yes, actually. Kind of far away, too. A small middle-eastern country.”

Don't call me. I expect we worked hard enough on your independence in the past few weeks. You can do this.
Let's talk about this, how you really feel, and how it will go in my absence.
The Western Wall, or "kotel"
The last time I left for that small middle-eastern country, a patient knew about it and attempted suicide in my absence. He showed me. But we had expected it and the family and covering psychiatrist knew what to do. We could say, even, that the patient ended up better for it, that extra special treatment a person merits in the hospital if the presentation is that severe.

People are okay, at least it seems within my practice, if a therapist is off to a conference or a presentation. But no such thing now, and a fib felt bad. I liked the idea of promoting tourism, maybe. “Everyone should visit Israel at least once in a lifetime. It is an amazing country, nowhere in the world quite like it.

Blank stares.

Immediate regrets for the blurt. And worse, once I let down my usual guard and added,
 "And for the first time I'm a little scared."
Israel felt scary to me, from Chicago. Despite the peace treaty, the country is always at war, and although the war is now more about rocks and fears of suicide bombers in pizza shops, the missiles were glaring. In fact, those launches Hamas supposedly had stopped did start up, if only once, during my tour, although Hamas apologized. A mistake.
Shraga's. The gourmet food is on every corner.
Was my fear rational? Not really. Nevertheless, you don't lay that trip on a patient.

He didn't bat an eye, is the truth. Maybe didn't hear, worried mostly about his own troubles. More likely, too surprised to respond.

Predictably, when I got back, there was rarely even a reference to my glorious vacation. Maybe a single question, "How was your trip?" to be polite.

The redirect, when that happens, takes seconds.

(3). Flying 
Austrian Airlines, not cheap on beverages.
So here, 34,700 feet above sea level on Austria Airlines, a flight attendant pours FD a half glass of Chivas. He had asked for a thimble-full. But they probably speak German, and perhaps a thimble is a glass in Austria.  Whatever the case, FD wants to sleep so he drinks half of it, asks me to hold the rest, return it to the attendant or drink it myself.

(Just flying European felt strange, but the new experience, like most new things, awesome, highly recommended. Plus it is really cheap). 

Knowing sleep rules jet lag, I sip at the Chivas, hope it will shut me down. But it doesn't.  Even in a dark cabin wearing eye-shades, and a decent yogi posture going, my head is stuck on the fact that this is what they call a vacation. That and it is only 8 PM, Chicago time. And I’m a little high, the scotch has nothing to do with it. I’m on vacation.

Mind you, this feeling is not only weird, but it is incongruous. Today is my mother’s first yahrtzeit, (a Yiddish or Hebrew word, rhymes with door-site), the first anniversary of her death, and rather than see that candle burn out (we light a 24-hour candle, give to charity), FD and I are on a plane, a little closer to heaven. Up in the air, at 37,700 feet, we assume we’re a little closer, that prayers are local calls. We have no evidence to the contrary.

At the terminal in Vienna we expect to have to run like hell (as is always the case) to make the connecting flight to Tel Aviv.  Our flight from Chicago had left two hours late. But the good people of Austrian Airlines have hustled. We made up the time.
Still I wonder if discussing the problem with my mother, asking for a little help to move us along, make time, helped. Do they have clout up there? No evidence to the contrary.

(4) The King of Morocco

It is the Jewish New Year season, and we think the whole world is judged this month. So it is kind of scary and people who aren't remotely religious come out of the closet and go to the synagogue, or merely hope their thoughts and prayer will be heard wherever they might be.

Anyway, my rabbi told over this story the week before to get us in the mood. He thinks it is true but isn't sure if the king is really the king of Morocco. 

The king of Morocco is visiting London to meet with a particular businessman, who happens to be Jewish. The man is expected to attend the Bar Mitzvah of the son of a close friend on Saturday. He asks the father of the boy if he can bring a guest, an important person. Of course, why not? The king is delighted.

At the party the king is introduced to the father of the boy. He takes out his checkbook and writes a check for $250,000. The boy’s father is shocked and upset. He tells the king that the gift is over the top, he need not do this. Most people give much, much less, he says, they knock off three or four zeroes. The man is honored by the royal's presence alone.

The king replies that it is not fitting for a king to bother with an insignificant amount. He doesn't write small checks. And there's no way he won't give a gift.

So it is with our King, concludes the rabbi.  He doesn't write small checks. We should think big when we are asking for things.Money, health, go for it.

Not hard, right?

May there be no more hate, selfishness, or illness in our world (and we in the northern climes could use better weather this winter). May we include one another, when we obsess about what we should have said, should have done, should do, for happiness and health, success, and good will, and work towards that.

A happy new year to all of you, friends.


This is a lichi. I had never seen one before visiting Israel. We eat new fruits on this holiday. My Israeli brother-in-law is always eating new fruits.

I liked Brussels airport. Also, they have cots for napping, enough said.
Brussels airport synogogue

Brussels airport mosque

Brussels airport humanist consultant

Brussels airport chapel

A beach in Natanya.


Tuesday, September 09, 2014

Ray Rice, Power, and Domestic Violence in the NFL

Rape, now more commonly called sexual assault, is the end and the beginning of many things. It can be the end of innocence and trust, for as long as it takes to recapture that, and the beginning of guilt, shame, fear, sexual problems, infertility, mental and physical illnesses, isolation, and more.

Tearing it apart, the perpetrator overpowers a victim, a person who protests, and having more power over this person, commits a crime of passion, of sorts, Those cries of "No, I don't want you to . . ."  (do whatever it is that is objectionable at the time) are overruled by brute force.

We tend to think of a sexual assault perpetrator as larger-than-life, stronger than your average Joe, but more often than not, he's not. Sometimes he's the person you would never suspect, might even respect (think of teachers). When the suspect is a professional football player he is stronger, indomitable.

Six years ago sexual violence was outed in the NFL.  Ben Roethlisberger, accused of numerous sexual assaults settled one of them, a casino incident. Stories like this are buried, no surprise.  If you want access to our locker rooms for your sports column, you had better make this one die of natural causes.

Now we have Ray Rice beating his wife to unconsciousness. And nobody is burying anything.

Strangely enough, before I saw the infamous clip, public since February (!), I was watching highlights of Monday night football and came to a crazy conclusion.  That athletes brush off tackles and crashes to the head is astounding. These people are stupefying, superhuman. Inhuman, brushing off falls that would put most of us out of commission for weeks. How does a person endure so much physical abuse and still pop back up and play ball?* Players learn to endure pain, is the answer, and it is admirable.

But here's the point:  Maybe they project that invulnerability onto others, assume we ordinary mortals can take physical abuse, too. There are other explanations, from poor family and peer role models to the narcissism learned as a child, treated special, always, as a potential star. Groomed for college ball and maybe the NFL, women and cars, hotels and alcohol, are assumed. Those courses on ethics are skipped, too boring.  And maybe men like Ray Rice actually are fooled into thinking that women like his fiance can take a wallop on the head, like he can.

Ray Rice needs to know what it is that happened there in the elevator, decking his wife with one blow, dragging her seemingly lifeless body from the elevator floor to the corridor. He is probably as surprised as any of us, and yet, it is unlikely this is his first physical altercation. His father died when he was one year old, shot dead. John Clayton:

"I faced a lot of adversity," Rice (told me once by phone), "and I had to be a man real young.".

The NFL response? New policies are in the works that will (surely) reduce violence perpetrated by players. That is the intent.

Not everyone agrees that the new policies will be enough. Certainly not those of us who work with victims and perpetrators. It is changing personality we are talking about: impulse control, narcissism, and empathy, and a different defiintion of manhood. A year in therapy is a start, but education, workshops, testimonies from survivors of assault, so many that the words of survivors are predictable, this type of exposure is what these very large men, players like Ray Rice need. Even with those workshops there will be sociopathic players who feel they are above being told what to do and what not to do, what is expected of them as human beings, members of the human race.

Social workers approached Roger Goodell, the commissioner of the NFL, with assault prevention workshops years ago. As anti-violence experts, we received polite applications. Fill these out. Let us know your plan. We'll get back to you. Don't call us. . .We'll call you.

Something tells me the applications hit the waste basket pretty quick.


 *Players aren't actually superhuman, and they know it. Concussions, many of them, are an occupational hazard. The self-abuse of a life-time in sports is future-changing, predicts a difficult retirement. Cognitive functioning, you know, is a terrible thing to waste.  I hope Janay Palmer is okay.

Thursday, September 04, 2014

When the Diagnosis is : All of the Above

Most of us aren't Diagnostic and Statistical Manual (DSM) experts, but are aware of this thing we call the DSM-5, or Diagnostic and Statistical Manual of Mental Disorders that therapists memorize. The bullet-point system of features at the corner of the desk is likely a well ear-marked spiral-bound copy of the bible. Docs flip easily to a suspected disorder.

"See?" we declare knowingly. "That's you."  Or more likely, "That's her."

Some of us read the patient right away. He belongs to either the anxiety disorder family, or the affective (depressive-manic) disorder tree, because so many of us do. The lucky belong to both. The experienced professional also recognizes substance abuse, eating and gambling disorders, personality disorders, everything.

Still, we work at that differential diagnosis, want to narrow the problem down, if there even is a real disorder, one that has met the full DSM criterion. Not everyone has a particular disorder, but we live in a world replete with mental and behavioral messiness, so a typical therapy visit also means someone else, someone who is not in the room, is the subject of that "See? That's her." Yes, you should worry when your partner gets a therapist.

All well and good. But what's a therapist to do when the patient begins by saying, for example, that as a kid he had an addiction to pot, and can't remember being depressed as it presents in the books, but knows he had suicidal thoughts. He will continue to say that he treated teachers as inferior beings and passive-aggressively refused to answer questions, yet never scored lower than an 90 on a test without studying. She'll tell you, too, change the gender, that she binged and purged before even knowing it would be popular in college, and that by the age of twenty started having obsessive thoughts when she saw a knife, visualizing the knife slashing her of its own accord. Or she might irrepressibly slash herself. Add to this a social network disorder that culminated in job loss, and compulsive sexual relationships on the internet. Oh, and she has a new job and she hates it.

All this without any family history, as if to say, It is my genetics that made me do it. I have a mental disorder and none of the doctors in the past have managed to narrow it down. Would you do that for me please? I'm under a lot of stress.

I look at you, do my best to read you. You return the favor, read me. I ask, How did you find me? Why me? This yields wonderful diagnostic information. Another question: What does your primary care doctor think?

Inevitably, assuming the pri-care is a family physician, the answer is: That I need counseling. I need to talk to someone like you.

Those of us who have helped people in one or two visits, who specialize in "only evaluations" or are in a hurry or don't have evening appointments might want to pass him on to another therapist. Our patient with a million symptoms and as many diagnoses and problems likely had a very messy childhood. One of my mentors once told me that if a person has been incested, that means twice a week for years.

Makes sense, right?  There are so many forms of incest, is the thing, and indeed, twice a week on the couch for years is an incredible luxury. And it usually isn't necessary, all due respect. Who has that kind of time? Job stress is at the top of the list. There is a V-code, I think, for that.

Upshot: If the patient with All of the Above* is your new patient, then settle back and relax. Feet up on the ottoman. Do the therapy that the primary care doctor has asked you to do. And don't worry about the diagnosis, the medication, or even who else you think should be in therapy. This one's yours. Embrace it.


All of the Above*: Not to say that there aren't a few diagnoses, but usually there are a few features of several diagnoses. One does have to go through that process, vetting those features, finding illness. All I'm saying is, don't let the diagnostic process get in the way of the therapy. Because it really can, seductive monster that it is.

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.


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?


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.