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Showing posts with label Kubler-Ross. Show all posts
Showing posts with label Kubler-Ross. Show all posts

Sunday, March 07, 2010

The Importance of Transgenerational

You know, it's all so fresh. I went to a conference last week, a really good one, and three-quarters into it realized my family had buried my father only two weeks past to the hour. I have no idea what happened in the third quarter of the presentation.

Later today somebody called me, left voicemail for me to call back. I totally thought it was about business, but all he wanted was to call, to see how I'm doing. That just threw me.

My dreams scare me.

I go through the usual words with people: It's hard. I find myself crying at nothing. I have a headache. I'm cold. I have a stomach ache. (Somaticizing isn't hard, but it is an art).

And it's very different, not what I would have thought it would be.
You get a break and it comes back. You're surprised every time.


Heck, I had four months to get used to the idea that my father was living on borrowed time, and we had some very intimate moments. Dying is very intimate if you share it, and it occurs to me that maybe some people have an extended dying just so they can be intimate.

Probably we can never be prepared, can never predict what it will be like, no matter the type of relationship we have had with a parent. If you take a hit, you shouldn't be surprised, and if you don't, it's okay. The books on death and dying recommend that if possible, grieve as a family. Discuss your different trajectories, mark important days, discuss memories. Let the emotions roll. And spread it out, talk to all kinds of people if you feel like it.

Meanwhile, here I am at work as if nothing has happened and it really feels this way at the moment. Gotta' love the brain.

A follow-up on eulogies:

I started out mine about my father admitting that before writing the eulogy I looked up the rules of eulogies in one of the rule books. There, in black and white and a little Hebrew, it said:
You can exaggerate. Not that much, but if there's a question, you can. You can err on the side of the positive.
Now this is incredibly important information. I don't know anyone who can't stand to be idealized a little bit in life or death, do you?

A story:

A man was dying. He had lived a full life but was clearly, undoubtedly, beleaguered with not one personality disorder, but with features of several. He hoarded, he was narcissistic, he stole on occasion, and his jealousy was completely, totally irrational, bordered on psychotic at times.

His son, let's call him Eugene, went to the funeral of a friend's father. His friend spoke glowingly of the deceased, tearfully, and as Eugene listened, he panicked.

"I'm ____ed," he moaned. "What in the world am I going to say about my father? My father was such a nothing compared to this guy. So selfish! And he's not going to make it through the year! He could die any day now!"

Eugene went home and quickly wrote a eulogy emphasizing whatever good he could find in his father's life. The focus was entirely on his father's good qualities, and he made some of the bad sound comical, not dysfunctional.

When the time came, when his father died, Eugene stood up in front of the crowd at the chapel and delivered a wonderful eulogy, had people in tears of laughter and love, and everyone said what a wonderful man his father must have been.

Eugene didn't know what to do, didn't want to correct anyone who said, Your father sounds like he was such a wonderful man. You were so lucky to have had him; what a wonderful family it must have been to grow up in. So he would disclose just a little now and then.

"My father was difficult," he might say. Or, "You couldn't correct my father, if you did he would call you stupid."

But this bothered him, made him feel guilty, besmirching the name of the dead, his father, the man who gave him life, for better or for worse. So he stopped it and let the positives of his dad's life eclipse the negatives. He could talk about the truth with his wife and his mother, for they knew this man. They grieved who he hadn't been, too, and their emotions were plenty rich. With others, however, he took one for the team.

He found that he was really angry and his anger wouldn't quit. Unable to shake it, he went to therapy. Here he learned that this is normal, being angry at someone who didn't treat you well, who could be irresponsible, difficult. Eventually he would be able to let it go, who his father really was, even forgive.

Perhaps it's not much of a story. But let me tell you how some of us would work a therapy like this, thanks, in part, to what we know about mental illness.

For sure we'd aim for acceptance while working through the full range of grieving, the sadness, the anger, the guilt, the denial, the shame-- the Kubler-Ross stages of grief. And some of us might even bring in other family members.

Family therapists will sketch out at an emotional family tree, inquire about the suicides, the mental illness, the infamous experiences in the extended family, reaching back in time. We want to know who left town and never came back, what became of the black sheep, what the norms are in the family about differentiation, and why. We inquire about how anger is expressed, and sadness, and who set these rules, and why. We want to know the meaning of success to those who are no longer living, and the meaning of failure.

To investigate, to get more of the story, patients are encouraged to interview living elderly relatives, to find photographs, letters. The job is to uncover, if possible, the good in the family, but also the mental or behavioral disorders, too, and the quirky, if not always so pleasant, personalities.

Based upon this, some of us will proffer a tentative individual diagnosis or three, defining, psychologically, members of the family who may have long since passed away, at least labeling the features. This may or may not make people feel better, but it is what it is and it's something to consider, something important to talk about, something to grieve.

"Is it genetic?" patients ask about a particular diagnosis.

We'll say yes, if we think so, or admit we don't know. Maybe, maybe not, depending upon who is fertilizing whose egg. But it's a good thing to know, isn't it, that if an ancestor has features of a disorder, that descendants might have these features as well?

For whether or not things are genetic, everything behavioral can be learned and passed down. All of us struggle with our nature, and we fight how we've been nurtured, too. Both are likely to be transgenerational, even dysfunctional in some way.

I like to think that we can fight both, that much of personality can be shaped and confronted in a nice way, and that most mental illness can be treated. We may have to change how we define success and failure.

The kicker, the part that is most difficult for many patients to buy in this psycho-educational family therapy, is that it's good to "out" our mentally ill, personality disordered, addicted relatives. Out them to the children, mainly, expose those who, dead or alive, have or had issues, or were perhaps differently-abled.

Certainly when it comes to mental illness, rather than attempt to erase a person from the family tree, own the mishigas, (rhymes with wish-ih-moss, Yiddish for craziness) and vaccinate the kids, empower them.

It's so funny. When you tell your kids about the colorful people in the family, they get it right away. And no, they don't want to be just like them. The research on self-fulfilling prophesies has always been a little light.

All that said, you don't have to roast anyone at a funeral, not unless you know your crowd.

therapydoc

Monday, March 30, 2009

Nobody Said It Was Easy

Not to overdo it with the music videos, but sometimes video gives a whole new meaning to a song. It's like doing therapy. As soon as you get the rest of the story in therapy, a person's life makes more sense. You get it when you get the whole truth, the history.

ColdPlay has a song that I like, The Scientist.

I listened to it over and over again, which I do, like a four-year old, if I like a melody. After the tenth time on this one, I thought I had it figured out.

A couple has a fight, The Big Fight, and in The Big Fight they break up. ColdPlay bemoans the break-up in the ballad.
Nobody said it was easy

It's such a shame for us to part

Nobody said it was easy

No one ever said it would be this hard

Oh take me back to the start
.
He wants to try again, go back to the start. Take Two.

It's what we do in therapy, really. We go back to the start, take a look at what went wrong, try something different. Generally the try something different is called an intervention, a part of a treatment plan. We determine which intervention by putting our heads together. It helps to have a therapist armed with dozens of these things different.

Trying something different, being somebody different is much harder than it sounds. Change is packed with difficulty. And it feels like a risk, usually. We like things the same.

But I got it wrong, the meaning of the song. It's not about The Big Fight, the one that you never forget, hard as you try.

The Scientist by Cold Play

Come up to meet ya, tell you I'm sorry
You don't know how lovely you are
I had to find you, tell you I need ya
And tell you I set you apart
Tell me your secrets, and nurse me your questions
Oh let's go back to the start
Running in circles, coming in tails
Heads on a science apart

Nobody said it was easy
It's such a shame for us to part
Nobody said it was easy
No one ever said it would be this hard
Oh take me back to the start

I was just guessing at numbers and figures
Pulling the puzzles apart.
Questions of science, science and progress
Don't speak as loud as my heart.
Tell me you love me, and come back and haunt me,
Oh, when I rush to the start
Running in circles, chasing tails
coming back as we are.

Nobody said it was easy
It's such a shame for us to part
Nobody said it was easy.
No one ever said it would be so hard
I'm going back to the start.



Surely about regret.

And whether or not it was his fault is immaterial. He wants to roll back time.

When something bad happens, something unexpected, something out of the ordinary, life threatening perhaps, there are emotional stages of grief. We think that for most of us, these are unavoidable, quintessentially human emotions.

We want to turn back the clock, do something different.

Forget ColdPlay for a moment.

Say you've been told you have cancer and have only so long to live (not the norm, that kind of news, but it happens). You'll grieve your future loss of life. Even if you've been told that your prognosis is good, that you'll be fine, that it is not life-threatening, your mind will play tricks on you. You'll still worry. You'll regret not having lived your life to the maximum, you'll think you've done something wrong, that you're being punished for the disease.

Forty years ago Elizabeth Kubler Ross (1969) let us in on the ways we grieve, even when we haven't lost anything yet. Anticipating loss can make us sick, just as having lost someone or something (money, for example) can make us sick.

I read her wonderful little book, On Death and Dying, in high school, and felt as if I had been let in on some big secret. Someone recommended it to me when I was dealing with my brother's death. It is probably still required or recommended reading for most graduate students in mental health fields, for mental health is all about holding it together. And loss wrecks our equilibrium. Maybe by now undergrads read it, too, high school students even.

Kubler-Ross defines the five stages of grief work, but there are more. We can thank my son-in-law for reminding me about guilt and self-blame. Kubler-Ross would have filed those under depression:

denial (this can't be happening, it isn't true);

anger (this is SO wrong, I don't deserve this);

bargaining (I'll give more charity, I'll be a better person, just change the decree!);

depression (no point in even trying to be happy here, life is meaningless now);

and acceptance (It is what it is, keep cool and play it out, stay in the moment, don't catastrophize, don't make it what it isn't just because you can, just because you have an imagination).

Acceptance tends to be the baseline for emotional management, but it's a goal, not a given. That's why Kubler-Ross puts it last. I would call it a mediating variable. Without it, no matter the intervention, the resolution of the problem isn't likely to happen. We'll still feel we're in the grieving process.

Acceptance underlies one of the lesser known cognitive-behavioral treatment modalities, Acceptance and Commitment Therapy (ACT) . Here acceptance is the springboard, the starting point, the place from which the real work in treatment begins.

Obviously you can't rush it, you're going to have to feel all of those bad feelings first, you have to, it's the way we're made. If you don't, you will eventually. They come back to bite you. But the idea in either case is to shoot for accepting things as they are.

Impossible. It really feels that way. Impossible.

So in therapy we try to make it possible. You work through the stages, the emotions, try all kinds of interventions, and at some point, miraculously, over time, if you don't rush it, you're there. Or you accept that you can never accept. That's accepting, too.

We'll talk more about ACT another day. It can wait.

But let's go back to the start, to ColdPlay. The fellow in the video, the one who regrets his part in the accident, is going to be stuck feeling bad for quite awhile. By making a video, turning grief into something creative, he has worked a fabulous intervention, something therapists forget to recommend sometimes. Stimulating another part of the brain like that, creating something new, if only for a little while, relieves some of the pain.

Unless. . .

he took Ecstasy the night before the accident, or maybe had some other drug in his system at the time. In that case, in therapy he might be encouraged to work a program* of some sort, commit to changing something about himself. We would stress behavioral change in this case, shoot beyond acceptance. Some kind of program.

I'd say, one that puts his science where his heart is.

therapydoc

*Working a behavioral program is not exclusive to the Anonymous programs for individuals with substance abuse problems. The 12 steps are really just a form of treatment protocol. You can see how they "work if you work them" at The Second Road).

Transitions

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