President-Elect Trump

I know, I know I said it.
I said that both Mr. Trump and Mrs, Clinton needed therapy (last post). People are taking down their FaceBook accounts because of things they have said publicly, and this should worry me. 

But that was yesterday. And the theme of this blog, remember, is that everyone needs therapy. So it isn't an insult, okay?

President-Elect Donald Trump acceptance speech

Today, the day after the election, I'm thinking more of the President-Elect. No matter the personality we saw during the contest, he knows this country better, more intimately, than any of us. We underestimated him.  

And this intimacy, this knowledge, is the reason he won the election without contest.  It is why he said he would give us hell if Mrs. Clinton had been elected, that he wouldn't accept the election results. He knew. He had his finger on the pulse of America all along, when nobody else did. 

America, to most of us, has been the America that is outspoken, everyone shouting at everyone else on some media or another. Yet in the big bell curve, in reality, not everyone wants to be the center of attention, and Mr. Trump spoke to that majority. President Nixon called his electorate the Silent Majority. The shape has changed, as has the demographic. But people wanted change, and they had no place to channel that desire until Donald Trump walked into their lives.

And that’s a type of social intelligence, is it not? Understanding the people in the country, the forgotten ones, those who have for years felt disenfranchised, unimportant. It could be interpreted, rightly, as intellectual, even emotional empathy. We’ll soon see if such empathy is universal, if it spans across the universe, if it is inclusive. 

People are really worried, or so we hear on the news, the radio interviews. Many woke up this morning, and hearing the outcome of the election suffered features of panic attacks— literal panic attacks-- shortness of breath, heart palpitations, dizziness. 

Jews just make jokes about being sure their passports are current. It is how we think.

The results seemed remarkable, unbelievable. For the polls had us ready to crown Mrs. Clinton, and whether we liked her or not, we had prepared for that, her resumption of Clinton rule. .

It was the surprise, the upset, that set off an arousal response, the panic, as much as the fear of what a Trump presidency might look like. Those who have learned the art of meditation, or emotional management might easily reverse the negative symptoms. A tried and true intervention is to remember not to dwell on the past, and equally as important, let go of the future. Only the present, what we are doing in a given moment, is within our control. Not that we can't work towards the future, put plans into place. But under the influence of anxiety, the here and now serves us better. Stay there. Do what feels good, right. Live one day at a time. Maybe pray. It is hard, but wrangling thoughts is a major component of serenity. 

Or just watch the President-Elect's acceptance speech. His voice, his posture, his very persona are reassuring, convincing, healing. There is none of the narcissism he’s been labeled with, none of that NPD, or Narcissistic Personality Disorder* that scares so many. Our new president looked and spoke Presidential. 

“It is time for us to come together as one people.” 

He doesn't say, "It's time to get to the work of deporting people." He talks of uniting, which is what new presidents all say after an election, but some of us expected another Donald, the one that is unbridled, who can't resist a snarky remark. But no, not a single I told you so, nothing negative about anyone, certainly not Mrs. Clinton. Only magnanimity.

If you read my last post, the one about social justice, you might remember that human rights activists and social workers do what they can to make things happen, to change deplorable conditions. Dr. Luis Zayas told an auditorium full of academics at the Council for Social Work Education annual program meeting that cynics and conservatives believe there will always be injustice, that it is inevitable. Get used to things being hard. But the social work response is just the opposite: Injustice is intolerable. 

So here's the big challenge, and a message to President-Elect Donald Trump. 

We’re all in agreement for the first time ever. Mr. President-Elect. It is time for us to come together as one people, a task that seems impossible. But the divisiveness, the hatred especially, should be intolerable, especially to you.

Accomplish that, make the seemingly impossible, possible.  Because you have the power to do this. Create an inclusive culture, one that bring us all together, and don't dial back the progress of your predecessors. Do it, make this country great again, as only a strong leader can. We are counting on you. Many fear you, disperse the fears. We could use a mentally healthy, loving United States of America.

And we know you hear the country's voices, that plurality, crescendo above us, above you. Make good, Mr. President-Elect Donald Trump. Go for it, the one people idea. Even if it wasn't exactly a campaign promise.

therapydoc

P.S. For those readers who feel this is a totally, ridiculously naive essay, I say. . . maybe.
For a much more rational opinion, one based upon everything we've seen in the past year's campaign, not based upon hope and a belief in the potential of man (when reaching potential, true potential is within his reach) read David Remnick's essay An American Tragedy, in The New Yorker. 

*Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by (five or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder (DMDD) is about emotional-behavioral management in children.  Reaching for more user-friendly semantics, FD refers to it as Calming Disorder, a seeming inability on the part of the child (hence the parent, too) to calm down.  DMDD is likely to be the latest flavor of the week, yet another label for children who are oppositional.  Willful.

We suppose that as these children age, as they grow into adults, they will be diagnosed as having Intermittent Explosive Disorder and treated with anger management.  Why we couldn't have used Intermittent Explosive Disorder with qualifiers: refer to children with a 1, adults with a 2, and a 1,2, or 3 to indicate the severity, is a mystery.  Perhaps the reason is that the temperament is chronic, not intermittent.

Here's the abstract.  I'll get to the article this week, but want to offer up a few thoughts regardless.  After all, they did ask me to be on the team to rewrite the DSM IV-TR.  Is it my fault that the page froze after checking "other" when asked for "type of license"?  I have two, and there was no way to communicate that. Calling in I was redirected, sent a new email.  But the link to the application didn't work a second time.

And life gets in the way.

Look for the article in PsychInfo if you have an academic affiliation. It might be on sale somewhere online if you don't.

Emotional dysregulation in disruptive behavior disorders.

Cole, Pamela M.; Zahn-Waxler, Carolyn

Cicchetti, Dante (Ed); Toth, Sheree L. (Ed), (1992). Developmental perspectives on depression.Rochester symposium on developmental psychopathology, Vol. 4., (pp. 173-209). Rochester, NY, US: University of Rochester Press, xix, 396 pp.

(The authors) present a view of disruptive behavior disorders as affective disorders and, from that perspective, discuss the emotional characteristics which are associated with the development of aggressive, antisocial behavior 
provide an overview of the disruptive behavior disorders, the history of the traditional segregation of behavior disorder from affective disorder, and the evidence and arguments for comorbidity of affective and disruptive disorders / consider possible developmental trajectories leading to these disorders / focus particularly on the role of emotion in early childhood and its implications for the development of deviant and aggressive behavior later in childhood and adolescence (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Seems to me we are looking for the prodromal, or warning signs of sociopathy, a disorder that defines what we have referred to as almost psychopathic in previous posts.

Parents are right to worry when their kids have symptoms of DMDD: uncontrollable tantrums, aggressiveness, an inability to manage emotion, an absence of empathy.  When they are cruel.  Dr. Cole has published on empathy in the past, and I think she is on the mark if she is thinking we have to teach children, all children, empathy.

We're talking about it right now because the DSM V is due out in 2013.  Teams of researchers, revisionists, are making all kinds of changes to what we commonly call disorders.  For example, Asperger's, childhood disorder in the current DSM IV-TR, has been known for decades to be characteristic of adults, too.   It is thought to be a spectrum disorder, on the spectrum of autism, and may lose its status as a disorder exclusive to autism.

According to yesterday's Wall Street Journal (Shirley S. Wang), "Aspie's" are up in arms about being subsumed autistic.  Not everyone likes the thought of being autistic, even if it is high functioning.  Yet, most of the "Aspie's" I treat tell me that they are very much in their own world.  They see the point.  More likely however, Adult Asperger's Disorder will make it into the DSM V, at least that is my hope.  Just a guess.

But back to our new flavor.  When we first recognized Bipolar Disorder in children, it amounted to medication, usually too much.  Manic kids were oppositional, hard to control by definition, and they suffered swings, clear signs of childhood depression.  Thus meds saved the day, theoretically, although those of us who work with a family model are generally reluctant to make that referral.

Children with Disruptive Mood Dysregulation Disorder are likely going to be over-medicated, too.  It doesn't take much to over-medicate children.  They are growing and changing all of the time.  And they are mini-emotional time-bombs under normal circumstances.  Having a motor that tends to puff and smoke at the worst possible times, it is understandable that parents are looking for help, lots of help, from that god of psychiatry, Big Pharma.

Thus we can only hope that parents remain patient, able to calm themselves, and bring little Joey to therapy.  If you are such a parent, stay in the room and learn strategies from the doctor/therapist.  The tried and true holding technique, grabbing the little tyke and holding her tightly (without hurting her) until she calms down, works for some kids, but as one reader puts it so well, restraining the child is:

 a tried and true way to exert dominance, lose the child's trust, and create permanent emotional scars.

I think we had both lose the phrase, tried and true, unless we can qualify them well.

Make sure no one is hurt no matter what you do.  Corporal punishment won't work, will work against you.  And although we are capable of holding, able to restrain children, being three times their size, we have to be careful. Not every child responds well to that.  If they are older, best to work on communicating in words, or in art, or play if holding is violently rejected.

There are other ways to treat DMDD.  Engage other siblings, certainly a second parent if one is around, or grandparents, aunts and uncles.  Use friends.  Use your people.  If you have none, find a support group.  Call the National Alliance on Mental Illness, NAMI.

Lose the idea that this is something shameful.  Get more into the idea that it takes a village to raise a child, because it does.

Behavioral modification won't always work, but try it early, start very, very young.  Even a two-year old needs to know the power structure in the family, that he is not the boss of you.  As a parent, you are the boss.

All of this assuming that marital dynamics lend themselves to the therapy, that the child isn't learning aggression in the home, a very big assumption.  And that the dyad at the top, Mom and Dad, or Mom and Mom, or Dad and Dad, have to have something of a working relationship themselves, must communicate, agree on a treatment plan.

It is most likely that children who will be diagnosed with DMDD, unfortunately, are identified patients, that their families are the patient, really, and that only a fraction, a tiny fraction of the children diagnosed in nursery, kindergarten, or elementary school, whichever system has booted them out, have the disorder.  If you hear the news: This child needs a psychiatric evaluation--it may not mean Disruptive Mood Dysregulation Disorder, no matter who slaps on the label.

I'll put myself out there and suggest that as a first line of attack, families need to find a good family therapist, not a psychiatrist, and leave the primary care physician alone about medicating the child.

When it is obvious that a child is dangerous, on the other hand, a team approach is surely necessary, with a primary care doctor, a child psychiatrist (go find one, good luck), and a therapist.  Sometimes  even hospitalization might be necessary.  Or so they're saying in the news today.

therapydoc

Ghosting

You have been rejected, dumped. Your ex hasn't been very nice about it, either. You feel used, used up, hurt beyond words. And because you have cried so much, you are beginning to feel angry. It won't take much provocation to do something rash, to exact vengeance. You are not in a charitable place.

And deep inside, you think this won't ever get better, that it can't, because there are too many memories, too many triggers. You live in the same neighborhood, frequent the same bars. You share friends, go to the same weddings. And every time you see him, or each time you run into her, you break down, have to start healing all over again.

Your therapist tells you,

"Well, that's what happens when you light up those old neural pathways. Stay the ___ away! No Facebook stalking. No mining friends for information. Avoid your ex whenever possible. The longer you stay away from the source (of neural activation), the better your chance to heal."

To heal in this case means detach. The advice is sound because forgetting is impossible when your physiology, your body, is busy remembering.

But there's something else at work, psychologically.  Relationships add to our identity. Our very self is inclusive, adds those we love. We depend upon these slices of our ego to be there for us in various venues, at predictable times, and that reliability adds to our sense of wholeness. Maybe we shouldn't, but we can't help but expect things to be predictable in close relationships. This is what it means to feel attached, security in numbers. Attachment and dependency are associated.

Not that love is dependency. But we get so used to our partners, that breaking up, establishing a permanent separation, is tantamount to feeling a part of us has died. We're accustomed to too many things. Even Henry Higgins* grew accustomed to her face.

She almost makes the day begin.
I've grown accustomed to the tune that
She whistles night and noon.
Her smiles, her frowns,
Her ups, her downs
Are second nature to me now;
Like breathing out and breathing in.
I was serenely independent and content before we met;
Surely I could always be that way again-
And yet
I've grown accustomed to her look;
Accustomed to her voice;
Accustomed to her face.

A huge piece of reality, of ourselves, is ripped away at the death of a relationship, whether we're waiting for it to die or not.

We see a lost lover everywhere, not literally, but everyone looks like her, like him, what I call phantom sighting. We crave the sensory stimulation that defined our relationship-- eating together, playing together, listening to the same songs, the physical and emotional intimacy, the sharing. Apart, we can't just change our habits, we still want to do many of the things we used to do as a couple. 

Thus it feels impossible not to grieve, not to feel angry, even when one can say, Good riddance! Even when the other has flaws as numerous as the ice cream flavors at the shop we must now avoid.

And as good as your therapist's intentions are, this theory of avoidance is as good as the carpet in her office. One can't just move to Hawaii. There's the lease, the mortgage, perhaps children to think about, parents. Walking away to avoid triggers isn't happening. Hiding, crying, avoidance feel like the only alternatives.

To complicate the grieving might be the knowledge that the other has moved on, is even happy, perish the thought.

____ ____ ____ (these are expletives) as Henry Higgins would say.  One might run into them in the usual places, the ex and your replacement. They now haunt your places. The thought of seeing him, the thought of facing her, is a tremendous source of anxiety. And it could happen.  The patient asks:

What do I do if I bump into either of them in the produce aisle?

The therapist:

What do you want to do?

Most common answer:

Run!

Running is a respectable solution, but as you were told as a child, one can't run away from problems. This will fail. Better to think, I have a right to be here, wherever I am.  I have shopping to do.

And if it happens, if you run into your ex or your ex with a new partner, and you feel the uncontrollable need to cry, which is your catastrophic expectation, Well, good. Let him see you cry.

But don't engage.

Unfortunately, this is an incomplete answer, guilting with tears. We don't feel the power crying, not unless we have a histrionic personality disorder. No one wants to be seen at Whole Foods with mascara dripping down a cheek. Far better to manage these negative feelings, or yes, leave the store, shop later. Your therapist has a small arsenal of emotional management techniques that might stave off the tears. Grab a few good ones. I personally like breathing. Slowly, deeply. And squeezing a pen.

If you think, perhaps, that the answer to What Do I Do When I Run Into Him/Her might be

Tell her off! 
or Punch him! 
even, Glare! 

then those of us of the cloth might suggest not. Signs of aggression only validates an ex's decision to break up. You want to look good, not crazy, you want to seem rational, to exude strength and independence. Verbal violence, throwing a tomato, undermines this.

That Hold your head up song by Argent feels good about now.

And if it's bad
Don't let it get you down, you can take it
And if it hurts
Don't let them see you cry, you can take it

Hold your head up, hold your head up
Hold your head up, hold your head high

And if they stare
Just let them burn their eyes on you moving
And if they shout
Don't let them change a thing what you're doing

Hold your head up, hold your head up
Hold your head up, hold your head high

So contrary to cookie cutter psychobabble -- that you must grieve, or just avoid-- we're saying these are mutually exclusive processes. Grieve away, of course, and avoid if you must, but not at Dominick's, Jewell, Albertson's, the hardware store, or anywhere in public. Wear sunglasses perhaps, but don't run.

You don't have to talk. Ridiculous!  Why would you? You're picking lettuce, he's at zucchini. No need to talk. He sees you, you see him. Does everyone deserve a greeting? Do we really have to converse with people just because we know where they have their birthmarks?

I put it like this to the patient:

Imaging the Queen of England. She recognizes, perhaps even chats at home with the man who polishes her silver. But in public she is standing tall, nodding at people who adore her. Does the person who polishes her silver run up to her and say,

"Queen Elizabeth! So wonderful to see you!" 

Does Liz cry out,

"Joel!  You're here! We must talk polish when you have a moment." 

No, they mutually ghost one another. He's invisible to her.  And he wants to be invisible.

The person who has dumped you no longer has conversation privileges. Your working agreement is null and void. No need for acknowledgement, validation.** Or as I like to remind patients, If you couldn't work out your differences together, do you really think you can do it apart without years of therapy, mediation, etc?

There's a blockbuster hit, a book that sold millions its first week out, Go the "F" to Sleep. I'm not recommending it, haven't read it or listened to it on YouTube, not beyond the first expletive. But I happened to catch the author, Samuel L. Jackson, on National Public Radio. Mr. Jackson said that one night his daughter kept popping out of bed and when he sent her back for the twelfth time, finally alone, he put his thoughts down in literary form. The rest is history.

He apparently didn't know the "ghost" bedtime technique. Before there was Ferber, there was ghosting.

The child, too big to confine to a crib, is cognizant of ghosts, but isn't afraid, has been taught there is no such thing as ghosts.  He knows the mantra, There's no such thing as ghosts, there's no such thing as ghosts, there's no such. . .

There may be, wink, wink, a tooth fairy, ironically, and a Santa Claus. Children should believe that the forces of the night are good.

The child has been fed and watered, but can't sleep and keeps popping up. You, the parent, need sleep. You need the child to respect your need to veg, to see an end to the day. The child, being a child, isn't terribly concerned with your needs, and wanders into the TV room.

I need something to eat.

You say to your partner, "I believe there's a ghost in the room asking for something to eat. I say we ignore it."

"Right-o," says partner. "I pay no attention to ghosts. If that ghost breaks anything for attention, there will definitely not be doughnuts for breakfast, nor snacks at lunch tomorrow. Could you change the channel, dear? I want to see Antique Roadshow."

The child continues to whine fruitlessly, or scream, but at some point realizes there will be no attention, none, to be gained from wakefulness. Bed will feel better than this, being treated as an unwelcome intruder, a ghost. Off to sleep we go.

So at the bar, in the store, on the street, in the subway, an ex, one who lights up those neural pathways, doesn't exist, merits no attention. You look past him, past her.

A ghosts of relationships past, let's just say.

therapydoc

*Henry Higgins tutors Eliza Doolittle, makes a poor flower girl a princess in My Fair Lady, a musical adaptation of Pygmalion.

**If you parted as friends, none of this applies. And surely, when there are children to parent, there will be some conversation necessary, a good deal, perhaps, to co-parent.  This dialogue is necessarily dispassionate, rational conversation. And not in public.