Celestial and Cerebral Reunions

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

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

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

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

Proof of Heaven? Maybe

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

Some people cope with loss by assuming there is an afterlife complete with heavenly reunions.  Sci fi, to me, but my cousin in Israel, hearing about the loss of my mom, wrote:

"Now all of the cousins are together." 

I have to write to her, now that I'm finally getting to thank you notes. It is comforting to her, the thought that our mothers are together now. Just hearing from her is a comfort to me.

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

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

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

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

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

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

We can always be a better . . . A nice little PhD thesis for one of you:

The degree of our involvement with a loved one before death will predict the intensity of memories and magnitude and frequency of flashbacks in the first months after death. 

You could use a hired caregiver group as a control, make up your own hypotheses. Other variables matter, too, type of relationship, cultural expectations, external support, income. It is likely, no matter, that if we're a go-to person, almost anything will remind us of the person we lost.

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

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

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

Examples:

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

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

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

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

Last week FD and I visited our kids and grandkids in Atlanta, and waiting on the curb for our ride to the house I think, I have to call my Mom, tell her we're here, arrived safely.  What used to be an obligation, and I think this is the real kicker, is something I wish I could do but no longer can.  My solution is to talk to her anyway, the mock call, an intervention suggested to others.

Hey Mom, we arrived, how ya' doin'?   No, waiting for them to come and get us.  Sure, will call you tomorrow.

Not to mention that one of her great-grandchildren looks like she did as a child.

I find it hard, a one-way call.

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

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

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

therapydoc

Judging Mother

The trend in psychotherapy in the first half of the twentieth century was to blame the mother for whatever the symptoms expressed by anyone else in the family. 

Then in the fifties it became fashionable to blame mom and dad.  Father took blame for supporting mother's pathological influence, be it abuse or neglect, and sometimes for behaving poorly himself.  He was given a pass, however, on neglect, didn't have to participate in family life because: (a) he worked, and (b) guys aren't supposed to talk about feelings or ask about them. Certainly not when they're tired at the end of the day. 

Then in the sixties, seventies and eighties, family therapists caught on to the transgenerational system.  We noted that pathological behavioral and belief patterns are passed down, consciously or not, from parents to children.

So we searched the transgenerational family tree, blamed grandparents, great-grandparents, great-great-great grandparents, even uncles and aunts and distant cousins, way up to the top branches-- the ganztza mishpacha (Yiddish, sounds like fonts-ah- dish-puck-ah) --  the whole family.  We blamed the family system for awhile then finally decreed: No one is to blame. It is the family system that is to blame, family dynamics, patterns that repeat, unchallenged, year after year after year.

At some point we came to realize that no family system is an island, and if we're going to blame anyone, anything, we might have to blame the entire universe; for even people and events in the news affect our thoughts and behavior, as do our teachers and co-workers, the people in the grocery store.  So we added "search" to the ecosystem to find a systems diagnosis, and used that for system change.

But sometimes it is just so obvious.  It's Mom.  We really can blame her, although the tree, those teachers, the neighbors, might be culpable, too; and Dad could get best supporting actor.  But Mom has a corner on emotional power, that power to make us feel happy, or to make us feel sad, and sometimes she knows it, can't help but wield it. And it hurts all the more because, rightly or not, we expect more from women.  When our woman doesn't deliver, it is the unkindest cut of all.

We'll put aside our wide-angle lens when father does it, too.  We stop looking for patterns when one parent or another is consistently hurtful, is negligent or abusive consistently throughout the "child's" life.  We stop looking because the patient, no longer a child, is really, really sick and needs treatment, understanding and empathy, may be cutting or suicidal.

A narrative points to a story of disappointment, pain, insults and drama, a relationship that never healed properly, one that didn't turn out nice, not like parent-child relationships should.  No fairy tale here.

The therapist sees cause and effect and doesn't like it.  The patient has shopped, priced, and compared, knows that many, if not most people have mothers (fine, fathers, too) who are not insistent upon the child's independence, who care for them when they are sick, who praise, rather than criticize, who don't withhold love, don't slap.  The adult patient is thinking that at some point a human being should stop, should shape up, should become someone who knows how to give.  Parental.

In this process, while talking through the narrative, neither the doctor nor the patient wants to label anyone bad.We tiptoe around the word bad, play with deficient, unknowing, mentally ill, a product of his or her parents. Mama didn't know any better; she is an improvement upon her mama.

Mother's culpability only becomes an issue when reality steps up and delivers.A call from her, maybe, asking for money, or time. Maybe new information from a sibling or a cousin.  Someone posts an old family video, or a picture. Facebook.  Anything and everything can be a trigger.  The patient is going along, doing fine, minding her own business, feeling fairly protected, when suddenly anxiety is off the charts, defenses shot to hell.  Like a broken child, she voices it in therapy:  I'm alone.   I was used to it.  But it is so clear, so painful, how she never loved anyone but herself.  What does she want from my life?  Why can't she just leave me alone? I'm alone either way.

That existential dilemma.

Those of us who have healthy parents have tucked inside healthy introjects, representations of the good mom, the good dad, home and goodness, an identity that gets us through tough times.  When a parent has been grossly negligent, absent, deficient, or terrifying, the child has no positive introject, no soothing representation of family.  When there's nothing inside to lean upon, that existential dilemma, loneliness, becomes a crisis.  Save me, they say, silently.

Sometimes I think I see abandonment everywhere, in every relationship, or its dear cousin, narcissism, selfishness. None of us are perfect parents.  We can't always be there for our children, and sometimes we are all about us.  It's true.  But we try to keep that to a minimum, try to be there for our kids, and we express our love, our undying love.  True narcissists, and people who are sick, sometimes people with addictions, might not want to but they abandon their children.  They are the only ones in the room, the only ones with feelings that matter, and their children miss out, suffer a slow emotional starvation.

In a good therapy we do look for the love, try to find what's below the surface, forgotten good vibes.  We spend hours seeking love in the history, giving people the benefit of the doubt, and we may find splashes of it.  Or not. Or the pickings are just so slim we might look at one another and sigh, agree to abandon the search. 

When we do that, it's okay, it really is. A person can do very well without parents, can find others as mentors, can be loved, protected by someone else. We think we need parents to be secure, but we don't.  So much more goes into being secure.

It's very hard to get to that place, to let go, emotionally, to stop hoping for what might never happen. When there is a cut off, miraculously, the world does not stop spinning.  It even feels safer.  It might be inevitable if a parent isn't amenable to therapy, or won't work on the relationship, maybe has no resources.  Or family therapy didn't work.  Most therapists don't bother trying to work with older parents.  Instead, they become highly adept at engineering sturdier umbrellas for surviving adult children.

The triggers are what make the umbrella something to keep in the car because there seems to be some kind of direct neurological pathway between the Mother event in real time and cutting and thoughts of suicide.  The cutting is to leech the pain or to send the therapist, the good mom, a message. Save me.

I bring this up because it begs an ecosystem solution.  Because I don't want to do the saving, not by myself. We talked about this a little in How to Save a Life.

The modest proposal,  a solution to the problem of judging mother is empathizing with son and daughter.  Since they are unidentifiable, since we don't know who they are and there may be thousands of them, we must empathize with everyone in every social context.  This may seem like an impossible solution, for so many of us simply haven't got the chip, but we know that empathy can be learned, like we all learn a new skill, like stopping at stop signs while driving. Those who don't stop at stop signs will be harder sells on empathy.

I'm thinking people should throw it into conversation, should ask one another, Do you think I'm an empathetic person?  Responses are likely to be honest.   It's a relief, honesty.  Expect to feel defensive but good, for this is a teaching moment.

Empathy works like this in a therapeutic context:
1. Someone complains about Mother.
2. The good therapist only cares about that complaint and how it affects the individual.  It is all about feeling this person's experience, the therapist feeling the patient's pain.
3. Questions apply; answers do not. We ask in order to better experience the pain of the patient.
4. We ask more.  We want to know all about it. Empathy is not about giving answers or suggestions; it is all about questions.

When a person is triggered, distressed, it is safe to say that anyone can be therapeutic by staying with this person, this friend in need. And best is to let the friend go ahead and judge. There might be a few rules to keep in mind.

This is not the time to say,

Give the benefit of the doubt. 
There must have been a good reason for. . .
You might have done the same if you were in that situation.

Not therapeutic, and for a person who has been abandoned many, many times over, the benefit of the doubt is hollow, reasons shallow. And you're likely to hear:
No, I would not have done this, no matter the circumstances.With attitude.

This is not the time to say,

You have to let go of your anger.  Forget about it.

Or worse,

You should confront her. Let her know how you feel.

Send the sheep to the wolf, why don't you.

This is not the time to say,

Forgiveness is divine.

Forgiveness is a process, for some, a lifelong process.

This is certainly not the time to say,

What you should do is . . .What you should have done was . . .

It is a good time to say,

Tell me, tell me about your anger.
You have a right to your feelings.

It is safe to believe that these feelings don't come out of nowhere.

There is a proverb, maybe a mishna (Google it) that says,

Don't speak to a man when he is angry.

The cutting, the suicidal behavior, this comes from a very angry, sad place.

Once the anger and sadness has lifted and healing is palpable, in therapy we talk about alternative narratives. We might rewrite the script, employ visual imagery, all kinds of cognitive behavioral interventions.

Wouldn't it have been great if you could have said. . .?
Why don't you put her in the chair and talk to her, tell her how you feel?

You can do that too, after the anger is gone. Timing is everything. Just be sure not to trigger your buddy again. Less said, seriously.

For it really is okay to judge someone, and it's more than okay, it is therapeutic to let another person judge. Even if it is the very same person who brought him into the world.

therapydoc

PS:  If you judge someone's mother, you're taking a huge risk.  I can say whatever I want about my mother, but you better well not.  That's my mother you're talking about.