John Seabrook, author of the book Flash of Genius and Other True Stories of Invention writes on the subject of Suffering Souls in the November 10, 2008, issue of The New Yorker.
Can new and improved MRI techniques identify and help analysts deal with psychopaths? The psychopath, think characters in a Thomas Harris novel, also falling under the label "antisocial personality disordered," are considered untreatable. Faced with the psychopath's penetrating, mesmerizing stare, the therapist is often reduced to a quivering mass. Or the therapist becomes an enabler of the manipulative psychopath, somewhat in the tradition of the so-called Stockholm syndrome.
Psychopathology is undoubtedly a form of mental illness; but it is distinct, and is not universally recognized as such. Cognitive neuroscience has seen the development of fMRI studies. To date, fMRI studies only reinforce different models of psychopathology. But there are high hopes for the portable scanner developed by Dr. Kent Kiehl. Kiehl is described by Seabrook as a techie whose early training in psychopathology coincided with the emergence of computerized neuro-imaging devices.
Whether Dr. Kiehl succeeds in guaranteeing that psychopathy be accepted as a mental disorder among the cold, calculating, and often urbane people who display it, and whether psychopathology will in time become a "treatable condition," the database Kiehl is amassing, among a population heretofore amorphously identified, will undoubtedly benefit society.
The American Mental Health Foundation applauds this and all research into the unknown abnormalities of the human psyche: which we generally know is, appropriately, the ancient Greek word for the Soul.
Adolescent behavior in its extreme forms is always in the news. The New York Times magazine, just two months ago (September 14, 2008), ran a long story on bipolar disorder in children. Except for the long-term problems associated with aging and senility, adolescence is the most stressful prolonged period of human development. It is complicated and pressure-packed under any circumstances—especially so when caregiving adults are faced with issues of arrested development and disrupted maturation.
Now that preschool classes are under full swing, there may be some parents who wonder if their own child is keeping up with milestones.
A common reaction of all us may be to try to look at the bright side and call this a "stage" or something "that will be grown out of."
Yes, it can be detrimental to label a young child as having a problem.
But yes, it can be even more detrimental to ignore a problem and lose out on helpful educational or therapeutic intervention.
If you have any concerns about your child, ask your preschool director, pediatrician, or school district where screenings are being held to assess any problems that can be addressed.
As a clinical psychologist, I have seen many children helped by these programs.
Under the auspices of LanternMedia, the American Mental Health Foundation has produced a short video about its history and program. You may watch it below:
A wonderful movie was made in 1942. The critics at the time considered it a standard "weepie." Yet, the film Now, Voyager, has stood the test of time. Why?
The title is taken from a short and obscure lyric by Walt Whitman, a two-liner almost of a type out of the still-to-be-developed Imagist School, on the unfulfilled want. Desire. Desire is certainly one of the great motivating emotions of the human world.
But this film is much more. Like The Snakepit, which was made several years later in the same decade, Now, Voyager, centers on a theme of psychoanalysis. Specifically, this movie--starring Bette Davis (Charlotte Vale), Claude Rains (analyst Dr. Jasquith), and Paul Henreid (Jerry Durrance)--is The Ugly Duckling story with a modern analytic twist.
Charlotte is a homely, painfully shy, even antisocial, upper-crust New Englander who lives under the roof and thumb of her sadistic mother. Enter Dr. Jasquith. Through intensive analysis, Charlotte is transformed into a beauty with stunning grace and poise. Liberated, she falls in love with Jerry Durrance, who is married and has a daughter with issues similar to Charlotte's. Everything works out, to some degree, by the conclusion of the film. (Undoubtedly, the Hays Office diluted the central relationships; the story is taken from a novel. But the contours of the story are clear.)
The movie touches on a number of relevant themes. One of the most important: Could psychoanalysis have such a transformative power? Dr. Jasquith is no Victor Frankenstein. Dr. Jasquith cannot create a new person virtually ex nihilo. Truth is, the real Charlotte was always inside her. It takes a talented psychiatrist to reveal the reality within, the core-human within--desire and spirit are unfettered. In her case, Charlotte was suppressed by a jealous, manipulative parent until Dr. Jasquith came along. Charlotte is helped to such a degree that not only could she act decisively and form a meaningful relationship, she could also help a young woman overcome many of the same emotional problems. As the movie begins, the idea that Charlotte would be in a position to help anyone would be laughable.
As played by Claude Rains, Dr. Jasquith is the ultimate film psychiatrist. Unrealistic? To a degree. The process of analysis can be terribly painful. It does not always work, as it does for Charlotte; certainly, not within the confines of a two-hour Hollywood movie. Most analysts could never be the perfect father or mother figure, the God-like figure we secretly crave. But Dr. Jasquith has an uncanny eye and an intelligence that transcends his immediate circumstances.
Now, Voyager, does not delve into the nitty-gritty of analysis--issues involving transference and countertransference for example. What it does beautifully is show, almost as a parable would, how analysis at its best and most effective could change the world for one individual. As the individual's world is changed, so is the world in which she lives.
Thank you for reading this blog, and all our AMHF blogs.
The American Psychological Association, a group of over 100,000 psychologists in the U.S.A., offers helpful information for professionals as well as the public on its website:
Reading this will provide anyone with a greater understanding of bipolar children and the problems that they and their families face.
There is hope for the future, as advances in psychopharmacology, genetic tests for liver enzymes that metabolize medicines, behavior therapy, special school programs, individual therapies, and parent counseling are developed.
We are very lucky that so many talented young people are choosing to devote their careers to helping other people in the mental health field. Here are some ideas on "depression" from a young woman who is studying to be a New York State Certified School Psychologist:
Depression is a disorder that affects all types of people regardless of their
background, culture, socioeconomic status, gender, or age. I think of all the
disorders or problems we will run into as psychologists, this will be most
prevalent (next to anxiety). People often misconstrue depression to be nothing
more than a passing mood that will go away on its own with time. What they fail
to realize is that although this may be the case for some, depression can also
be a clinical medical condition that significantly changes the way one thinks,
acts, feels, or even responds to their environment.
Research shows that depression is commonly mistaken for other disorders such as
such as Bipolar or ADHD. Studies done on gender and depression illustrate that
women are twice as likely then men to suffer from depression. In adolescence,
girls are also more likely to suffer from depression than boys are due to
developmental issues. It is important for those working in the helping field to
be prepared and have the proper knowledge necessary to handle depression.
Depression can have some serious consequences if overlooked. Suicide is one
consequence that is strongly linked to depression. Suicide is a scary topic to
deal with and the worst case scenario for all parties involved. By
understanding and better detecting the different components of depression, we
can work towards early treatment of this disorder and help prevent further
suffering.
On this day of sadness and mourning I'm thinking about a book that Anna Freud wrote during World War Two.
CHILDREN AND WAR was written for the women of London who were holding down the country during the deadly German bombings. These heroic women did just about everything to keep London alive in front-line conditions.
Anna Freud addressed concerns about "how do we deal with the children when we are under continual attack" with special concern for the bombing raids.
One major theme of the book is to always make the children feel safe, keep routines going, even on the worst days where there is bombing, keep the schools going, even if underground, and find courage to find steadfastness within oneself so that fear and anxiety are not transmitted to the children.
One memorable thought will always remain with me: keep the birthday parties scheduled! Even on the worst days, there will be things to look forward to--affirming life and celebrating its presence, even when living in the subways or bomb shelters.
Anna Freud's past treasure of understanding people and events provides at least a modicum of shared experience and ways to cope when things appear to be the darkest. Keeping our children mentally healthy even during the worst of times may be a task we need to be prepared for.
Our thoughts and prayers are with everyone on 9-11-08, especially for those who have suffered directly or lost someone they love.
The contest-winning caption on the Wizard of Oz group-therapy session drawing is in.
The judges went for the cheap laugh.
"And my hourly fee is six hundred dollars. You're not in Kansas anymore." The winning entry is by Bill Craig of Ridgewood, New Jersey.
Mr. Craig has written an amusing caption to be sure. His victory ought to be untainted. It is funny. I am not knocking him. For all I know, he may be a professional in the field.
Unfortunately, the caption does make light, unfairly, of a serious situation.
Am I being hypersensitive and humorless? Perhaps. But the caption plays on the idea that the therapist is in it only for the money.
Would someone "pay any price" to feel better? To feel happy? Do therapists, especially group therapists, exploit the misfortunes of those who seek help?
Just the opposite.
One of the hallmarks of Dr. Stefan de Schill's group work under the umbrella of AMHF was the economic advantage this work offered each patient.
There are six members of the cartoon group. Let's imagine they meet twice a week. That is fifty dollars per patient. Not bad.
When group work is well led, by a professional with the gift for this work that is also well-trained, the special dynamic that emerges over a period of time can have enormous beneficial consequences.
We may laugh at the contrast of big-city Oz with Kansas, as conveyed to the frowning book characters--six-hundred bucks for an hour of listening!--but let's remember this is serious work.
Money is an important aspect to be sure. Dr. de Schill believed that to charge nothing would function as insufficient motivation for almost any patient. It is human nature to work harder when the stakes are higher; when there is an actual investment; when one pays. But those in group sessions benefit not only from the other group members themselves, that special dynamic of self-discovery--and more to the point of The New Yorker drawing--from the reduced fees each member pays.
I have been reading a wonderful book, DRIVEN TO DISTRACTION: Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood by Edward M. Hallowell, M.D., and John Ratey. M.D.
This book brings to a general trade audience wisdom gained from peer-reviewed studies and research. Unlike some books on this topic, there is no ax to grind or ideology to defend. The authors have expertise in both the medical, cognitive, and behavioral treatment of this problem. Much of the attention has looked at boys with ADD; their antics can test the patience of teacher, parent, or saint. Many think boys are overdiagnosed with this disorder. However, girls and adults may be underdiagnosed. The authors offer screening tests and DSM IV criteria for ADD. These can be used as a first step and are obviously not valid for diagnosis.
There are helpful chapters on how ADD enters a family or a marriage and whose presence reverberates around all relationships. This knowledge forms a basis for connecting the person with ADD back into meaningful relationships with those who can offer great support--if the problem is acknowledged, diagnosed, and talked about.
I discovered great wisdom in the chapter that teaches us how to discern the presence of ADD with anxiety, depression, substance abuse, borderline states, and family problems. Are these different manifestations of ADD + another condition or are there many different and unique disorders? Perhaps brain imaging studies and further research and understanding will lead to new categorizations in DSM V and VI.
There are 50 tips on how to manage ADD--each helpful and practical. I especially like this one: "Recharge your batteries. Related to number 30, most adults with ADD need, on a daily basis some time to waste without feeling guilty about it. One guilt-free way to conceptualize it is to call it time to recharge your batteries. Take a nap, watch TV, meditate. Something calm, restful, at ease." (p. 250). Those without ADD may find many of the approaches helpful!
For parents and teachers, there is a section on 50 classroom management tips. This chapter would be especially helpful to therapists who consult in schools.
Is there a genetic link to ADD? Is it present at birth? Is is strictly a neurological disease? How do small environments or even the environment of our culture itself potentiate or even cause the problem?
Many theorists and researchers grapple with this as I write.
Freud started his career as a neurologist and believed that psychiatric conditions over time would be reformulated into neurological ones as our understanding of the brain increased. This poses an interesting challenge to psychodynamic therapists: how do you talk about the presence of this gorilla in the living room, present and powerful in the developmental years of early childhood, cunning and able to disrupt even the best of families, and complicated enough to challenge even the most competent diagnostician? I believe this challenge will be met, and to the benefit of very many people.
In the latter part of the 20th century a dramatic shift occurred regarding the manner in which psychiatrists and other mental health professionals described and diagnosed psychological problems.
DSM I, the first version of the Diagnostic and Statistical Manual, was a modest size paperback handbook providing broad categories of mental health problems. It was the job of the therapist to extensively interview the client and to discover the unique strengths and weaknesses of this person, a full background history, and to work to discover how treatment could help give the person greater psychological freedom. This assessment was something that couldn't be done in an hour. If one were to read different assessments by a master therapist, one would be truly amazed how each was different and captured in writing a unique human being who was striving for psychological health. DSM II continued in this manner.
By the 1980s, insurance began to require more specific diagnoses in order to provide reimbursement. DSM III--a much larger book than either of its predecessors--offered more categories for "illnesses" and very specific criteria for identifying these. "Symptoms" might be very behavioral, such as "obsessions and compulsions for more than one hour per day" or "a chronic disturbance in which 15 or more of the following were present."
It was the intention of the Task Force creating this manual that the diagnoses continue to be a first step and that highly detailed individual descriptions of each disorder would follow.
Unfortunately, the pragmatics of how this manual was used led to shorthand definitions--often with the clinician going no further than the symptoms in the book. Sadly, sometimes the numerical code became the most important part of the assessment.
Under this system, 500,000 people could receive a diagnosis of Major Depression, and a detailed historical and contemporary exposition of the experience (phenomenology) was lost.
The PSYCHODYNAMIC DIAGNOSTIC MANUAL, created by a task force of the American Psychoanalytic Association, offers clinicians with ways to shift away from the specifically behavioral symptoms and to produce a full phenomenology. The book is readily understandable and free from jargon and offers clinicians a companion resource to use when working with the DSM IV TR.
One hope for a future edition of this work is to offer discussion and treatment approaches for older clients and the complex mental health problems they and their families grapple with.
The citation for the book is: Psychodynamic Task Force. Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations, 2006.
Not that I am such a rabid reader of The New Yorker magazine, but in the past several weeks their cartoonists have outdone themselves in relevance to AMHF.
At this writing, the "Wizard of Oz" group-session caption has not been selected. It ought to be final by Labor Day. But the August 25 and September 1 issues again play--literally--on the theme of analysis.
One drawing, by Charles Barsotti (Aug. 25, p. 78), depicts a Freud-like analyst on the right, taking notes with his left hand, while a righthanded baseball player, in full uniform, including glove, is on the couch. "My life is a powerful blast to center field easily snagged on the warning track."
The September 1 cartoon is on page 126, and is by Robert Mankoff. In a shuttered room (which might have been Dr. de Schill's home office), the analyst sits cross-legged on a large easy chair. Like his Freudian confrere of the previous cartoon, the psychiatrist wears thick glasses, which likewise hide the details of his eyes, He sits beneath a framed diploma, with a large lamp, so that he is flanked by the patient on the couch, and the leamp and end table. "But if you cure my hypochondria I won't have hobbies."
Games. Play. And psychoanalysis. What is their relation? The priest-poet Gerard Manley Hopkins describes the mind as a great cliff. Sheer. A place from which the sane could fall at any moment. But there is that playful side, too. These cartoons, as well as TV shows such as "The Sopranos" and "Psych," indicate our self-fascination. They illustrate how quickly and totally emotions can shift, without warning. How there is the comical side to the severe Hopkins poetic world.
This week, we have the three finalists among caption-writers in The New Yorker Cartoon Capton Contest. "And my hourly fee is six hundred dollars. You're not in Kansas anymore." "If you adopt her, please understand that she comes with a lot of baggage." "Home--is there really no place like it? Who'd like to start?"
All come from the group-leading therapist. To remind readers, he is flanked by The Cowardly Lion and Dorothy. The Scarecrow and The Tin Man are next in the circle. Seated in the forefront, opposite the therapist, are a man and woman outside the L. Frank Baum story but nonetheless part of the group. Everyone wears a sad expression.
The New York Times on Tuesday August 12th offers an article describing the problems faced by parents with special needs children when it comes to finding "sitters" or "helpers".
They even report on a national service that can match parents with caretakers.
When one imagines the difficulty encountered just in finding a sitter for a non-special needs child, the task of finding such a person for the special needs child can seem insurmountable at times.
Individuals with Special Needs as well as The Elderly...too often, our society wants us to forget they exist. How much easier it is to turn our heads and pretend that we just don't see.
"What you do to the least of mine, you also do to me."
One of the goals of "The New American Mental Health Foundation," as we embark on our work in the 21st century, is to develop programs for this population. We know this is a tall order. With your support, and the good will of many, in the spirit of our visionary founders that made us the first nonprofit foundation of its kind devoted to research in mental health and well being, we will keep this dream alive.
Dr. David Crenshaw is one of the leading experts on psychotherapy with children and we are grateful to him for writing this for our blog:
Aggressive Children have too many Tears Buried Inside
David Crenshaw, Ph.D., ABPP
The profound losses of those born and raised in extreme poverty; urban youth who grow up in dangerous and crime-filled neighborhoods where exposure to violence can be a daily reality, often cause wounds, both visible and invisible, that in many cases result in traumatic losses, often never grieved. The child or family may be unable to attend to their grief because it would make them too vulnerable and threaten their orientation to survival.
What happens to this buried, unexpressed grief? In many cases it turns to anger, and ultimately to rage. Some of the angriest kids that are encountered in clinical practice are children whose grief was buried long ago in the inner recesses of their psyche. When the losses are compounded and buried so deep that the child can no longer acknowledge the sorrow, the result can be dehumanization of the losses. At this point the child can evolve into what is considered the ultimate menace or threat to society because the child not only loses his or her capacity to feel anything for his or her own losses, but can no longer feel for the pain of others. The child then becomes capable of committing a violent assault or even a homicide without any feeling of remorse whatsoever.
Children, who never develop the capacity for empathy or those children who lose the capacity to feel empathy for the losses of self and others due to repeated, unresolved traumatic losses suffer deep lacerations to the soul. They have lost their sense of humanity as well as their soul.
Dignity and self-respect becomes an extraordinarily vital issue if that is all that children can claim as their own. Many youth who suffer repeated losses experience devastating assaults on their dignity and self-worth as a result of being born into extreme poverty associated with limited educational and vocational opportunities. Some face threats from violent homes, neighborhoods, and schools.
If your very existence is at stake everyday, survival becomes your total preoccupation. It is hard to contemplate a future, one does not dare to entertain a vision, and hope may be dangerous because emotional survival may be contingent on keeping expectations low. How does a child who along with the rest of the family dives to the floor in his or her bedroom to dodge stray bullets from a gun battle in the violent streets outside the home, learn to trust, believe in self or others, embrace hope for a better future? Just staying alive is the challenge of each new day. Many families in our land where great wealth is enjoyed by a privileged few don’t know where there next meal will come from. The pantries in these families are not well stocked. Food for the day is purchased as money allows or not.
Climbing out of the deep hole, the slippery slope of abject poverty is a treacherous undertaking. Just when the family believes they are making some headway, often a child becomes ill, a parent loses his or her job, the car that was barely running is now completely dead, and they find themselves once again sliding to the bottom of that deep pit. If a child grows up in a society that devalues the poor, women, people of color, he or she finds out at an early age that class matters and it powerfully determines what doors will be open or closed to him or her. The devaluing messages will come in many forms but no child can escape the inevitable insult to one’s dignity and humanity. To be judged harshly and narrowly because of gender, race, class, ethnic, regional or national group membership is a dehumanizing experience. It is like an arrow that pierces the soul, a searing pain to the very core of self.
Moreover, an immeasurable number of children are forced to endure aggression as helpless bystanders, watching members of their families and communities fall prey to gang warfare and other acts of violence, all the while living in constant fear for their own safety and well-being. Sexual victimization is another form of violence experienced by children living in chaotic and hostile environments.
What can heal the lacerations to the soul of a child?
Violence can’t be condoned in any way as a solution to our social ills. In fact, violence is ugly, deplorable, and can only lead to further suffering. But, far too long only balm has been applied to the deep wounds that need healing. We need more comprehensive solutions that address the social toxins described so eloquently by James Garbarino in his book The Lost Boys. Until we as a society more adequately address the devastating impact that abject poverty, frequent exposure to violence, the ravaging effects of drugs, the despair that emanates from limited educational and employment opportunities, we will only be applying balm to the wounds.
Due to the shattering of the sense of trust in children exposed to violent crimes and abuse, I have long advocated for intensive individual treatment since the dyadic collaborative therapeutic relationship provides an opportunity for the child to learn to trust again at a pace that is safe and largely determined by the child. For children who have had so little control in their life the ability to determine the pace is crucial. This is not always possible in group and family therapy although those modalities offer some distinct advantages of their own and may be helpful at a later point in the child’s healing. To heal the wounds of an individual child, we must go beyond anger management and social skills training, although these interventions can make a contribution, they do not substitute for addressing in-depth the emotional wounds, unacknowledged and unsupported losses that these children repeatedly suffer. To accompany them through the emotionally focused work of addressing these lacerations to their core self, requires that the therapist be able to deal with profound sorrow and rage.
It is through the experience of empathic acceptance by the therapist that the child can begin to experience empathy for self and others. Children will not tell their stories of pain and trauma unless an empathic healer is present to hear them. The kids can always tell and are never fooled. All too often they have encountered adults who did not truly want to hear their pain and they will only reveal their lacerations to the soul when they are convinced they are in a safe place with an empathic adult they have gradually, after persistent and relentless testing, learned to trust. It is by telling their story and learning it can be heard in a non-judgmental way, and that the pain of it can be borne and tolerated by the trusted other, that they learn their own pain is survivable. They gradually internalize the empathic acceptance of the healer so they begin to empathically accept themselves.
I never cease to be amazed at the hope, courage, and resilient spirit of these children. At the same time we should never assume that no matter how poisonous or toxic the social and economic circumstances of their lives are that these children will somehow manage to rise above it, to be resilient. I have been inspired by a number of courageous and remarkable children, but for every child who incredibly overcome the steep odds there will be many children who will not be able to make the steep climb out of the deep crevice that their lives’ harsh beginnings represent. It is not easy to crush the spirit or lacerate the soul of a child, but it can and does happen, sadly all too frequently.
David A. Crenshaw, Ph.D., ABPP, Founder and Director of Rhinebeck Child and Family Center, LLC (www.rhinebeckcfc.com) Co-author with John B. Mordock of A Handbook of Play Therapy with Aggressive Children and Understanding and Treating the Aggression of Children: Fawns in Gorilla Suits. Author of Evocative Strategies in Child and Adolescent Psychotherapy; Therapeutic Engagement of Children and Adolescents: Play, Symbol, Drawing, and Storytelling Strategies; and an edited book: Child and Adolescent Psychotherapy: Wounded Spirits and Healing Paths. All of the above books published by Jason Aronson/an imprint of Rowman & Littlefield (www.rowmanlittlefield.com )
