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A Psychologist's Thoughts on Clinical Practice, Behavior, and Life

When Families Must Cope With Their Child's Serious Chronic Illness

Parents have varying levels of success in coping with their child's lingering medical illness. This derives from whether "poorer" or "better" interactions are used by their doctors and medical establishments. Some are vague regarded diagnosis and prognosis when communicating with parents while others describe the illness realistically but also focus on possible research breakthroughs and the parents' hopes during remissions when the child lives comfortably at home. Yet family mourning is inevitable since, until the child's diagnosis, they were considered normal and happy rather than chronically ill and suffering.

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Recurring Nightmares and their Elimination

Dreaming occurs nightly but they are not always remembered. The more painful the dream, the more likely it will be remembered and dreams can be painful indeed.

 

A young child dreamed repeatedly of being eaten by wild animals, and for an adult woman the dreams mirrored her continued sexual abuse when a child. Yet eliminating this pain is not rocket science since dreaming has long been understood. And despite their occasional discomfort, all dreams are our friends I tell my young patients. They are movies that we create in our mind to tell what is troubling us, perhaps being afraid of a school test or the like.

 

Interpreting a recurring nightmare, whether of a child or adult, will usually eliminate it. Unless the interpretation was faulty, or incomplete with there being more to the emotional conflict that it symbolizes with the person being unable to resolve it at that point in their life. An adult's nightmare that persisted for decades took three years and two interpretations to disappear completely, there having been important personality changes needing to occur first. The initial interpretation reduced the nightmare's frequency but a timely, second interpretation was needed to eliminate it.

 

There is a logic to nightmares just as with physical symptoms. A fever disappears when the infection is gone, as does a nightmare when the emotional conflict that it symbolizes is resolved.

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Why Fanciful Explanations of Autism Persist

While parents rarely feel guilty when their child becomes physically ill, this is not true when they develop emotional problems. Autism is perhaps the most affected of these attitudes which, in its severest form, devastates family life.

 

Though recent infant research has confirmed what clinicians have long sensed, that the parent-child interaction plays an overwhelming role in its development, denial of this fact persists. Thus we read of continued, failed attempts to relate autism to vaccines or pollution or whatever, any cause but parenting. This is understandable since the sight of a severely autistic child horrifies and no parent would willingly accept blame for this.

 

All children have strengths and limitations, as do parents who had their own childhood struggles. A parent's personality must mesh with their unselected child and mismatches naturally occur. The unconscious is very powerful, and one must recognize its power. Thus, once a child's emotional problem is recognized and help for it is sought, any parental guilt is undeserved and counter-productive.

 

A positive thought is that autism is vastly and inaccurately over-diagnosed. In my long experience, in both medical and psychological settings, I have seen fewer than five severely disturbed, self-mutilating autistic children, and fewer than twenty diagnosable autistic children with lesser symptoms. Moreover, young children whose behavior exhibit some autistic features can have these symptoms disappear through ordinary play psychotherapy, sometimes in just a few months. And with lengthy, extensive services, major change can be made in even the most disturbed autistic child's life.

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Failure and Success in the Psychotherapy of Autistic Children

The aloofness noted in autistic children often becomes a self-fulfilling prophecy when their therapist considers it a given, something amenable only to simplistic reward/punishment behavior modification techniques. But the autistic child does have relationships though these are inadequate and require nurturing through play therapy.

No special techniques are required since the basic difficulty of autistic children is communication and play is the primary language in conducting psychotherapy with children. Thus, autistic children must be related to individually with their aloofness not being taken as a rejection of interpersonal contact but merely their inadequacy at it. A recent study found that most infants, who had communication difficulties associated with autism in their second year of life, were later no longer diagnosable as autistic when their mothers were given early intense instruction in communicating with them.

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Why the Unsophisticated Diagnosis of ADHD Persists:

The Attention Deficit Hyperactivity Disorder (ADHD) diagnosis persists despite it possibly being the most unsophisticated notion in mental health for the past two-hundred years. In the late 1700s an English physician described the symptoms as "mental restlessness." In early 20th century America it was described as Minimal Brain Dysfunction (MBD) of which a Harvard psychiatrist remarked that any doctor who uses this diagnosis has a minimal brain dysfunction (a cute remark, I think). ADHD is merely its latest incarnation and makes no sense with more diagnoses on the East Coast than the West Coast and more boys than girls, apart from its symptoms being identical to anxiety and depression.

 

In both children and adults, when these symptoms are present and not related to real worry or unconscious conflict, they reflect Elements of a Borderline Psychotic Psychostructural Organization. Which does not mean Psychotic or Borderline Psychotic but rather a weakness of basic ego capacities because of faulty early developmental experience which occur during the first three years of life and affect the development of reality testing, mood regulation, sense of self, and control of behavior and thinking.

 

The ADHD diagnosis has persisted, I believe, for a number of reasons:
1. Large, profitable mental health and pharmaceutical industries have grown up around it.
2. Ego psychology has grown out of favor with a consequent dearth of education of clinicians on sophisticated early life ego and child development. My (long deceased but still mourned) doctoral advisor once said that to understand human behavior one must go to psychoanalytic concepts, that there is simply no where else to go, and I agree.
3. Sixty years ago most psychiatrists provided therapy but today few do, apart from those who have had psychoanalytic training and these are not many. Thus, apart from reasons 1 and 2, they prescribe drugs. Which, alas, some parents demand and doctors comply. As a mother once said to me, she would rather that her child had a brain tumor than an emotional problem since a tumor could be cut out. Most new patients don't know what therapy is and must be educated.

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Gabrielle Petito's Murder and Freud's Benediction on an Unmarried Psychiatrist

While not downplaying the power of unconscious motivation, Petito's murder, which is not unusual for abused women, might have been avoided had she followed one simple rule: to better know your partner before becoming intimate.


Nearly a hundred-years ago, an unmarried American psychiatrist underwent his training analysis with Freud in Vienna. This then lasted six months and, at their last meeting, Freud expressed the wish that the doctor be lucky enough to gain a happy marriage. "With all your psychological knowledge can luck be a factor?" the surprised doctor asked. "Of course, because one cannot know someone without living with them for a long time."


Thus Freud's good advice for all: It takes a long time to know someone. Take it.

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The Inexaustable Strength of Mothers

My experience with treating mothers has long impressed me with their strength. Despite their continuing daily tasks of tending to wandering-about youngsters, seemingly incomprehensible teenagers, difficult husbands, and an occasional sickly rabbit or other pet, they cook, clean, negotiatate with school officials, provide transportation to appointments, and cope with such intermittent crises as helping with children's homework and arranging for home repairs. All while trying, and often failing, to care for themselves.


Part of this is inevitable since, in most families, the mother is the emotional center of the family, which also makes her the major recipient of children's complaints. If a child is unhappy, it's HER fault. Is this fair? Of course not but that's how it is.


Which is not to say that the father's role is unimportant since, though the mother (or mothering figure who can be a male) is the most important figure during the first two years of a child's life, the father becomes equally important during their third year, serving to pull the child from the symbiotic relationship with their mother into the larger world and, ultimately, independent adult functioning.

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Why Some Youth Can Benefit From Psychotherapy and Others Can't

Critical psychological development is gained early in life. Later, this may not happen even if the patient is provided the most talented of psychotherapist.

Change is difficult and some cannot tolerate the inherent dependency of this type of treatment. A teenager or young adult may need a firmer path in life before they can accept this childhood-like experience that they struggled to escape though there are great differences between the two. Unlike during childhood, a therapist does not make demands, even that of being liked. Their goal is merely that their patient's goals be achieved, so long as they are healthy and some  of which they may be unaware.
Yet for some youth the completion of education through college or graduate school or technical training comes first. They must try to ignore their anxiety and depression until the better day when they feel confident that they can--independently--survive financially in the adult world.

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What the Deadly Disorder, Anorexia, Really Reflects

One crucial task of early childhood is for a child to develop a secure sense of who they are or, as psychologists call it, a sense of self. This ordinarily occurs naturally through a child's continuing interactions with their parents but if these were inadequate, the child's poorly developed ego capacities are unable to cope with severe stress, particularly when the powerful feelings of adolescence arise.

 

Then, symptoms occur with low self-esteem being the least severe. More troubling symptoms can include confusion about their identity or even personality disintegration (psychosis).

 

Anorexic symptoms typically arise in adolescence when there is a need to integrate powerful feelings within the personality. Feeling vulnerable and the loss of control over their body, which the ego's Executive Function provides, the teenager attempts to bolster their self-esteem and gain a sense of control over their body through concrete actions: obsessive focus on their body and diet, and constant exercise.

 

Because the anorectic person lacks awareness of the connection between these behaviors and their underlying fragmented personality, they tend to resistant psychotherapy. This, despite anorexia having the highest death rate of all the mental health conditions.

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Normal Lingering Grief

Watching the current Netflix documentary on the 9/11 terror attack aroused my teary memories: walking through Manhattan's Grand Central Terminal soon after with its posted photos of missing loved ones who were almost certainly dead, and at a later 9/11 memorial. This, though knowing none who died in the attack.


Contrary to popular belief, there is no normal way to grieve. Some initially cry, others cry years later, and some never do. Having dreams in which the deceased lives and speaks is common. The anniversary of a loved one's death can have a powerful impact with some tearfully describing it long after. A relative's death is occasionally even positive, liberating healthy autonomy strivings after an overpowering, destructively possessive relationship has ended.

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