DIRECTORS'S COLUMN

By Seth Warren, PhD

As I was just completing the finishing touches on my December column, I wanted to reach out to our members and talk about Sandy, the feelings of trauma we all shared, the more serious losses some of our members experienced, and to wish all our community well for the holidays.

But just now the news about the shooting in Connecticut broke, and something changed for me; I no longer felt like just going on with my routine. Another horrific tragedy, mindless violence, sadness, and then, back to business. Back to my work, back to the laundry, back to my holiday shopping, back to my Director's column.

I thought of Auden's poem, Musée des Beaux Arts:

About suffering they were never wrong,

The Old Masters: how well they understood

Its human position: how it takes place

While someone else is eating or opening a window or just

     walking dully along...

In Breughel's Icarus, for instance: how everything turns away

Quite leisurely from the disaster; the ploughman may

Have heard the splash, the forsaken cry,

But for him it was not an important failure; the sun shone

As it had to on the white legs disappearing into the green

Water; and the expensive delicate ship that must have seen

Something amazing, a boy falling out of the sky,

Had somewhere to get to and sailed calmly on.

In the immediate aftermath of this event, I cannot tell if this time it will be different. Other horrific such acts have happened, all too many of them, and somehow we manage to go on with our own small lives, to "sail calmly on." At the moment it feels different. A part of me does not want to accept this, some kind of grotesque new "normal," just part of life now in our world of disconnected and distraught people with easy access to the most murderous of weapons. The murder of twenty small children in their elementary school classroom seems to reach a new, and finally unacceptable, place of horror.

Have we, as psychoanalysts, anything to say about such awful acts? Any insights to offer a world so damaged by atrocities like this? People are already beginning the search for motives, to understand the reasons for an act such as this. The killer is being diagnosed in the media, "psychopath," "psychotic," "insane," just evil. These words all seem rather futile in the face of such violence and loss. I remember a movie, Antonia's Line, in which one of the protagonists, a young girl, is raped by the town psychopath, and she turns for consolation to her beloved mentor, an elderly philosopher played by Max Von Sydow, who, holding her in his arms and weeping, declares that "the world is filled with demons and monsters!" That comes closer for me.

What to do with the demonic? What to do with the unbearable? What to do with the knowledge - yes we know this, because this is the simple and unavoidable conclusion - that there is something in the unconscious that seeks to destroy, of all things, the most beautiful, the most precious, and the most innocent?

At this moment I do not wish to "sail calmly on," although I know that life will continue as always. I do not wish to engage in politics, though I know that this society undoubtedly can do better. I do wonder if something meaningful can arise from this unspeakable violence.

I wish you all a safe and peaceful holiday season, a peaceful new year. I look forward to seeing you all at our January holiday party.

"May all sentient beings be free from suffering and the causes of suffering."

http://www.ibiblio.org/wm/paint/auth/bruegel/icarus.jpg

(Editor's note: This piece was posted on the NJPA listserv this week, and we thought it would be both timely and helpful to reprint it here. Readers are welcome to contact the author. Some links to other useful articles are also below.)

Thoughts on Talking with Children about the Connecticut Tragedy

Guest Author: Tamara Shulman, PhD, FAACP, ABPP

When something so tragic and terrible occurs, there is really no one way to talk with kids. My experience consulting after 9/11 confirmed that each child and family is different and will need different ways of processing this tragedy. Children with experiences of trauma and loss, anxiety and other issues may be particularly vulnerable. Children directly involved will need specialized support and intervention. But many more children will be emotionally affected by today's events.

I'm sharing some thoughts on what may be helpful to the children, parents and others in my professional and personal life.

One thing that parents can do immediately is limit a child's exposure if the child is not directly involved. Parents are also anxious and upset-we all are-but keeping the television news on or discussing this at length when a young child is present intensifies the child's anxiety and experience of danger. Children may not perceive this as a rare event, upsetting but also distant from their own life, if it is replayed constantly in their home. A common distortion is that the event is occurring repeatedly when it is seen repeatedly.

Children need to be reassured that they are safe, that the police came right away and helped everyone they could help, and that parents will come right away if there is any danger. We cannot promise safety but parents and therapists can help with perspective and responsiveness. Listen and accept the child's feelings. It is harder than it sounds to listen when you cannot "fix it", but really listening is very useful.

Sometimes children's feelings of helplessness are helped by doing something active, such as making a picture or card to send to the school in Connecticut. This is not meant to minimize this horror at all-only to suggest finding ways of not overwhelming children who are not directly involved. Slightly older kids are already seeing this online and more direct discussion is needed. The adult should follow the child's level of concern  and listen sympathetically. Parents can also be alert to changes in sleeping, eating and other behaviors that may suggest a need for professional advice. Separation issues and anxiety symptoms may increase among school age children.

Tragedies like this also dramatically affect parents and professionals-we need to be aware of our own feelings to be helpful, and sensitive to how frightening this is to parents and other adults as well as children.

Psychologists in school settings will be responding to these issues but on a Friday afternoon many parents will be on their own helping themselves and their children make sense of their feelings. The tragedy is senseless, but feelings are not. Listening to children and acknowledging their feelings can be comforting, even though we cannot explain or change what has happened. There are no simple answers but there are ways to genuinely help.

Tamara Shulman, Ph.D., FAACP

Board Certified in Clinical Psychology, ABPP

NY Lic. #6444; NJ Lic. #SI-1332

340 East 64th Street, 2nd Floor, Suite 7, NYC, NY 10065

925 Clifton Avenue, Suite 103, Clifton, NJ 07013

212-980-0578

973-471-9506

Fax:  212-980-0578

E-mail:  tshulman@att.net

http://www.tamarashulman.com

Links to Useful Articles 

Practical Suggestions for Assisting Children in the Aftermath of a Tragedy 
( http://www.aaets.org/practicalsuggestionschildren.pdf ) 

- Parent Guidelines for Crisis Response 
( http://www.aaets.org/parentguidelines.pdf ) 

- How Do People Respond During Traumatic Exposure? 
( http://www.aaets.org/during.pdf ) 

- Helpful Information During and After a Traumatic Event 
( http://www.aaets.org/helpful.pdf ) 

Our Events: A Workshop with Dan Hill, PhD: Theories of Affect Regulation: An Overview 

By Marion Houghton, EdS, LMFT

On October 14, 2012, Dan Hill, PhD, member of the NYU postdoc faculty and founder of the PsyBC website, returned to CPPNJ to elaborate on the presentation he made at the Rutger's Women's Center last spring. His talk was extremely well-attended and enthusiastically received by the audience.

Dr. Hill acknowledged John Bowlby as the key figure in the history of attachment theory. When Bowlby began advocating for attachment research in the 1960s he quickly succeeded in alienating the entire psychoanalytic establishment, according to Peter Fonagy (Other Press, 2001) who addresses this historical reality in his writing, saying that there was "bad blood" between the two camps.

Dr. Hill describes two branches in the evolution of attachment theory. Classical Attachment Theory begins with John Bowlby and continues with the work of Mary Ainsworth (Strange Situation), and Mary Main (Adult Attachment Interview) and culminates in the current work of Peter Fonagy, et al., which focuses on "states of mind" and "mentalization" as ways to think about how attachment is regulated between individuals. The second branch also begins with Bowlby and Ainsworth and then is further elucidated in the modern work of Allan Schore. Dr. Schore's integration of attachment theory with developmental neurobiology and infant studies has transformed it into a psychobiological theory of affect regulation which Dr. Hill calls Modern Attachment Theory.

On October 14, Dr. Hill spoke as an advocate for Schore's theory of affect regulation, and identified four components of this clinical model:

                        A Theory of "Bodymind"

                        A Theory of Development

                        A Theory of Pathogenesis

                        A Theory of Therapeutic Action

In Dr. Hill's words, "nothing is more basic to the survival of the human being than the affect regulation of the 'state of bodymind'." He described the regulated "bodymind state" as optimal for development, whereas hypo- or hyper- arousal involves some degree of dissociation. Dr. Hill emphasized that the infant is born incapable of self-regulation and that it is the attachment bond that facilitates the early processes of implicit communication between caretaker and infant that are the medium for right brain-to-right brain attunement and affect regulation. According to Schore, the attachment system is activated by fear, and the caretaker functions as a safe haven or secure base from which the infant can explore. Dr. Hill noted that the therapist becomes the new attachment figure, especially for patients who have a background of moderate to severe relational trauma.

For those of us who are interested in the implications of doing clinical work as new attachment figures for our patients, Dr. Hill will be discussing a theory of therapeutic action in Part 2 of this seminar which will be held in early 2013.

Faculty Forum with David Appelbaum: Under the Microscope: Inquiry as an Interpersonal Technique - December 2, 2012 

Lenfell Hall provided the appropriate setting for an intimate discussion among CPPNJ analysts and associates with David Appelbaum as our guide. He gently raised the topic of inquiry as a valuable tool that has sometimes been "underappreciated and underutilized" in the history of psychoanalytic practice.

Dr. Appelbaum observed that in an effort to understand unconscious content, we may be distracted from asking about what is "right there" in the therapy session. He cited some historical voices opposed to asking questions-e.g., classical psychoanalysis promoted "free association" as the preferred technique. He asserted that with the emergence of the interpersonal perspective (Harry Stack Sullivan, Edgar Levenson, and Alan Cooper) inquiry became essential. Sullivan advocated looking for gaps in the patient's narrative as a way of helping a person to deal with "problems in living."   Sullivan viewed the gaps as evidence of anxiety, which he viewed as causing "selective inattention" in the patient. Dr. Appelbaum explained that people's life stories have missing information due to tremendous anxiety that we as therapists need to appreciate in order to help our patients discover how to live their lives differently.

According to Appelbaum, interpersonal analysts see themselves as "participant observers" and inquiry as participation in the therapeutic process. Inquiry is where the action is... it shapes the relationship with the patient and works the patient's process. "It's like riding a wave together."

That is how the presentation played out with David Appelbaum: the interactive process he elicited from the audience captured the spirit of inquiry. We all became participant observers.

Book Review

Anatomy of an Epidemic. Whitaker, R (2010). New York: Crown Publishers.

Reviewed by Claire Vernaleken, PhD

Practicing psychologists may be initially skeptical of Anatomy of an Epidemic. Robert Whitaker, neither a health care practitioner nor a researcher, is an award winning writer who has served as a watch dog on the use of pharmacological research and practice, which has demonstrated the dangerous 20-year trend between 1974-1994 of worsened treatment outcomes for people with schizophrenia, depression, ADHD, and bipolar disorder as well as the surprising finding that schizophrenic individuals from poorer countries demonstrate better outcomes than wealthier countries, with a possible explanation being that individuals in less wealthy countries receive less medications than others.

Whitaker explains that the 50-year rise in biologically based treatments beginning with Thorazine and moving towards the SSRIs, should have plausibly led to a reduction of psychopathology and disability from psychiatric conditions. However, this has not been the case. Whitaker highlights the opposite trend: a greater percentage of adults and children being diagnosed with mental disorders over this time span.

Whitaker also investigates the development of many pharmacological agents by his review of medical libraries dating back to the 1800s. The author reveals how many commonly used psychotropic medications were "discovered" by happenstance, how medications designed for non-psychiatric purposes soon became a psychiatric staple based on their emotional and behavioral side effects. This means that many of the most widely used "psychotropic" treatments were not specifically developed for the mentally ill.

Thorazine, Miltown, and Marsiled, for example, were developed for the treatment of infectious diseases but were discovered to alter mood, behavior, and thinking with such side effects presumable to help psychotic patients. Additionally, Chlorpromazine, a major tranquilizer, acted similarly to a frontal lobotomy while Meprobomate, a minor tranquilizer, blocked emotional responsiveness. The chemical imbalance theory was created from the idea that these drugs altered something and that was sure to mean there was a biological abnormality present.

Whitaker examines the limitations of "double blind" methods within psychiatric research by reporting on the typically short-term durations of most clinical trials, usually no more than six weeks and how many results revealed there were higher rehospitalizations rates for patients taking the drug than within the placebo group. There is also a questionable utility to "double blind" when both administrator and patient know active drug is being used rather than placebo, where unlike drugs that do not alter mood or behavior, the patient and doctor will observe drug effects. Why did some patients become more vulnerable to psychosis over the long-term when using these drugs? By the 1970s there was more evidence to suggest the counterproductive effects of medications in treatment for mental disorders, including depression, bipolar disorder, anxiety disorders, and ADHD than was previously discussed and those treated with drugs seemed to have poorer recovery rates than those treated without medications.

Whitaker discusses the use of current cocktails and references data by stating   "400,000 children with newly diagnosed bipolar disorder arriving via the ADHD doorway and 500,000 through the antidepressant doorway." He alluded to the issue of drug side effects and withdrawal symptoms being similar to DSM-IV diagnostic criteria. He reports one study after another where presumably the "chemical imbalance" view of psychopathology is unsupported. and proposes that psychotropics may have a negative impact in the context of no clearly defined biological causation or dysfunction.

Anatomy of an Epidemic also reports on data linking neurotransmitters to mental illness: serotonin to depression and dopamine to schizophrenia and how studies at major universities and institutes failed to support the notion that 5-HIAA (5-hyrdoxyindole acetic acid), a metabolite of serotonin, would be low in psychiatric individuals and that within groups of psychiatric and non-psychiatric subjects there was wide variability. Similar studies on the role of dopamine failed to support the premise of elevated dopamine levels in schizophrenics and additional research suggested that individuals on long-term psychotropic medications were hypersensitive to dopamine. By the 1980's the dopamine theory of schizophrenia had been challenged. In 2001, Steve Hyman, now provost of Harvard University, then the Director of NIMH confirmed that antipsychotics and antidepressants do not normalize brain chemistry, they disturb it. Because of the disturbance of the bodies own normal feedback loops, that is the titration of chemical levels in relation to the body's production, patients treated with these drugs now had a disturbance in their own capacities to produce or shut down these chemicals.

A closing section of the book directly implicates the role of money in mental illness and the ways it stimulates the continued championing of medications in mental illness arvard University, then the Director of NIMH confirmed that both these classifications of drugs do not NHhh "Bipolar disease, once very rare, is now said to inflict 1-2 percent of the adult population and if the 'intermediate' bipolar disease is to be counted, 6 percent," Whitaker reports. As this diagnostic expansion happened, pharmaceutical companies and their allies mounted "educational" campaigns making both the illness and medications household names. There is lots of money in mental illness: money not in the form of documented and reliable treatment but in the production of drugs, asserts Whitaker. And if we believe what is unproven, we are wasting valuable time and resources and contributing to suffering.

Anatomy of an Epidemic is sure to transfix the reader. A riveting text challenging commonly held beliefs about biology, mental illness, and the role of medications, there surely will be those within and outside the health care field who question Whitaker's assertions, potential biases, and his credibility, given he is not a researcher or practitioner. To that, I urge one to read the book, as it is a must-read for mental health professionals.

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Thank you for joining us. Look for our next newsletter in January 2013.