Self-regulation, toxic stress, and Baltimore.

On first sight, you might think that the title of this article leads to one of those four-part pictures from Sesame Street entreating you to decide “Which One of These Things Doesn’t Belong”. Actually, all three of the subjects in the title do go together, it’s just uncomfortable to confront that knowledge.

So, let’s break it down.

Self-regulation is a set of skills that stretch between the domains of cognition, emotion, and and behavior that allow adult humans to make good, prosocial, rational, decisions even under stressful conditions. This group of abilities is based on healthy brain development in the early years, which is fueled by good-enough parenting, and the meeting of the basic physical needs of food, water, and shelter (there is some debate about which is most damaging to forfeit, and the front runner may be the parenting). When things go right for a baby, s/he develops the capacity to regulate her own emotions, thoughts, and actions well enough to fit in socially and survive to adulthood. When things don’t go well, self-regulation may be delayed or halted in one or more domains. A kid or adult with crap self-regulation abilities might appear hostile, aggressive, violent, smart-mouthed, withdrawn, anti-social, hyperactive, lethargic, or unfocused. Other things can cause those behaviors, but quite often, self-regulation is the real culprit, especially when kid is exposed to what’s called toxic stress. Here is a recent research brief about this little combo, read it if you want more depth that a blog post can provide: http://www.acf.hhs.gov/programs/opre/resource/self-regulation-and-toxic-stress-foundations-for-understanding-self-regulation-from-an-applied-developmental-perspective. It’s fascinating.

Toxic stress is different from everyday stress in terms of frequency, intensity, and duration. Most people have some aggravations, annoyances, and frustrations every day. Folks with toxic stress have catastrophic, life-threatening, chaotic, terrifying stress every day, all day. Toxic stress is a nightmare for anyone trying to develop or maintain mental and physical health. There’s a mountain of evidence about ACEs (Adverse Childhood Experiences) and the nasty things too many of those can do to a person over time. Check out the ACE home page for the numbers: http://www.cdc.gov/violenceprevention/acestudy/

Lastly, Baltimore (and Ferguson, and North Charleston, etc. etc.).

The (White) police have been shooting up Black folks again. That this happens isn’t news to most people. That it is continuing to happen so often and that so many local jurisdictions haven’t done anything to assess or change the systems that set up the circumstances that foster these murders is shocking. For Black and brown people living in places with a high load of toxic stress, that’s the last straw. Toxic stress is literally poisonous. Chronically elevated levels of cortisol and other stress hormones cause the kidneys, heart, and lungs to overwork. Soft tissues like veins and arteries wear out early. In childhood, people exposed to too many ACEs face an uphill battle towards mastering self-regulation in all three domains. Regardless of gender or race, a person growing up amidst toxic stressors develops self-regulation later and less broadly than the same person would in a more safe and stable place. When an adult with a high toxic stress load and low levels of self-regulation is attacked, threatened, or in a hostile-seeming situation, he or she is more likely to react with violence and aggression than a person who lives somewhere safe.

This is not to say that adults shouldn’t be held responsible for damage they do while enraged. However, in places with high levels of toxic stress, no one should be surprised when the proverbial shit hits the fan when yet another citizen is murdered by the police. One of many reasons that the death of Walter Scott in South Carolina and Freddie Grey in Maryland provoked such extremely different reactions from the public was the response of the people who were perceived to be in charge. Although both cities have high levels of toxic stress, the officer who killed Scott was immediately arrested and fired from the force. In Baltimore, no arrests have been made, no announcements from the authorities have been made about suspending the officers involved, and it seems to the citizens there that no one cares. Both cases are obviously tragic and have provoked anger and grief in their respective communities.

In Baltimore, people who are already tired of not mattering have been reassured that they don’t. In North Charleston, it seems that the police force has found a way to communicate to its people that they do matter. When you’re already up against a wall, the last thing you need is someone to shove you up to it harder. That’s when people, many of whom are already short on patience, break. The limbic system essentially stops asking the upper levels of the rational brain for input, and action takes over from reason.

I wish I could close this little rant with some smiley sentence about things getting better. I am glad that Science has now empirically validated how important early environments are to healthy adult development. I am grateful that interventions for schools and clinics are in the works to help stressed out kids learn to self-regulate earlier and better. I’m left wondering if any of it matters.

Book review: Four Ways to Click, Amy Banks (2015)

Amy Bank’s first book, “Four Ways to Click” (2015) New York: Tarcher/Penguin, distills the wisdom of the magnificent Jean Baker-Miller’s theories, infuses them with a new dose of relevance and importance via recent neuroscience findings, and pours out information written for a general audience.  Dr. Banks, who is also a practicing psychiatrist, had some help from professional writer Leigh Ann Hirschman making these ideas come across in such simple and basic language, and I’m very grateful for that. I’ve been at a few training sessions Amy has led over the years, and I always leave feeling like my brain has over-indulged, much like my tummy feels right after Christmas dinner. Her ideas are brilliant, and in this new format, even normals like myself can get a firm grasp on them.

True to its title, the book breaks Dr. Miller’s Relational-Cultural theory (RCT) ideas down into four basic bites: Calm, Accepted, Resonant, Energetic (CARE for short). Each of the four bites,which she calls pathways, has its own chapter, where Amy explains what brain and nervous system parts have to engage to make that bite happen. She also tells us what emotional and behavioral symptoms emerge when that part is out of whack.

Two other key components of this book are the “3 rules for brain change” and a self-scoring assessment readers can use to determine how well balanced (or not) they are with the four basic relational pathways (The CARE parts). The three rules aren’t new to anyone who’s been reading the newer neuroscience books, especially the applied texts. The rules all relate to basic science about neuroplasticity, or what it takes to create new automatic or default thoughts and behaviors. It really boils down to the fact that you have to practice – a lot- to make changes permanent. It’s nice to have the brain science explained, although telling readers to practice a lot would be ok, too.

The self-assessment is pretty handy. It doesn’t purport to be psychometrically sound, which is fine, since it’s not being used as a true diagnostic tool. I was surprised that there doesn’t seem to be (unless I overlooked it) any reference to Liang,et al and the Relational Health Index, which has been around for several years and is quite similar to this scale. Amy’s CARE Relational Assessment is tailored to fit within her framework, while the RHI is designed to fit under the more broad RCT frame. I don’t know the back story on this part of the book, but it does make me scratch my head a bit. The RCT world is small and deeply connected. Amy took pains to thank a lot of people in the acknowledgements section, but the RHI team aren’t there.

I found this little volume (it’s only about 300 pages, with the index, notes, table of contents, etc.) to be very accessible, and I imagine that clients who have at least a 10-12th grade reading level would find it interesting and helpful. I read most of it while waiting for an oil change to be completed, and found it very engaging. I’m encouraging my graduate students to pick it up as a good resource to recommend to their clients who are struggling with out-of-whack neural/relational pathways. It’s a nice introduction to how the brain influences and reflects our relationships, and understanding that interplay can be a life-changer for clients.

Repotting time

My mama says lots of memorable and useful things. One of her best is about the periodic need people have for repotting. If you’ve ever had a house plant, or a garden, you know what happens when you get lazy and let the thing grow so big that the roots end up molding themselves to the pot. The same thing happens to people. Some experience it more often than others, but at some point, we all feel the need to move into a new pot. Our roots get all bound up. We can’t get enough spiritual nutrients. We begin to droop. Mama says, it’s time to repot yourself. Note that she doesn’t say, ask someone to repot you. It’s a thing you have to do on your own, albeit with help, most times.

I’m feeling might root bound lately myself. The pot I’ve been in for the last seven years is feeling too tight. There’s no room for growth, and I’m constricted.

Noticing that it’s time to repot one’s self (again) is simultaneously terrifying and invigorating. No one who’s ever changed jobs or careers or partners or towns is a stranger to that feeling: standing on the event horizon of an exciting new start, terrified to step out into it. I’m at the tug-of-war stage of repotting just now (I’ve done this several times as an adult, I’m starting to see the patterns). I know my current gig isn’t doing it for me anymore in terms of allowing me to stretch in productive, growth-fostering ways-but it’s steady. In particular, the paycheck is steady, and that’s a major consideration at midlife.

So, how to decide when and where to plant myself next? Jean Baker-Miller, who was always decades ahead of her time (her “New Psychology of Women”, written in the 1970s, is still revolutionary) is helpful with questions of repotting. While Dr. Miller intended her list of 5 good things to be an evaluation tool for interpersonal relationships, I find that it works for careers as well. Her 5 good things are: increased creativity, increased clarity, increased self-worth, desire for more (in her case, relationships, in mine, projects related to a career position), and increased zest or energy.

When I think about my current gig as a  graduate school professor, I find that I see it now as energy-zapping, ego-deflating, and generally something I need a break from, rather than something I want to do more of. Seven years ago, when I finished my PhD and began my first job  as a professor, I felt the five good things keenly. I felt creative about my teaching strategies and ideas for curricular changes, I felt good about myself based on my new status as a professor, I felt that I’d have time to do the things most central to my mission in this life: advocate on behalf of children and women, write about those issues, and help younger people learn to be effective therapists. Although there were the usual ups and downs; stupid meetings, stupid decisions by pointy-headed administrators, and difficult co-workers, the balance sheet still came out in the positive- until recently.

Now when I look at JBM’s five good things and think about my work, I get frustrated and angry. I don’t have those things at work anymore. We’ve had some big personnel changes in the leadership of the university over the years, and the cumulative impact is that my responsibilities for record keeping and nose counting keep climbing, while at the same time, I matter less and less to the institution and loose my creative freedom a tick at a time.

This slide in balance hasn’t been particularly dramatic. I imagine it’s the same for most workers in organizations at different times. Day by day, my sense of mission and accomplishment has shrunk, while my sense of being forced into a too-small pot has increased. It’s now time to find a new pot.

During the next year or so of transition, I know I need to refocus on my overall mission for this life. I need to stretch creatively and loose 99% of the administrivia in my life. That much is abundantly clear. I’m still working on the details, which means I need to spend a lot more time doing creative thinking and processing (I LOVE the new adult coloring books by Lacy Mucklow & Angela Porter- they’re perfect for focusing thoughts) and talking to folks in the new line of work where I’m planning to plant myself.

If you’re in a similar situation, I encourage you to use JBM’s list of good things. If your current gig isn’t meeting those, what are your options? Can you make enough changes in your work setting to make a difference in the goodness? If not, what’s your ideal pot? If you don’t yet have a clear overall mission for your time in this life, now is as good a time as any to meditate on that and start forming ideas about what shape of container would best support your progress towards those dreams. And a bit of gardening advice- rootbound plants don’t bloom.

Ghosts

In the past week, my family lost two Grande Dames, the likes of whom we shall never see again. They were sisters. The elder died unexpectedly, the younger faded out after a long period of debilitating illnesses. Loosing one of them would have been tough, loosing them both almost simultaneously can only be described as shocking. Their relatives joked that the younger sister was always afraid of being upstaged by the elder. so she had to go out at the same time just to have a nicer funeral- that actually might be truthful in some way.

While I was travelling to and from and around the two funerals (both in a small town down south, where my people have lived for many generations) I was struck by the feeling of being watched, followed, seen by unseen eyes. It is quite likely that this feeling was a by-product of stress (the air journey was awful, delays and changes galore) and sadness. However, I think the core of it is more opaque and dense than simple stress.

I’ve made the choice to do as many Americans before me have done; I’ve gone west (and east, and north, and south at various times) to find my fortune. I’ve left home, answered what Joe Campbell referred to as the hero’s call, packed up my knapsack, and gone. Most of the time, this feels right and as it should be. I can’t imagine how restricted and confined I’d feel if I still lived in the town where I grew up. It’s a perfectly good town, but the world is huge, and I aim to see most of it.

It’s a good thing I have the wanderlust- it’s nearly impossible to be an academic and stay put. Higher education demands mobility, at least early on in an academic career. Most professors are not-from-around-here. The idea behind that is to inhibit intellectual inbreeding, which is important when designing universities. You really don’t want all of the professors at State U to be from that state.You’d have a very limited view of life that way.

On the other hand, having all these islands of outlanders sprinkled around the country makes from some odd conglomerations of folks. College towns, and colleges inside of other towns, are often communities of outsiders and rootless wanderers. Many have come with or created families and have stayed in one place quite some time, but they’re (we’re) still not OF the place. Many times, professors pile up together like rats on a raft to make their own little rootless floating communities of chance and location.

I don’t often think of the place where I live now as a raft and myself as a rat on it, but when I go home for real, it does strike me that although I’m not around much anymore, I do still have long sucker roots that go back into the soil of that little southern town.

I am very much aware that my situation is far from unique. Black folks left the south in their hundreds after the Civil War, and again after WWII to seek better jobs up north. White folks did, too. Refugees are everywhere around the globe. People move all the time just because.

However, since this is my one life, it does strike me as a big deal that I live in one place, but am bound to another. I do not believe I’d ever live there again, nor do I want to. I’m fine where I am, and I’ll probably move a few more times to places that interest me or offer opportunities.

I am mindful of the ghosts. There are ghosts that do a fair job of haunting me every time I return to that town. Ghosts of people and events that shaped my life in a million big and small ways. Most of them are friendly and welcome. Some, of course, strike up a chorus of ache and grief for the missing of the people and times that were then and aren’t now.

When I come back here, mostly the ghosts settle down. I don’t have the stinging feeling of acute loss and memory and separation much. Ghosts do fade a bit, but they don’t ever wholly disappear. If I’m quiet for a while, I begin to feel them at the edges of my consciousness, just hanging out, reminding me that things are different now. And although that’s expected in a life of any length at all, it does pull at me from time to time and I wonder how many more ghosts are ahead, how many more I can live alongside peacefully.

I’m not entirely sure how to manage all of them, some days. That is a work in progress, one I imagine everyone has to master at some point or another. For now, I’m just trying to keep them peaceable and placated so I can get on with the present. We’ll see how that goes.

Common factors versus specific ingredients in therapy: Who wins?

One of the Big Issues in psychotherapy is, and has been for ages, whether the common factors (empathy, trust, the therapeutic relationship) or specific ingredients (the techniques) are more important to helping clients get better. This argument rages on, especially in training programs. We have limited time with our students to prepare them to go out into the world and make it all better for everyone (which is not much of an exaggeration in how most of us see our mission). So, how best to spend our precious semester hours: focusing teaching on the common factors or the specific ingredients?

If research funding is any sort of barometer of importance (and I’m not sure it is), you’d have to conclude that specific ingredients are where it’s at- sorry, I am pathologically incapable of ending a sentence with “at”, so here’s a useless clause. Almost all of the funding coming out of the big federal programs at NIMH, SAMHSA, and NIH are targeted at finding out what, specifically, works for all sorts of people and their problems. Some of the big pushes are aimed at developing multi-modal programs, where, for example, you might have medication management alongside psychotherapy and job skills training for addicts. The programs aimed at research on therapy itself, however, tend to focus on the specific: determining if cognitive-behavioral therapy works for people with eating disorders, finding new diagnostic indicators for PTSD, deciding how long a person with depression needs to be in cognitive-behavioral therapy to get back to work, etc. All of the big federal agencies fund big studies with the hope of finding big answers to big questions, and their work is extremely important.

The findings from the studies funded by the big agencies, and private entities, often drive what insurance companies and Medicaid/Medicare will reimburse providers for providing. The idea, called “evidence-based practice” sounds like solid common sense: they’ll only pay you to do things that research tells us actually works. It’s supposed, I guess, to keep therapists from waving feathers around and chanting and getting Blue Cross to pay for it. I’m all for effective treatment, as long as that’s really what we’re looking for in the research.

Here’s the rub: all of the big studies funded by the big agencies with big grants, which are the bases for the guidelines for reimbursement, look at the small picture- the specific ingredients. And guess what? We’ve known for at least two decades now that the specific ingredients aren’t as important as the common factors in treating clients effectively.

There were a couple of Very Important meta-studies in the 1990’s (Wampold comes to mind) that pretty clearly showed that it matters a lot less what you do in therapy than it does how you do it. Of course, because all endeavors must have critics, the idea that how trumps what has its detractors. Most often, they claim that common factors, which are squishy feelings, can’t be said to be more important than “medical” interventions, like behavior charting and thought stopping techniques. The medical-model side of the house, which often controls the federal funding apparatus, seem to think it unthinkable that the major mover in therapy is the relationship.

I imagine there are a couple of reasons that common factors theory isn’t taken as seriously as it might be. One reason is the squishy-feelings aspect of the common factors themselves. How do you “empirically” measure such things as empathy, insight, clinical judgment, and connection (I have empirically in quotes because I don’t believe true empiricism is possible in therapy research, but that’s a blog for another day)? It’s far more simple to measure how depressed or anxious a person getting Treatment A is than his neighbor in Treatment B than to devise a way to measure how Therapist A connects or doesn’t with Client B versus Client C. The second, more insidious, and I imagine, honest, reason for the continuing popularity of specific ingredients theory is the basic struggle between the chalice and the blade, or the feminine side of healing being rejected by the more masculine side.

It’s not a popular (or possibly, wise) thing to do to say that our whole Western medical model, especially in psychotherapy, may be predicated on the repression of the feminine. It’s also not really where I was planning to go with this essay when I started writing it, but I think at this point, leaving aside the obvious conflict between empiricism and feminism would be cowardly of me.

I don’t have any solution for the common factors vs. specific ingredients divide, but I think it bears more investigation, and probably with a bit of irony and a slightly jaundiced eye.

As for where I’m leaving off in regards to how to focus time with students of psychotherapy, I leave that to the recently departed genius Miller Williams, an excerpt from the magnificent poem, “The Associate Professor Delivers an Exhortation to his Failing Student”.

If one Sunday morning they should ask you

the only thing that matters after all,

tell them the only thing you know is true.

Tell them that failing is an act of love,

because like sin,

it is the commonality within.

How failing together we shall finally pass.

Journey-Making

As I struggled to stay up until 9:00 last night (thanks, jet lag), I caught an episode of a new series on PBS, Sacred Journeys. This episode was about Jerusalem, highlighting the choices of several very diverse American citizens who had gone there to find…something.

One of the statements made by the narrator that struck me as fascinating was about the “physicality of place”. His general point was that, even with all of our high-tech video and audio devices, there is no substitute for being present in a location to evoke the psyche. The whole series is about the topic of pilgrimage, a concept that isn’t yet dead, or even resting. Several religious traditions including Islam, Judaism, and Hinduism, require their followers to make a physical journey to sacred sites in order to fully grasp the messages they offer. Many of the people on the show were Jewish or Christian and were visiting Jerusalem in search of physical pieces of their faith traditions. However, such journeys are also popular among the un-churched masses, today’s “spiritual but not religious” group. This trend seems to point to an unmet need basic to humans not always adequately answered by Religion.

But, why in this time of easy (ish) travel and easy access to information from all over the planet, do people still find it so necessary to pack up a bag and hit the road to find their souls? Certainly, a thousand years ago, when life moved at a much slower paces and there were no video feeds from the Church of the Nativity on Christmas Eve, it made sense for people to journey to sacred places in order to see where important events went down- even if the travel was much more dangerous and difficult than it is today. What is it about “the physicality of place” that still attracts us to the idea of leaving our sofas and stocked fridges and heading out for the unknown?

These questions led to two possible answers, one courtesy of Carl Jung, the other from my Celtic ancestors.

Carl (and Joseph Campbell) liked to make an analogy of a person’s life to the journey of a hero in myths and legends. The idea here is that each person is the hero is his or her own little mythic tale, beginning with The Call and ending with The Return, with many adventures in between. Over the years, this concept has attracted a great deal of attention in the psychotherapy community, from James Hillman and Archetypal therapy, to Michael White and Narrative therapy. Seeing yourself as the hero in your own myth can create feelings of purpose and continuity where chaos existed previously.

The second consideration is related to the image for this essay- the labyrinth. Mazes and labyrinths have been used as tools for prayer and meditation for untold time. Currently, many churches (especially the Episcopal) have prayer gardens with labyrinths on the church grounds. Walking over the four quadrants and into the center (which also is the basic layout of a mandala) is supposed to assist the walker in his or her meditations by making a physical journey to match the cognitive one.

Although many churches have labyrinths, they aren’t exclusive to Christians. The idea is most probably more ancient than that, meaning it likely has pagan roots. Apparently, taking a short, symbolic journey to sort out your thoughts is equally as old and powerful as taking a longer more literal pilgrimage  to a place of some spiritual or historical importance. There seems to be something about the act of walking, making physical contact between the liminal world of ideas and emotions and the literal world of physical sensation, that humans crave at a very basic level.

All of which brings me to my point: no matter how hard Western civilization tries to sanitize and disembody the human experience, it will always be defeated by the basic wiring of the human animal. We, as a species, are not only our thoughts. We are not only our words. When we suffer, we must have motion, physical contact with people and places and all of our senses in order to process the thing that caused the suffering and to heal. No drug can ever replace tactile experience (although some medicines are very helpful to many people). No “talk therapy” alone can fully wrap around the totality of any human experience: for that, we invented art, dance, play, and journeys. We need to use all that we have in order to heal what’s broken and strengthen what’s healed.

Graciousness

When I was growing up, manners were a Big Deal. Table manners, party manners, school and church and friend’s house manners were all bundled up together in what my mother sometimes called “home training”. Essentially, manners give us cultural reference points for how to behave appropriately for our class, age, gender, position, and culture. Because of my rather intense “home training”, I am able to write a damn fine thank-you note, host a cocktail party successfully, attend a wedding without causing a ruckus, and otherwise generally behave in a way that befits an adult White woman in the U.S. (especially the South, where manners remain a Big Deal).

While I’ve been roaming around India, I’ve had occasion to reflect on the role of manners in a global village. India is a very diverse and ancient place- the manners of the people here are traced back millennia, and can be quite complex and formal. For example, on the first day of our conference, the Chief Guest (a high-ranking bureaucrat from the University) was over an hour late. The opening of the conference was delayed until he arrived, at which time he gave a rambling, off-topic talk for another hour. No one left or began to talk to friends, or checked texts. Every single one of the 200+ audience members waited quietly and respectfully until he finally quit talking and left.

I cannot even imagine the depths of arrogance involved in being a person who thinks nothing of keeping 200 people waiting for an hour (he did not apologize) and proceed to ramble for another hour. My fellow Americans would’ve walked out, possibly after setting him ablaze.

Which brings me back to manners.

In my small experience, Indian people are intensely mannerly, to the point that I’ve begun to wonder if they might all be psychic. I think inside my head, “I’d love another cup of tea”, and it appears. Seriously. As a guest in an Indian home, you are not allowed to lift a finger to help your own self, no matter how stubbornly American-ly self- sufficient you may feel.

Really, manners generally boil down to displays of graciousness. In the West, this generally means helping guests, elders, and friends feel at ease. In India, graciousness seems to extend past helping others feel at ease to helping others feel a sense of being respected and valued, sometimes at the cost of the ease of the host. For example, if you say to your Indian host, “Wow, it’s hot in here”, you may find the whole family being organized into teams to fan you, or to fix the AC, or to otherwise insure that you experience no discomfort whatsoever.

The Indian sense of graciousness involves a level of self-sacrifice I’m not sure I can really grasp as a Westerner. An Indian person would far rather be hot, tired, out of cash, and foot sore than to have a guest do the smallest thing that might require effort. It’s a complete reversal of the usual power balance we see in the U.S.- here, the guest is not just made comfortable, he or she is made to be entirely without any cares of any sort for the duration of the visit regardless of what else the host may need or want to be doing. This appears to be true in homes of Hindus, Jains, Muslims, Sikhs, and any other religious or cultural group on the subcontinent.

Interestingly, this concept of complete graciousness to guests seems to extend to clients in the psychotherapy setting. I’m only beginning to put together the whole picture for myself, but it feels as if therapy here may be practiced with a natural sense of attunement and empathy that we work hard to cultivate in therapists in the West. I wonder if we all began to treat our clients as guests in our home rather than as paying customers involved in a business transaction if there might be a shift in the depth and effectiveness of our work?

ONE.

I read this morning about the death of Stella Young, a disability activist in Australia. In her brief years, Ms. Young managed to make a very large impact on disability policy, and changed a lot of people’s ideas about the limits of those with disabilities. She did this in between frequent surgeries for her painful condition.

Reading her story made me think of some other people who have single-handedly made an oversize positive impact. Here are a few exemplars:

1. Tony Kerwin, founder of Destiny Rescue (destinyrescue.org). Tony is an electrical contractor from Australia. One summer on vacation with his family, he decided that the sale of young children for sex had to stop. So, he went back to Australia, sold his business, sold his house, roped a few pals into his nutty scheme, and founded Destiny Rescue. Ten years on, DR has group homes in Cambodia, Thailand, Myanmar, the Philippines, Mozambique, and is working on opening operations in India and the Dominican Republic. To date, DR has rescued and housed over 1,000 children trapped in sex slavery.

2. Ann Jernberg & Phyllis Booth (ok, they’re two people, but Ann died before she got to do all she wanted to, and Phyllis picked up the baton). Ann Jernberg worked in Chicago Head Start in the 1960’s. Her job as interventionist was to help kids with behavior problems. By herself. In  Chicago. Being a smart woman, Ann quickly realized one person could never meet the need of thousands of preschoolers, so she set about creating a program of interventions that other speech-language pathologists, social workers, teachers, and psychologists could use. She called it Theraplay and today, The Theraplay Institute (theraplay.org) trains helping professionals around the world in developmentally appropriate interventions for young children with behavior problems and trauma. Interestingly, science is catching up with Ann, finally, and explaining how Theraplay activates the parts of the brain related to human connection and healing.

3. Jean Baker Miller- Was a one-woman crusade against the patriarchy in psychiatric medicine in the 1960’s and 1970’s. Jean was a psychiatrist, and she knew that the dominate paradigm of individualism, separation, and “standing on your own two feet” was unnatural and isolating. Despite a deluge of sexism, she marched on, publishing “Towards a New Psychology of Women” in 1976. Eventually, her ideas evolved into Relational-Cultural Theory, which informs the practice of hundreds of therapists worldwide (jbmti.org).

4. Soulaf Abas- Is a one-woman mission to tell the children of Syria that the world hasn’t forgotten them. Soulaf is an MFA student and visual artist living in the US from Syria. When the civil war broke out, her family suffered. When she heard that the children in the camps in neighboring countries thought the world had forgotten them, she scratched up some grant money and went to work. She gathered dozens of drawings and letters from local children for the children in the camps. And then she flew back to the region, spent 10 weeks in the camps leading art-based activities for the kids, and gave them the letters and drawings from the kids here.

All of these people are bright and passionate, but none are wealthy, exceptionally well-connected or superhuman. And this is only a set of four out of who knows how many people with similar stories around the world. Imagination is the only limit.

In the comments, please share stories of others who have made an impact.

Heartache is a Real Thing.

Last night, I watched a documentary called “Shunned” about the old order Amish (old order is sort of like orthodox) practice of shunning. I have no idea how the filmmaker managed to get access to the people s/he interviewed, but the whole film was first-person stories of leaving the order. All of them, including a young woman who had only left home a few days prior to her first interview, talked about how painful it was to disconnect from the world they knew to enter a world they didn’t understand and were raised to believe is evil and dangerous.

The pain of being away from family was compounded greatly by the fact that leaving the order means you’re also excommunicated from the church, which means you’re going to hell. The Amish believe in a very literal, physical afterlife experience, so spending time in a burning pit is not a metaphor for them, it’s a real thing that happens. This belief is part of the reason that the Amish practice of shunning is so effective as a disciplinary method in the community.

In the Amish world, members of the community who don’t follow all of the rules can be shunned, usually for a specific period of time, but sometimes permanently. Shunning involves isolating the person from the group; they sit alone at meals, work alone at chores, sleep alone, sit alone in church. No one speaks to them except to give directions. Once the period of punishment is over, the person is usually able to rejoin the community, but will certainly think twice before making the same mistake again.

The Amish have been using shunning as a way to keep order in their communities since the inception of the religion. It works. Really well.

Shunning is sort of the idea behind our prisons, but far more effective because it’s even more painful. The people in the documentary used the term “heart broken” a lot when describing how it felt to be turned out by all of the people in their lives who matter to them. Heartache is a real, actual experience of pain. If you’ve ever been dumped, you know this. Science, however, has long poo-poo’d the idea of heartache as actual physical pain.

As it turns out, the Amish and dumpees everywhere are right. Emotional pain is just as painful and as real as physical pain. Eisenberger & Lieberman (2005), a couple of neuroscientists, proposed an idea they called “Social Pain Overlap Theory”, or SPOT. Essentially, the point they made is that the pain of social exclusion or teasing processed along the exact same neural and biological pathways as physical pain.

Another term I really like from neuroscience is “technomyopia” which is the idea that only studies that use fancy machines can prove things we know and have always known from common sense and common experience. SPOT is a great example of that; humans have always known that having your heart broken hurts like hell. In fact, it hurts as much as breaking any other part of you. But because scientists have seen this happen with fMRI’s and other fancy machines, it now has a name and is considered to be empirically true.

And that’s a good thing.

With Eisenberg & Lieberman’s work, therapists and other squishy-feelings types can say, Hey, because SCIENCE! when we talk about the pain of heart ache and social exclusion. So, back to the Amish for a minute.

One of the reasons the old-order Amish continue to exist, although their lifestyle is very harsh, non-luxe, zero-tech, and isolated is that they are geniuses at forming and maintaining communities. Amish families usually live in clumps of a dozen or so. Families tend to be large, so a dozen families can make up a community of enough folks to do all of the farming and other work needed to sustain themselves with almost zero contact with the rest of us. The people in the community come to depend on each other for their survival, as well as for friendship and emotional comfort. They are all important to the community; everyone matters to everyone else.

Amish folks are rarely alone; they work in groups, eat at long family tables, go to church every week without ever sleeping in, children share beds, etc. Shunning works because the communities are so effective. Because every individual matters to the community, the community matters to the individual. Shunning is horrible because the community is wonderful.

The dominant culture in the U.S. isn’t very good at the community thing. When was the last time you sat down to supper with all of your siblings, your parents, and your bachelor uncle? When was the last time you helped your bff build a house? Who grew your salad from lunch yesterday?

Shunning is still painful for the rest of us. SPOT insures that anytime a human being is isolated by others, removed from the communal table, and told they’ve done wrong, it’s terrible. When your co-workers don’t invite you to happy hour, it sucks, even if you’re 40 and you know it’s not really the end of the world.

Even when our communities are loose and poorly constructed, SPOT is real. The Amish are careful to put a time limit on the shunning. Amish people who are shunned know it will end, and they can go back to belonging (usually, excommunication is a little different, but even then, people can return, it’s just a lot harder. Forever shunning is like capital punishment and is reserved for serious offenses, like murder and rape). Shunned Amish people know it will only last a few days or weeks, and then they’ll be accepted right back into the fold.

When we shun or exclude people in our world, there’s no clear limit on how long it will go on, or what the person can do to return. This is particularly damaging for adolescents, who desperately need to matter, but don’t have the social skills to make it happen or the experience in life to know that everything is temporary, and that this too shall pass. To an adolescent who is excluded from the community of his/her peers, it seems like forever, like capital shunning.

And here’s my point: as adults, we know social exclusion hurts. As smarty-pantses, we even have scientific proof of this, the SPOT. We need to do a much better job of making sure there’s a way out of the shunning penalty box for kids. Kids who don’t believe that they matter often don’t think anyone else does, either, and we know where that leads.

Jingle Bell Rant, or how not to loose your mind in the next month.

Even as a child, I’ve had a serious mismatch between my reach and my grasp. Every time the family went out to one of those cafeteria type restaurants, my mom chirped at me about having eyes bigger than my stomach. Over the years, I’ve learned exactly how much pie I can actually consume, but I’ve never really learned how many activities I can realistically do in 24 hours.

Just like the kid with too many desserts on her tray, I’m approaching another season of holiday goings-on with a calendar that may just pull down the Google server it inhabits. There are parties (often potlucks I have to cook for), school events (both at my university and the boys’ schools), impending visitors (and of course, the house is a purple wreck), presents to wrap (and mail to my family all over everywhere), and so, why not go to India for two weeks?

You see my problem.

In light of my darling spouse having not yet invented the two-places-at-once machine he’s been promising me for years (along with a pony, a jet pack, and a laser that will zap people in meetings) I’m in the rather appalling position of having to take my own advice.

I hate it when that happens.

It happens kind of a lot.

As a counselor, I have talked with literally gagillions of clients about managing overwhelming schedules. Often, the outcome of our conversation is something like this:

1. Look at your calendar, and without any judgement or internal “shoulds”, find the entries that give you joy to consider. Make a list of them.

2. Look at the same calendar, and again, without any judgement or internal “shoulding”, which entries fill you with dread? Make a list.

3. Compare the lists. Which is longer? Is there a pattern (e.g.: all of the “joy” items involve your kids, the “dread” column is all about your in laws)? Are any of them scheduled on the same day/time?

4. Imagine you go to bed tonight as usual, and overnight, there’s a miracle that only affects your calendar. When you wake up tomorrow, what’s the difference? What’s gone? What’s still there? Has anything multiplied?

5. Go back to the list (making physical contact with paper is really important here, for brain reasons I don’t have time to tell you because I have 3 meetings today, just trust me). If the miracle of the calendar happened, what would happen to the lists?

6. Take each miraculously transformed item one by one and decide what part of the miracle of the calendar you can pull into reality.

  • Some of the dread stuff (for me, this is almost always work related meetings and end of the year reports) may have to happen, but can it happen on another day or time that would be better?
  • Is there any dread stuff you can eliminate or condense? Maybe trade off school meetings with your spouse or see if you can combine two work meetings?
  • How can you expand the joy? This doesn’t have to mean adding yet more stuff to the calendar, but how can you pull that experience into more of your life? For example, if one of your joys is seeing friends at parties (my fave), how can you explore the feeling that gives you, and then add more of it into your life? A few quick emails, calls, or texts everyday can help expand on that joy. This part takes some thinking, and often, some creativity. If you get stuck, I recommend taking some paper and a crayon (yes, a crayon) and doodling about it until your left brain makes an AHA! available to the right brain for you.
  • If you’re still feeling freaked out after all of that, take a page from one of the most celebrated curmudgeons in psychology, Albert Ellis. Ask yourself (in a cranky old Bronx guy accent) What’s the worst that can happen if I don’t….?  If the answer is, I’ll loose my job, you probably have to suck it up and do the thing. If the answer is, I won’t be seen as perfect by all my neighbors and acquaintances, you can skip it.

Most importantly of all, don’t try and measure up, even to your own internal standards of perfection. Honestly, there is no such thing as the “right” way to cope with the festive season. Sometimes, that makes it harder to find the balance point, because it’s one of those things everyone has to figure out on his or her own. Here’s the take home: When you are a little old person, what do you want to remember when you reflect on the holidays? Focus on that. Maybe make a doodle about it, or a collage or a sculpture, or a sand tray. As Mrs. Parker used to say, “Time doth flit, oh shit”. Fill it from the joy column.

How to win at parent-teacher conferences.

Since I spent a decade of my life as an elementary school counselor, you’d think that attending parent-teacher conferences on the parent side of the table would be a cake walk. You would be wrong. Regardless of which side of the table you’re on, these things often have one tragic flaw: sometimes, someone on the teacher side has a personality that better suits him or her for work as a hermit. Or maybe an HR rep for the Spanish Inquisition (I’ve met my share of terrible parents, too, but that’s a different story).

So, when faced with the Teacher Who Will Not Retire/Leave/Stop torturing children using my tax dollars to gorge him/herself, a few tools can be handy to have (I don’t mean bring a hammer to the meeting,  but it can be tempting).

We had such a meeting for Boy 3 yesterday. He’s a sixth grader, which is a terrible thing to be.

3 has cruised through his academic career to date mainly on his adorableness and inherit genius. When confronted about his frequent mid-day naps in first grade, he gave his teacher one of these looks: http://hero.wikia.com/wiki/File:Puss_in_Boots_Eyes.jpg

And she let him nap in class.

SO, he gets to middle school with the expectation that he can continue to charm his way along, not turn in any work, ace the tests, and be perfectly fine. We tried to warn him that middle school teachers are somewhat less susceptible to kitten eyes than elementary teachers, but we’re adults and therefore unwise in the ways of the youths.

We requested the meeting because 3 is making C/D/Fs in all of his classes, in spite of the kitten eyes and acing the tests. He apparently hasn’t turned in a homework page in weeks- he does the work, he just doesn’t turn it in. Somewhere, there is a dragon sitting on a huge pile of homework, generated but not turned in by, 1 and 3.

Anyway, his father and I turn up at the appointed hour to see what we can do about this mess. 3 does not want to repeat a grade, and he knows he won’t touch an x box until he’s 30 if he doesn’t get it together pretty fast. I had requested/demanded nicely that 3 also attend the meeting, which puzzled the evil teacher, but they fetched him anyway.

To open the meeting, one of the teachers (none of whom we’d met before) reads a list covering 2 lined pages of sins and maladroit actions of 3. 3, in his defense, sat and listened, turning very pale but not using the Eyes.

I then broke in and requested that we open the meeting by telling what 3 is doing well.

This was hard for the Evil Teacher. The other 3 easily came up with how smart he is, how friendly he is to other kids, how he can make A+ on tests, etc. Evil Teacher began with the yes buts. I detest the yes-buts. They are the heart and soul of passive-aggressive nonsense and are frequently the underlying cause of relationship problems. She starts with, “Well, now 3 is a smart boy, WHEN he decides to use it”.

I managed to supress an urge to bang either my own or Evil Teacher’s head on the desk. Instead, I summoned my Skillz and said, “You kind of backed into that one. What can you tell us that is going WELL?” Blink. Blink. One of the other teachers said something nice, and we moved on.

At this point, I pulled out paper and began making notes. When I was a counselor at a  school, I had forms for this purpose. When teachers don’t use them, I kind of know the meeting is really about shaming the child and telling the parents they suck rather than actually solving the problem. Few educators will admit this, but it’s true. Teachers, counselors, principals, etc who really want to help you will stick to a problem solving tactic and will almost always make notes.

On my improvised form, I write, “Date, Present, Identified Problems, Identified Solutions, Person Responsible, Follow Up Plan”. This is not rocket science, people. It’s very basic common sense stuff, but it really helps focus the meeting and often keeps Evil Ones from derailing the process and turning it into bitch-and-moan hour.

From here, it was a bit of an effort to corral Evil Teacher’s mission to shame 3 with her condescending remarks about both his observable behaviors (which are appropriate to discuss here) and his global self as a human (which is not). Fortunately, the other teachers are all good eggs and were able to identify very specific things 3 needs to do in order to earn better grades in their classes without condescending to him or making global inferences about him self. This was helpful.

At the end of the hour, I had a list of three problems and four solutions. Everyone in the room had some responsibility for the success of the plan (which is crucial), even though 3 himself had the lion’s share, which is appropriate because it’s his grade. When I got home, I scanned the notes into the computer and emailed them to all of the teachers and gave 3 my copy so he can keep it in his binder (it’s currently on the dining room table, but we’re making baby steps).

As we were leaving, Evil Teacher said, “It’s always nice to meet parents who care”. This is one of the most toxic things teachers can ever believe about parents. It’s charged with all sorts of race/class/gender judgments and indicates a very low opinion of humans in general.

I was so proud of myself for not throttling her, I can’t even tell you how much.

3 and I had a nice chat on the way home from study tables (he’s now staying after school 3 days a week until he’s on honor roll). He didn’t say it in so many words, but I think he was very grateful that the meeting was about things he can actually fix and not about shaming him for who he is. When I think about the damage done every day around the world by teachers like the Evil One, I get serious heartburn. Let’s focus on some solutions, people. There is a right way to handle these conferences.

Explaining empathetic attunement in India

As some of you may know, I’m preparing to take a group of my graduate students to India next week for a two-week whirlwind tour of the northern parts of the country. One of many highlights of the trip is a two-day conference at NK college in Mumbai. I’m the keynote speaker, and of course, my topic is play therapy.

I get to talk about play therapy a lot. Usually, I’m talking to professionals or grad students who already have a pretty decent idea of what play therapy might be. At this conference, I get to introduce the idea of play therapy to about 150 college students (mostly psychology majors), professors, and professionals who have probably never heard of play therapy, AND who live in a very different cultural context from the one I inhabit.

To call this a bit of a challenge is a serious understatement.

I’ve been working on my outline and slides for months now, and I’m not satisfied with them yet. I’ve got the usual suspects lined up: Virginia Axline’s 8 principles, the basic attending skills in play therapy, how to set limits, some brain stuff. But I don’t yet think I’ve captured the IT that makes play therapy such a powerful modality for working with kids.

When I think about what the IT, the driving force of play therapy, is I get lost for words (which is not a common occurrence, trust me). What can I call the magic that happens in the space between the child and the play therapist? You know, that feeling of being invited into the inner world of the child’s imagination and thoughts, being in sync, attuned, congruent, aligned? This, in my opinion, is what makes therapy tick. I find it to operate most powerfully when I’m helping my client access his or her creative, affective brain, getting out of the rigid, verbal, linear left brain and into the visual, contextual right brain. I’ve just never found a perfect English word to describe it, and now I have to find a way to describe this to a group of people for whom English is a second, third, or fourth language.

When I teach beginning counselors here in the United States, I often use Judith Jordan’s idea of mutual empathy to explain the “it” of therapy. Mutual empathy differs from one-way empathy in therapy in its bi-directionality. In most ways of working, therapists are trained to use empathy to enter the world of the client. In mutual empathy, the therapist feels the clients feelings with him or her, and helps the client to understand that their feelings impact the therapist as well; that their feelings matter to the therapist. I believe that this process occurs naturally in engaged play and expressive arts therapy. Left brain-to-left brain contact, which science now tells us helps grow and repair relational neural pathways, may be the “it” I’m raving about today.

But how to explain that to 150 Indian students and scholars? In an hour?

I’m still working on it. However, I have found a word in Urdu (a cousin of the language of old Persia which is widely spoken in northern India, also the language of some of the greatest poets who ever lived) that might help: manoos. It seems to be a little different from our word empathy, and from the Hindi word for empathy, which means the same as the English. Manoos seems (I say “seems” because I’m definitely not a linguist nor do I speak Urdu) to impy a feeling of care and warmth for another person or an animal such that it/they are no longer a stranger and there is a mutual affection and understanding between yourself and the other.

Maybe manoos isn’t the answer to explaining the empathetic attunement therapists must use, but I’m going to move ahead with it for now. Maybe manoos will at least start a conversation about how inadequate language can be in the face of felt experiences? I’m going to keep wrestling with this, and hoping for a flash of enlightenment.

Rumi, one of many brilliant poets who wrote in Persian, a cousin to Urdu, wrote:

I closed my mouth and spoke to you in a hundred silent ways.”

Maybe that’s the definition of tuning in?

Book review: The Interpersonal Neurobiology of Play (2014)

Among my favorite things (cue singing) in the world to read has to be books about brains. I’m fascinated by all brains- human, mammal, lizard, doesn’t matter; love ’em all. What’s a real gem is a book about brains that I don’t need a dictionary to plow through that gives me information I can use for something other than trivia night at the local pub.

Theresa Kestly’s The Interpersonal Neurobiology of Play (2014) is one of those rare finds. It’s the latest entry in Norton’s series on interpersonal neurobiology. In my opinion, it’s one of the stronger offerings. It’s a very tightly edited trim volume of only 205 pages including the index. Every single one of those 205 pages is worth reading.

The prose is clear enough for an absolute beginner to grasp, yet has enough complexity to entertain brain geeks like myself. The book is based around a series of well-designed graphics (another fetish of mine) which make the material at once well-organized and visually compelling. A lot of it is also new to me- I’d never heard of Jaak Panksepp, a brain guy Kestly quotes throughout the book. I really thought I’d heard of all the Big Names in brains by now: Porges, van der Kolk, Siegel, Perry, etc. But here’s a new one! And he has some really interesting ideas that directly apply to play therapy and play in general.

Since this little book is so packed with great information, I’m not going to reveal the details here. Suffice it to say that if you’re a play therapist or a brain geek, you need this little book. It would also make a fab gift for your favorite therapist.

Here’s a link to amazon, although you can buy from any seller. I don’t get any kickbacks for purchases.

http://www.amazon.com/Interpersonal-Neurobiology-Play-Brain-Building-Interventions/dp/0393707490/ref=sr_1_1?ie=UTF8&qid=1417449376&sr=8-1&keywords=kestly