Grieving for our Parents

This week's New York Times Magazine has a fascinating article by Christopher Buckley about the deaths of his parents, Pat ("Mum") and William F. Buckley ("Pup"). The article, excerpted from his upcoming book, is about his ambivalent relationship with them. Christopher is a wonderful and compelling writer. He tends to write in a style we clinicians call, "rambling, but goal-directed." He often digresses, but there is always a purpose to it, and returns to his main point quickly. He is an apple that didn't fall far from his parents' tree.

Christopher's mother died 11 months before his father. He relates seeing her in the ICU. At a point when she may have already been dead, he found himself saying, "I forgive you." Like so many essential things we say, his words surprised him. Then, a few months later, with his father facing death, they had this interaction:

I had planned to leave mid-July on a trip to the West Coast. One night as we watched the first of three — or was it four? — movies, he said apprehensively, “When are you leaving for California?”

“I’m not, Pup. I’m going to stay here with you.”

He began to cry. I went over and patted him on the back. He recovered his composure and said, somewhat matter-of-factly, “Well, I’d do the same for you.”

I smiled and thought, Oh, no, you wouldn’t. A year or two earlier, I might have said it out loud, initiating one of our antler-clashes. But watching him suffer had made my lingering resentments seem trivial and beside the point.

I wondered, while keeping this vigil with him, whether to bring up certain things and talk them out so that, when the end came, nothing would be left unsaid between us. But each time I hovered on the brink, I found myself shrugging and saying, Let it go. Perhaps it was another way of saying “I forgive you” — as I had to Mum that night in the hospital — on the installment plan. I felt no need for what is called, in other contexts, the “exit interview.” I was able to love him now all the more, and actually laugh (inwardly, anyway) at that “I’d do the same for you.” Oh, yeah? Ho, ho, ho.

We come to terms with a loved one's death by accepting them as they are. It is at best unnecessary, and sometimes counterproductive, to try to leave everything said, or to "talk things out." Instead, we need to understand that in the face of death, "my lingering resentments seem trivial and beside the point."

When we grieve for our parents, we grieve for them as they were, and we grieve for what we have wished they were. As we come to terms with that discrepancy, we come to terms also with our own lives. We do not have to be perfect to be valuable human beings. Our past mistakes and our current faults do not make us despicable; they make us unique and human. In some ways, Buckley is telling us, our faults are just as precious as our our assets.

The Psychology of Jealousy: Guest Post

I recently had a request from Sarah Scrafford, to post on JND. As I haven't been posting lately, I welcomed her offer. Below are her thoughts on the psychology of jealousy.

The Psychology of Jealousy

Relationships are complicated, even when things are going smoothly. You never know when you’re going to be overcome by emotions like anger, sadness, and the worst of them all, jealousy. It’s an evil, green-eyed monster that makes your life miserable; it eats away at every shred of happiness you have until you’re a bundle of nerves and an emotional mess; and it makes you do things you would never do when you’re in your right senses. We only have to look at the female astronaut who put on a diaper and drove all through the night to attack a rival for her beau’s affections to see the truth of this statement.

A close friend and I were discussing a couple whose relationship had hit the doldrums. He wanted in, she wanted out; and the more she wanted out, the more he wanted in. My friend was of the opinion that that’s the way human beings are – when we know that we cannot have something, we somehow seem to want it even more. So when someone close to us withdraws and retreats into a shell, we seem to crave their company and affection in the worst possible way. It’s worse when there’s a third person involved, when you know that someone else is getting what you think you deserve. Jealousy comes rushing in and takes over your life, making you incapable of rational thought or reasoning.

While I’m no psychologist, here’s what I know about the psychology of human relationships – the best way to attract someone’s attention is to pretend to be totally unaware of them. This works really well when they know you’re interested in them and when they’ve rebuffed your advances at least once. The moment you stop hanging around them or trying to get them to show an interest in you, they’re going to wonder why you changed your mind, why you’re not as into them as you seemed to be before. And this hits their ego, the one that you helped inflate with your undivided attention.

If they’re the mature kind, they realize this hurt ego for what it is and let things go; after all, they’re really not interested in a romantic relationship with you. If not, they’re definitely going to hang around you more, check if you’re looking at them from afar, tease you a little with a text message or a mildly flirtatious email, or invite you out for a cup of coffee. But before you jump for joy at this new attention, let me warn you that this interest, the one that’s riding solely on a hurt ego, will disappear the moment you begin to reciprocate, unless your beau is really into you by this time.

Yes, as Shakespeare rightly said; it’s a tangled web we weave, when we first practice to deceive. The psychology of relationships is complicated, more so when we have to play games to win over the people we really want.


This article is contributed by Sarah Scrafford, who regularly writes on the topic of online radiography schools. She invites your questions, comments and freelancing job inquiries at her email address: sarah.scrafford25@gmail.com.

Traumatic Brain Injury and Football

Almost exactly two years ago, I posted a sports rant focusing on the effects of repeated concussions on football players. Here it is Superbowl time again, and another story has surfaced on the topic. (Also see here.) I assume these stories are released at Superbowl time to get more play.

The study of the brains of former NFL players is being conducted by the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine. Credits are as follows. I added the parenthetical clarification of the acronyms:

CSTE (Center for the Study of Traumatic Encephalopathy) is a collaboration between SLI (Sports Legacy Institute) and USM (Boston University School of Medicine). SLI was founded by former Harvard football player and WWE pro wrestler Chris Nowinski, and neurosurgeon and concussion expert Robert Cantu, MD, chief of Neurosurgery and director of Sports Medicine at Emerson Hospital in Concord, Mass, and clinical professor Neurosurgery at BUSM. The work at BUSM is being led by McKee, an associate professor of Neurology and Pathology, director of the Neuropathology Core of the BU Alzheimer's
Disease Center, and the director of the brain banks of the Framingham Heart Study and the Bedford VA Medical Center, and Robert Stern, PhD, associate professor of Neurology and co-director of the BUSM Alzheimer's Disease Clinical and Research Program. The CSTE received initial funding for their research from BUSM and subsequently received a $100,000 grant from the National Institute on Aging to support their work. This past week, the group of researchers learned that they received a $250,000 grant from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).

According to the story, players have been asked to donate their brains for study under the "88 Plan," named for John Mackey who wore jersey 88 for the Colts and now has severe dementia. So far, 7 NFL players have been evaluated, an 6 have been diagnosed with chronic traumatic encephalopathy. Trauma refers to damage. Encephalopathy refers to brain pathology. Hence, traumatic encephalopathy is a technical term for brain damage caused by head injury.

One can diagnose encephalopathy through brain imaging, psychological tests, and by clinical signs and symptoms. However, in this case, the diagnosis was made the most reliable way, by autopsy, so there is no mistaking the severity of the problem. Interestingly, the players' brains had some similarities to Alzheimer's patients. Most of the players showed signs of memory loss, impaired thinking, depression, and impulsive behavior. They also may have abused substances. Two died of suicide and a third died of a self-inflicted gunshot wound ruled accidental.

This is pretty scary data, but I want to add two cautions to interpreting the data. First, these are people who have died early, between 25 and 50, so they had severe and repeated injuries. If we examined players who lived a full life, we would certainly see a different picture. This is why the authors have carefully avoided claiming that most NFL athletes have brain injury.

Second, the players with traumatic encephalopathy played at a time when concussions weren't taken seriously. The NFL has developed procedures for managing concussions and when to allow a concussed athlete back onto the field. The NCAA has supported studies of concussions. The American Academy of Family Physicians has a nice summary of how to manage concussions in high school athletes. As mentioned above, the quality of the equipment is also being evaluated. So, now that concussions are being taken more seriously, the pervasiveness of traumatic encephalopathy should be declining. But we don't know that for sure.

As someone who spends most of his time in his head and others', I question why we accept this risk at all. Remember the old commercial, "A mind is a terrible thing to waste"? When a child or a young adult athlete is concussed, the rest of their life is at risk. And for what?

Controversy over DSM-V

This week, I finally got a reprieve from numerous reports and paperwork, so I can dust off the old blog and have some fun again. There is no better place to begin than the controversy over DSM-V.

Background

First, some background. DSM-V stands for Diagnostic and Statistical Manual--Fifth Edition. Of course, in psychiatry, numbers can be misleading. DSM-V will actually be the seventh revision, as DSM-III was revised once (DSM-III-R) and DSM-IV was also revised (DSM-IV-TR. TR stands for "Text Revision.") It's published (and jealously guarded) by the American Psychiatric Association.

When I started out in the 1970's, DSM-II was the manual we used, and it was awful. Definitions were vague, and you could diagnose the same person with anything from depressive neurosis to schizophrenia without much difficulty. DSM-II was generally denounced as irrelevant and unnecessary by behaviorists and humanists. At the time, diagnosis had little to do with treatment, so it really was unnecessary. In hospitals, physicians would argue endlessly about a patient's diagnosis, with no change in treatment after they had differentiated what kind of schizophrenic they were dealing with.

DSM-III changed all that, as diagnoses were made on the basis of behavior. Specific symptoms were identified and you had identify a certain number of symptoms in order to diagnose depression. This was a great advance in two areas. First, research could be focused. If you wanted to research a treatment for depression, there was now a clear operational definition for depression. That means that we could compare different studies without comparing apples and oranges.

Second, DSM-III gave us the ability to communicate what we were treating to third parties. It was published when insurance companies were beginning to pay for psychotherapy. Unfortunately, many therapists didn't know an adjustment disorder from major depression. Consequently, managed care used DSM-III to refuse to pay for many treatments. We had to learn to say, "Here are the symptoms that show the client is depressed and here is the progress I am making on them. Once we learned to do that, managed care stopped refusing psychotherapy and we now generally get as much time to treat clients as we need.

The Controversy

DSM-IV has been a small improvement over DSM-III, but it's still controversial. Now DSM-V is on the horizon and it's generating more heat. A recent article in the New York Times picked up on the controversy. There are a number of points of controversy.

First, there is no real understanding of the causes of mental illness. We're still not even sure if there is such a thing as a mental illness. Psychiatry has been moving toward a neurobiological model of mental illness, but is still far away. If you ask a psychiatrist what causes depression, you'll hear one of two answers. You might hear, "We don't know," which is the honest answer. However, more likely, you will hear some mumbling about serotonin and biochemical imbalances. Those guys are just blowing smoke. Just ask them to define a healthy biochemical balance; their response will be entertaining. Unfortuantely, more than half of the members of the task force writing DSM-V have drug company connections, so you know they will remain committed to a neurobiological model.

Second, diagnoses are often points on a continuum. Consider what is now called Attention Deficit/Hyperactivity Disorder (ADHD). Our ability to pay attention falls along a continuum from fleeting to intense. When we diagnose someone with ADHD we are saying that their attention on the average, falls below some imaginary point on that continuum. That imaginary point is also arbitrary. Do we abandon children who fall just to the normal side of that point? How about children who fall mostly to the average side of that point, but occasionally their attention and concentration crash and burn?

Third, the inclusion of a diagnosis in the manual has always been unsystematic and has many social implications. Why is repetitive handwashing considered obsessive compulsive disorder, while repetitive shopping is not? Is binge eating a disorder, or does the person just need to grow up and get some self control? In DSM-II, homosexuality was considered a diagnosable mental illness. In DSM-III, homosexuality was removed as a diagnosis. There is a straight line from deciding homosexuality is not a mental illness to deciding gays should have the right to marry.

Fourth, how open should the process be? The APA has had the members of the DSM-V task force sign conficentiality agreements. Dr. Robert Spitzer, a member of the APA task force on DSM-V has raised concerns about it. (More about the controversy can be found here.) Given the social implications for some diagnoses, there's a lot at stake here. But, it's difficult to balance the need for open, scholarly discorse, with the risk of being personally attacked by one pressure group or another.

Who gets treatment is affected by diagnosis. When I diagnose a child with autism, that child becomes eligible for a wide range of services that a child with plain old "mental retardation," would not get. Interest groups in a lot of areas would like to see their own diagnoses included, so more services become available. A battle is raging over whether or not transsexuality should be included in DSM-V as a mental illness. Some would like it to be normalized; a person should be able to cross dress if they want to. However, others would like to have insurance cover sexual reassignment surgery. You can't cover a procedure if it isn't treating a diagnosis.

Conclusions

DSM-V will almost certainly move closer to a neurobiological model and away from a psychosocial model. That will lead to less emphasis on psychosocial treatment. I don't hold that against psychiatry; they treat mental illness biologically. However, psychotherapy still has much to offer. Psychotherapy is still the best (or at least a competitive) treatment for personality disorder, post-traumatic stress disorder, and some depressive and anxiety disorders. Generally, psychotherapy reduces the risk of relapse. Yet, if we structure our diagnoses around neurobiolgical models, psychotherapy will be marginalized. Already, family and marital therapies are extremely difficult to justify using DSM-IV. Somehow, diagnoses should also be there to allow for psychosocial treatment and to encourage more research in that area.

Despite these problems, we still need a diagnostic manual. Psychiatric diagnoses, for all their arbitrariness, give us a way of organizing research and communicating therapeutic information. At some point research will give us a handle on the nature of mental illness, and a clear diagnostic system will emerge from that. In the meantime, this is the best we've got, and none of the critics have given us a good alternative to the writing of a new manual.

APA Passes Resolution Passes on Psychologists' Working in Detention Settings

The American Psychological Association has just issued a press release stating that the membership passed a resolution forbidding work in settings where "persons are held outside of, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the US Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights."

The full text of the petition is here.

If I read this right, there are no significant loopholes.  Psychologists should either work for detainee's well being or not at all.

It's about time!

I think some people thought that there was room for psychologists to work within the system to better the detainees' situation.  I don't believe that's possible.  While it's enticing to think of the heroic psychologist fighting the system, human nature (not to mention Solomon Asch and BF Skinner) tells me that the psychologist would just be co-opted into the system.

It was also particularly galling that the AMA had done this long ago while the APA wimped out. So, as I often teach my clients, time only goes forward.  It would have been better for APA to have done this sooner, but doing it today is better than doing it tomorrow.