Monthly Archives: February 2015

Culture – What Can Caregivers in Our Culture Learn from Caregivers in Other Cultures?


I am convinced that you can’t fight culture. Whereas we in the US have multiple subcultures, there is a general culture that values multi-tasking, technology use, and lack of downtime. The consequence seems to be a relative lack of tolerance for ambiguity and spontaneity, both of which are often associated with creativity. That is not to say that there are not creative individuals in our society nor that there is no creative activity, but it seems to me likely that one has to step out of the typical mind set and pattern of activity of contemporary American life to be truly creative. I accept the misconceptions that underlie idealization and the romanticization of other cultures, particularly those of developing cultures closer to their ethnic roots. However, I cannot be blind to the advantages I see here at the orphanage and school in South India and in the orphanage in El Salvador where I am a regular guest.

Two apparent advantages are – at least in the case of the younger children – plenty of down time, and few toys, especially tech toys. In the evening last night, the gentleness of the temperature matched the tempo of the activity of the courtyard of the boys’ residence. Boys of different ages were playing in two main groups. One group was playing with a volleyball. Two older boys, one of whom had just graduated college, were playing ball together with obvious enjoyment. About 6 much younger boys were trying to capture the ball, while also imitating the older boys’ athletic moves. Sometimes the older boys would allow them to take the ball, and there would be a playful skirmish between the younger and older boys that looked more like a soccer game than the original volleyball. Other times, the older boys continued to play together without much attention to their younger followers, who watched them closely, while also running around. How much learning was going on in that admiring observation, and how much healthy physical activity and enjoyment! There was no conflict among the boys that I could see.

The other group of boys was playing with stiff slender stems of a plant that they used as arrows. They fixed a small rubber band to the rough end of the stick and pulled it with their fingers while pointing the stick upwards. When they released the rubber band, the stick soared into the air. After a while they identified a tantalizing target – a huge jackfruit hanging low on a tree. As the arrows hit the target again and again a milky substance started to seep mysteriously from the fruit. Here also, there was no real conflict. No adults were constraining their activity, telling them what to do or what not to do. No one cared that the fruit of the tree was being injured – it wasn’t as if a precious garden tree or a piece of furniture in the family home was being harmed. The children were free to play unencumbered. How many of the limits we place on children are dictated by the environment in which we expect them to play?

The comfort of the boys in the courtyard was mirrored by the children in the kindergarten classroom. Thirty two children were sitting on small mats on the floor, overseen by one teacher. The teacher, a superb teacher I had known from earlier visits, was calling on the children one at a time to come to the front and create a story out of a picture with four panels of images. This is a rather sophisticated task, requiring them to create a coherent narrative out of the pictures, and the children were doing a good job. At least as impressive was the attentiveness of the other children while the narrating child was at work. Every once in a while one child would start to cause a minor disruption. The teacher did not call the child’s name from a distance. Without speaking at all at first, she moved to his or her side and put her hands gently on their shoulders, moving them back into position. Is there any way we can transport this into our culture?

“Come here right now!”: The Iceberg Effect and More About Transitions


I find myself talking about transitions to the parents I see perhaps more than anything else. A parent will say, for example, “When I call her to come to dinner and finally say, ‘Kate, I need you to come here right now!’ I will either get a nasty response or none at all. If she does respond it will take 10 minutes and more nagging before she comes! Why does it have to be that way?!” the beleaguered mother will ask. These parents are good parents of good children. Most of the children whose parents consult me have major or minor neurodevelopmental problems, ranging from autism to ADHD or the kind of organizational problem commonly called “executive function disorder”. All of these problems involve difficulty making transitions. The good mother who is explaining that her daughter does not come when she calls is looking at the top of an iceberg. She sees a little mound of snow or ice. It is a simple, reasonable request. Why can’t her daughter make a “normal” response? However, beneath the water is a huge iceberg of patterned behavior and the meanings associated with it that has been built up over the child’s life.

Let’s analyze the mother’s “simple request” to “come now”. First of all, she is requiring that the child take in the auditory command. This is harder for some children who have ADHD or who have what is called “auditory processing problems” than for others. The mother might not know that Kate has auditory processing problems or if she did hear that from a tester, she may not have entirely understood what it meant. Or even if she did understand what it meant when the tester was explaining it to her, it is hard to keep in mind during the course of family life.

Second, the mother’s command requires Kate to shift her attention from whatever she was doing at the moment to what her mother is telling her. That shift in attention can be much more difficult that you would think. It involves taking apart the current organizational state of the child – her attention, narrative (the story of what she is doing), and her motor activity. It requires Kate to change her postural position and her physiological state of excitement or of comfort, and prepare for something else. Usually, these shifts in our state of being take place out of awareness. We have an intention to change, and it all happens – we stop reading, get up, and walk to the kitchen to start cooking dinner. We don’t realize that all these small changes of everyday life take energy. Other transitions – sleep to wake, home to school, bedroom to bathroom, bedroom to kitchen table, pajamas to school clothes or even worse, snow pants, also take energy. For some children it requires more energy than for others.

In addition to all those shifts, there is the relational and symbolic meaning associated with the transition. For Kate’s mother it may mean, “Oh, dear. I shouldn’t have taken so long reading that paper. I need to get dinner started!” That may be slightly annoying, but no big deal. For Kate, her mother’s calling her may have a very different meaning. That may be something like, “She is bothering me again, just when I got comfortable watching t.v. I had a really hard day at school and Susie was mean to me, and Mom just can’t give me a break. Why is she always making me do things and not Freddie (little brother)!” I am not suggesting that these coherent sentences appeared in Kate’s mind, but that her mother’s reasonable request may feel entirely unreasonable to her, and this meaning comes together with all the other transitional demands – that she shift her attention, her body, get stirred up inside instead of comfortable, etc.

There are two general antidotes for the stress of transitions. One is routine and the other is what I call “herd mentality”. Herd mentality is more available to teachers than to parents of children in small nuclear families. I first noticed it at the orphanage in El Salvador when the little children – most of whom had suffered early neglect and abuse and therefor could be expected from a neurodevelopmental point of view to have difficulty with transitions – all seemed to manage transitions relatively well. I came to think that it was because they all did the transitions together. When it is time to come to dinner and all the other kids start heading in the direction of the dining hall, the stragglers seemed to notice the general movement and catch up, as if noticing that they didn’t want to be left alone. There is another factor – those children didn’t have the hypnotizing effect of video games or other screens to interfere with the process of the transition.

In addition to the herd mentality, there is the importance of routine. What I tell parents is that routine is their best friend. That is because a routine has momentum. The teacher of the children in the preK classroom in the photo above is using routine, herd mentality, and the rhythm of dance, to facilitate a transition. Once you have established a routine the child does not have to move into that state of limbo, an extended disorganized state, with all the stress that entails. (Remember that stress can be expressed as irritability or aggression!) Instead, although the child may not want to interrupt what she is doing to come to the table, it is easier for her to do it. Kate’s mother’s command does not “come out of the blue”. Dinner is at the same time every night, more or less. Kate’s mother has given her a warning five minutes ago, just as she always does. She may even have gone into the family room to join Kate temporarily in her present state (“That looks like a good program! How about if we record it so that you can finish it later!”) and then used her own body to generate a rhythm in the direction of the kitchen. She may also have initiated a conversation about something that interests Kate – “Remember that girl, Karen, who moved out of the school? I just heard that she was moving back!” All these things help establish a routine. Once the routine is established, it makes everything easier.


Peter Fonagy Lecture at IPMH I: Mentalization Based Therapy

MBT (Mentalization Based Therapy) focuses on how the person feels now, rather than on the past. Imagine yourself talking to a client. Try to think about how you would think about the situation the person is describing. When the other person isn’t making sense, it is because he is not bearing in mind the person he is talking to – you. That means he isn’t “mentalizing”.

The therapist makes “simple sound-bite” interventions that are affect-oriented (related to love, desire, hurt, catastrophe, excitement), and focus on the patient’s mind, not on his behavior, nor on his past. MBT relates to a current event or activity, and identifies non-mentalizing as getting in the way of the patient’s stated goals.

Technically, the therapist in MBT notes breaks in the patient’s mentalizing – when the patient starts to talk as if the world is against him and he is the helpless victim, for example – and rewinds the conversation to the moment before the patient stops mentalizing. Suppose the patient is explaining a disagreement with her boss and then says that her boss treats her the way all men treat her, in fact the way you, the therapist, is treating her right now – by not ‘hearing’ her! In fact, she should leave right now since she is just wasting her time in this therapy!” You might then go back to what the boss said to her that morning and explore how it feels the same as what is going on now between you. How is she feeling ‘not heard’ by you? You accept responsibility for contributing in some way you do not yet understand, for generating this terrible feeling in the patient.

In MBT the mind of the patient becomes the focus of the treatment. Your job as therapist is to help the patient learn about the complexities of his thoughts and feelings about himself and others, how that relates to his responses, plus how “errors” in his understanding of himself can lead to actions that cause problems for him. It is not your job to tell the patient how he feels, what he thinks, how he should behave, or what the underlying reasons are. Instead, you are helping him build new competencies for maintaining a self-reflective mind even under the stress of intense affect. Peter recommends adopting a “not knowing” stance, conveying to the patient a sense that mental states are opaque.

In the therapy, the therapist first of all helps the patient become better regulated. That sounds familiar, doesn’t it? You want to lower arousal as much as possible. Then you validate the patient’s perceptions. Finally, you begin the painstaking work of trying to get the patient to see the situation from another person’s point of view – that is “mentalizing”. Suppose the patient says, “I am just a bad mother.” That is not mentalizing. You stay with what she is saying right here, recognize the self critical feelings are flooding back, and do not turn your attention to the past. If she is not mentalizing when she tells you about herself as a mother, go to another subject and help her regain her more mature perspective, then return to her distress as a mother.

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