Category Archives: Articles

Interventions in Infancy

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Now we are ready to look at infancy. As a matter of a fact, this topic may be relevant to parents of preschool children, since these parents are often having second or third children when their first is in preschool. What we are talking about is showing parents what they can do to help their babies feel secure. If babies feel secure and safe in the infant-parent relationship, they are creating the expectation that reunion with their parent will bring comfort and safety. That expectation is correlated with a “secure attachment strategy”. When the baby is upset and cannot manage to comfort himself, he anticipates that his mother (or other primary caregiver) will comfort him, so when his mother approaches, he already begins to calm down.

The infant mental health mini-course that the nonprofit organization, Supporting Child Caregivers (SCC), teaches emphasizes the three tasks of parents – to protect, nurture, and enjoy their children. We believe that parents deserve the support of the community in raising their children. That support begins with ensuring the physical and emotional support of the pregnant mother and continuing to support the parents of the growing child. The more parents can be protected from stress, or the more they can be helped to deal with the stress in their lives, the more they can help their babies feel secure. Of course, stress can come in different packages. Most of the work SCC does is in developing countries, where there is a high incidence of chronic poverty, domestic violence, and serious illness.

However, my work in the U.S. has taught me that the stress on parents of infants even in affluent communities can be great. One important source of stress is isolation. In contrast with collectivist societies, our society does not offer new mothers easy access to alternative caregivers such as family members or neighbors. In the Indian villages I visit, mothers congregate around the village square. In the U.S., new mothers often do not have a natural way of connecting with other mothers with whom to share their worries and complaints and to gain useful information. I want to emphasize that I am not suggesting it is easier to bring up an infant in a poor country, but only that in addition to similar stresses, there are also different ones.

For example, parents of newborns in the U.S. are often burdened by the cultural demand to “multi-task”. In order to feel productive and organized they believe they must be getting many things done. It is hard to do that when you have a newborn. In order to be available to respond to the baby, it is necessary to let go of most other agendas. This can be stressful to some parents. Also, in the age of technology, parents are often “plugged in”. It is painful to observe mothers pushing their babies in strollers while they talk on their mobile phones to some distant friend, and to imagine what their sense their babies are making of the relationship.

Another big stress in Western culture is the responsibility given to parents to produce a perfect child. The expectation that good parenting produces a good child is a relatively recent one in the history of humankind. The corollary can lead to relentless self criticism- if your child has problems, then you are not a good parent. Let me clarify an important point. Whereas I have been emphasizing sensitive and responsive caregiving as a building block of healthy development, I do not mean to say that good caregiving ensures a healthy child. This is part of what I was referring to in the previous post as “uniqueness” of the child and the family.

Children are different. Infants are different. Ask any parent of more than one child whether this is true. One of my criticisms of Attachment Theory is that it does not account for the uniqueness of infants and the active role they have in making meanings about safety in the infant-parent relationship. Do we doubt that a premature infant makes the same meanings about comfort and safety as a full term baby, or that a baby with high reactive temperament can be made to feel secure as easily as a baby with an easy temperament?

Let me talk about interventions in the next posting.

Other Alternatives to the “Little Girl with a Curl” Problem

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

The second option is consultation to the parents, for example, video feedback. This can be a very effective way of showing parents in visual form the nonverbal communication they might be unconsciously giving their child. The therapy takes the form of the therapist’s analyzing videotapes taken in the therapist’s office, or sometimes in the family’s home, and then looking at them together with the parents. For example, in one family video of mine, the father was stretched out across the floor in a supplicating position, trying to get his son to comply with my request that they play together. (Remember that effective limit setting contributes in important ways to the child’s sense of security.)

Feedback like this is usually followed by an invitation for parents to talk about what they might have been feeling that motivated the behavior they saw on videotape. Often, the self-reflection initiated by the video images helps the parents identify inner conflicts that interfere with their conscious intention of setting limits on their child’s behavior. For example, in this case, the father might recall the way he felt controlled by his mother when he was a small boy. This unconscious identification with his son might be influencing his difficulty collaborating with his wife in setting limits on the boy’s behavior. The main drawback in using this excellent technique is expertise. It is very difficult to analyze videotape and relatively few clinicians are trained in it.

The third option is dyadic or family therapy. This option is a good choice in that it can help both parent and child (or the whole family) become more aware of the way they actually behave in relation to one another in contrast with the way they imagine they behave. With reference to Attachment Theory, the therapist might be seen as a new source of security, creating a sense of safety experienced by both parent and child, and allowing both to take risks at trying new approaches that might have seemed too difficult at home.

There are many schools of family therapy. For example, there is “structural family therapy” in which the therapist focuses on identifying dysfunctional patterns of relationships within the family and disrupting them in the service of creating more adaptive ones. By contrast, a psychodynamic family therapy might focus primarily on the symbolic themes presented by the family in a play session. For example, in one family meeting, the “problem child” instructed his parents to “help (him) herd the animals into the barn because a big storm is coming!” Despite the parents’ conscious intention to support their son’s agenda, the play ended without getting the animals into the barn. The therapist thought that the family was showing her their problem – they were showing her how helpless they all felt to contain the impulsive aggressive outbursts of this little boy (“the storm”).

The final option is individual psychotherapy – play therapy – for the child, plus parent meetings. Play therapy requires a therapist who is trained in psychodynamic psychotherapy. That means that the therapist has learned to make sense of the symbolic representation in play of the child’s inner world. For example, if the child anxiously fingers a broken toy and then moves to play with something else, the therapist might imagine that he is afraid of his own or someone else’s aggression and its destructive potential, and the therapist will attempt to explore the child’s more elaborated fantasies. In this case, the fantasies might be about the child’s fear that his aggressive behavior towards his mother will hurt her and destroy their relationship, making him a bad boy and causing him to be abandoned. The therapist might then slowly support the child’s capacity to reflect on these fantasies, gaining insight into what thoughts and feelings motivate the aggression – for example, that the mother loves his sister better than him – and helping him discover a more complex landscape of meanings than the polarized all bad and all good ones the child started with. The work with the parents will focus at least in part on helping the parents understand their child better, gain empathy for him, and learn new approaches to setting limits. For example, in this case, the mother might find ways to help her son make a repair after hurting her, instead of punishing him with a lengthy time out.

It is hard to describe these complicated processes in such an abbreviated way, but I have tried to offer you some ideas about what to do to try to make the “Little Girl with a Curl” problem better. Returning to Attachment, you can see that problems with roots in infancy can be approached in various ways later on; there are many ports of entry. Each individual is unique and will make different meanings of themselves and their family relationships. I will talk more about this uniqueness and its relationship to Attachment Theory in my posting on interventions in infancy.

 

Growing the Attachment Strategies of Preschool Children

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

I am going to offer several ways of doing this, with the understanding that I will continue to think about it and add more later.

The first option is to intervene in the school setting with the help of teachers and other school professionals. The second is consultation to the parents, for example, video feedback. The third is dyadic or family psychotherapy. The fourth is individual psychotherapy for the child; this would necessarily include meetings with the parents. These options are offered in order of increasing intensity of intervention with the idea that if parents choose an intervention of lesser intensity that proves ineffective, they may then choose a more intensive alternative.

Intervention in the school setting is predicated on the assumption that school is a safe environment; that means that the child is adequately compliant with the teachers’ directives, follows the school routine, can access the school curriculum, and can relate to peers relatively well. If the school is safe for the child, the teacher and parent can prepare him or her for appropriate behavior at pickup by breaking up the transition into manageable steps, previewing the experience, and having a teacher available to coach the child and parent through the reunion.

The parent should follow up afterwards with behavior designed to consolidate the positive reunion by encouraging the child to talk about her day and giving the child comforting feedback for difficulties and positive recognition for achievements. This is the tricky part, because the pattern that gets established when the child makes a fuss about pickup generates stress in both parent and child, so that warm, responsive communication at pickup time is usually contaminated with anxiety. Even when the pickup is successful, both parent and child are anticipating some negative experience. Also, there is an unconscious pull back into the problem pattern. That is because it is a habit, well practiced and therefore “simpler”, taking less energy in the short run, though more in the long run.

The parent can try to make declarative statements instead of direct questions that put the child on the spot – starting the comment with “I’ll bet” or “I wonder if” or “I’m thinking that”, for example, “I’ll bet that you liked the cooking activity today,” or “I wonder if it was sad for you that Martha was absent from school today.” If the child gives monosyllabic responses, just tell her that you guess she needs to rest after a long day and maybe you can talk about it later.

The thinking behind this plan is not strictly behavioral. It draws on Attachment Theory and nonlinear systems theory (odd bedfellows, actually) in that it seeks to practice more adaptive interpersonal patterns – reunion – over and over again, with the input of support (“energy”) from the teachers. If a new strategy for reunion after a separation is more successful and is practiced enough to become a stable part of the parent-child relational repertoire, it can facilitate the child’s development in a more general sense.

I will discuss the other options in subsequent posts.

The Problem of “The Little Girl with a Curl”

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

A particular problem has come to my attention over the years consulting to a preschool – children behaving in controlling and sometimes aggressive ways to parents at school transitions. Teachers report that the child behaves badly with his or her parents at drop off and pick up. Often the teachers express amazement that the children who seems well behaved in school, can change dramatically when they are with their parents – boss them around, even push or hit them. Another behavior characteristic of this problem is the child running away from the parent or refusing to come with them at pick up time. It is difficult for even the most empathic teacher to avoid the suspicion that the parents are somehow allowing their child to mistreat them by not setting adequate limits for the child. Supportive evidence is sometimes found in parents restraining from disciplining their children in the school.

This situation reminds me of a Mother Goose rhyme that my parents read me when I was a young child about a “little girl with a curl”. The rhyme goes, “There was a little girl who had a little curl, right in the middle of her forehead. When she was good, she was very, very good. But when she was bad, she was horrid.” I always secretly worried that I might be that girl.

Perhaps partly for that reason, I have given this problem a good deal of thought. My conclusion is that the answer to the mystery of the “little girl with a curl” mystery is rather complicated. The reason I say this is that when I talk to the parents of these children, I get a wide variety of answers about their child’s behavior in different settings. Some children are relatively well behaved in most settings and become suddenly noncompliant and belligerent at pick up time. Other children are compliant when they are involved in activities but become disorganized and unhappy during unstructured time at home and in school. Some children are usually cooperative but have difficulty with all significant transitions – bedtime, getting up time, leaving an activity, etc. Other children are always a handful.

What ties together all the children who fuss at pick up time and behave defiantly with their parents but not necessarily with their teachers? All these children are expressing difficulty with finding a positive strategy for reuniting with their parent. The subject of reunion strategies falls into the domain of a theory that informs much current developmental research and that has now also become popular in the vernacular – Attachment Theory. I have talked about Attachment Theory in other blog postings, because of its importance in research. The essential feature of Attachment Theory is that it presents the infant’s essential motivation as staying close to the parent in order to feel safe and secure. If the infant achieves the capacity to feel secure in his relationship to his mother, then he is free to explore the world, knowing that he can easily return to the safety of that connection.

We know that an important but primitive response to threat is running away or aggression. Remember that the “fight or flight” response of the sympathetic nervous system is one of the main “bottom up” as opposed to “top down” responses of the stress regulation system. That means that we must feel confident in our capacity to achieve security in order to use our thinking brain to tell us what we should do in a threatening situation. Transitions are inherently threatening, even small ones, because they require us to disorganize ourselves on the way to a new organization. That is, we have to stop playing in the sandbox in order to join Mother, get into the car, stay still in the car seat, etc. Playing in the sandbox is a complex organization involving a cognitive plan (building a castle), a motor rhythm (dig, pour, pat; dig, pour, pat), an affective and physiological state (contented, calm); and maybe even a compelling interpersonal experience (collaboration or competition with a peer). That is a lot to take apart in order to get into the car. And the hardest part is the disorganization in between the sandbox play and the car seat, between one organized state and the other. How do children manage that transition? It starts in infancy with the regulatory aid of the parent.

These interpersonal regulatory patterns that start in infancy gain power and stability as parent and child repeat them over and over again during the course of daily life. One pattern, that Attachment Theory would call “secure”, is demonstrated by the parent-child dyad who are able to support the child in managing all these disorganizing (and therefore threatening) experiences of – letting go his plan of building the castle, discontinuing the motor rhythm, interrupting the calm and contentment, and giving up the competition or collaboration – and maintaining adequate regulation and sense of security until the new car seat organization is established. I say “parent-child dyad” because I do not see this activity of facilitation transition as emanating exclusively from the parent. Although sophisticated advocates of Attachment Theory would probably agree with me, Attachment Theory largely tends to place the responsibility squarely on the mother, who carries attachment patterns within her even before her child is born, according to the AAI.

I will tell you how I use these thoughts about Attachment Theory in my search for answers to the “girl with a curl” problem in my next posting.

More on Family Values

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

I would like to add another piece to the posting of the previous post on family values. It is related to “truth” but what I am actually referring to is “pretend”. A recent Harvard Gazette (March 27, 2017) issue referred to a panel at the Berkman Klein Center for Internet and Society discussing “fake news”. The panel noted the difficulty defining the term with clarity since it can encompass anything from an opinion piece cited as news to state-sponsored propaganda. What I found most interesting about the article was the focus on the idea that “fake news” has a “cultural logic” that appeals to a particular audience (Xiao Mina, ibid). Another scholar on the panel, Sandra Cortesi, suggested shifting the focus from the question of whether something was “true” or “false”, to the question, “What do you value?”(Cortesi, ibid). It seemed to me, reading the article, that this speaker was onto something.

In the past half century, our society has experienced a disorganization that has included a fracturing of traditional values. Maybe some of that fracture is due to the radical change in the way we communicate and even relate to one another at a distance through screens. Maybe it has to do with the related effects of globalization and the breakdown of the comfortable boundaries that affect our sense of safety. Maybe it also has to do with changing economic factors such as the loss of certain reliable jobs and the pressure to innovate. I am sure that economists, social psychologists, and sociologists have many more answers than I. However, it does bring me back to my emphasis on family values and how important they are. If societal changes create strain on traditional family values, what do we do? Living together in a civilized society requires certain rules; can we afford to give up values like “truth”?

I had an even more sobering thought. Being a child analyst, I am fascinated by and committed to the value of pretend. But pretend depends on truth for its existence. How many times has a child reassured me (or himself) by announcing firmly during a play session when the mother doll was getting skewered, “Don’t worry. It’s just pretend. It’s not true.” The difference between “pretend” and “fake news” is that pretend is a creative act that represents a meaning intolerable in its original form, such as a murderous wish. A pretend murder in play has fanciful elaborations – and most important – it has the flexibility to be undone. In its pretend form, it can be transformed to allow new possibilities. Whenever a child plays “good guys and bad guys”, I wait for that wonderful moment when one of the good guys switches over to the bad guy side. Then I might say to the child, “Hmm. If that good guy switched sides to become a bad guy, I wonder if a bad guy could switch to become a good guy.”

In his play, the child is creating a space for dynamic transformations that make possible positive change. That is not true for fake news. The political untruths and fake news spread by this political administration and some of its followers have none of these features. They are rigid, stark, and reductive. The false equivalency between the accusation of Obama’s foreign birth (the “birther controversy”) and Hillary’s misremembering a glorious but false event (the helicopter under fire incident) should be evident, even without the continued restatement of the former and the embarrassed retraction of the latter. Fake news makes a mockery of the idea of positive change.

We as parents and supporters of parents, which should include all of us, now face the challenge of reviewing our family values and growing them into the contemporary world. In many ways we need them more than ever. Truth – lies spread over the Internet have motivated anguish and even suicide in our youth. Responsibility – refusing to take responsibility for one’s actions – such as Trump’s accusations of Obama’s wiretapping, or inactions such as the poor preparation for replacing Obamacare, has degenerated into infantile assigning of blame. Respect – lack of respect for the beliefs of others, such as immigrants of other faiths and even for one another with different points of view, makes dialogue impossible. Protest – against offensive government actions, on the other hand, can invigorate us and force our elected representatives to behave according to our values. And I must add compassion, for those who would lose their safety net if certain government policies were enacted, and for those suffering the unimaginable horrors of war in other parts of the word. Yes, now is a time more important than ever to strengthen our family values – to live by them and to teach them to our children.

Co-Parenting II

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Co-parenting frequently breaks down in parents’ efforts to organize home life or set limits. That may be in part due to the emergence of different parental styles in the planning process, such as when the parents are deciding on a bedtime for their child or establishing family rules. One parent may feel that the organizational plan (for example, setting a regular bedtime, the number of warnings a child is allowed before a consequence, whether a child is allowed an alternative meal choice, etc.) is too rigid, while the other parent feels it is not strict enough. These conflicts often arise from what seems natural or necessary because of the parent’s own experience as a child. Sometimes the parent believes that the way their parents treated them shaped them in helpful ways. Other times the parent believes that the way they were brought up was hurtful and insensitive to their needs. In addition to differences in the way they grew up, problems in “co-parenting” may also arise from basic difficulties the parents have negotiating a common agenda. One parent may tend to be more controlling or bossy than the other, provoking the second parent to dig in their heels or resentfully submit, etc.

When these problems occur, it is important to return to a focus on the child. What is the child telling you that she needs? If she is tired the next day, perhaps she needs an earlier bedtime or some other change in her bedtime routine. (Of course, telling her this when you are trying to get her to go to bed will not usually lead to a good result!) If she requests something else to eat at the dinner table, perhaps an alternative meal choice is justified. It is good to be flexible within limits. The problem comes when parent and child – or parent and parent – get into an escalating control struggle and share the perception that only one winner will emerge from the battle. The truth of the matter is that in a struggle, there are always two losers. That is because both parents and child want the child to grow up healthy and strong, but struggles build unhealthy and maladaptive patterns in the child’s mind which are reinforced with subsequent struggles. The pull to get into a struggle, often against a background of family tension, can interfere with generating or establishing healthier patterns of interaction. Good co-parenting occurs when one parent can see that the other parent is in danger of falling into a struggle pattern and can give them the emotional support they need to avoid it.

Children need routines and predictability, especially in families with co-parenting difficulties, or in families of children with school or behavior problems. Often these two things go together because difficulty co-parenting clearly interferes with effective parenting, and also because some children are harder to parent and generate more than usual stress in their parents. Children with school and behavior problems may lack the personal resources to accommodate to the typical demands of school and family life. A common set of problems that cause trouble in school and at home are problems organizing oneself in time and space. That makes transitions particularly challenging – the transition from sleep to an awake state or from an awake state to sleep, from an activity to homework, from a video game to supper, from a quiet indoor activity to outdoor play, from free play to paying attention to the teacher, etc. One way to help children in all these circumstances is to create routines and stick to them. Often children benefit from “visual cues” such as words or pictures on calendars. These cues must be kept in a visible place that is commonly visited, such as the kitchen or the bathroom. However, none of these aids will be useful if they are not practiced regularly and frequently. For example, it is helpful to refer to a calendar of the day’s events both at bedtime and at breakfast. This is an area of parenting that often breaks down. If two parents can maintain a routine, they are doing something right.

Co-parenting

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Co-parenting

Recently, a couple of parents came to consult me to ask me about “co-parenting”. This is a term that parents typically use to refer to working together as parents when they are divorced. In this case, the parents were married, but they still had trouble coordinating their parenting behavior. They attributed this difficulty to difference in parenting style. I have heard of this kind of difficulty many times before, and I particularly appreciated these parents seeking consultation about it.

Let me first say a few things about “different parenting styles”. Conflicts between parents may arise for a number of reasons. Three common reasons include: different experiences of being parented as children; chronic stress in the family; underlying conflict in the marriage. Often more than one of these factors is present at the same time. Let’s take them one at a time.

Suppose that the father was raised in an authoritarian family in which his parents were strict and what they said was law. The children would not dream of speaking disrespectfully to them, and discipline for transgressions was swift and sometimes harsh. The mother, on the other hand, was raised in a household with progressive values and style of discipline. In practice, that meant that the father was the “bad guy” disciplinarian and the mother the reluctant protector the child ran to when he fled the father’s discipline. This meant that the father felt unsupported in setting limits on the child’s behavior and the mother felt burdened with having to respond both to her partner’s and her child’s distress.

There is an answer to how to think about how to change this situation. Note that I do not say, “resolve the problem”. The answer about how to think about the situation is to put aside the conflict between the two parents and focus on the needs of the particular child. I will follow this line of reasoning in responding to the questions the parents in my practice brought to me.

The first question the mother asked me was how to manage the morning transition. She explained that her 8-yo son was always forgetting what he had to bring to school, and he not infrequently called her from school because he forgot some sports equipment or a piece of homework. The father expressed his frustration about his son’s disorganization and insisted that the mother ignore his calls and let him “learn from experience”, but the mother felt that to do that set her son up for failure.

Further exploration suggested that their son had a more general problem with organization that impeded his ability to make transitions. (Remember that to make a transition you have to take apart your current state of organization, such as eating breakfast at your kitchen table, and reorganize it in a new place and with new expectations, such as school.) With this in mind, the parents and I set up a routine (remember that routine and ritual are parents’ best friends!) for how to manage the morning transition. Children need routines and predictability, especially children with organizational problems (sometimes referred to as “executive function disorder”, though I do not like to use the term “disorder” in children if I can avoid it). Once we established their child’s need for external predictability and order, we could move on to discuss how each of them – with their different parenting styles – could work together to provide that for him. The father took in my explanation about how the child could build organizational capacities that were not yet in his repertoire by practicing routines created by both parents, and he volunteered to keep an eye on how the family maintained the routines. The mother said that she could validate the child’s feelings about being confused, overwhelmed, and criticized, while also holding to the routine. Both parents agreed to try to learn from each other in the process of helping their child grow stronger.

In my next blog posting I will consider the parents’ next question: “How do we translate the difference between our two parenting styles for our son so that he understands where we are coming from?”

The Election and Family Values

2qwKCSSxn_Ou-Y6GXKf2y7tTHC_nxM7oxbtlgqSrJw0,NDariSEd2Qz1v1zn_zUdsiMVch9e_NP6yQYWhR4NeSg

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

After the election, I was moved to write a blog post to parents and other child caregivers to support them in talking to their children about the election. Many parents at the preschool where I consult were angered or weeping at the election results, and there was a natural concern that their children would feel frightened and insecure and wonder what the world was coming to. Immediately I found a number of excellent essays and blogs that stressed what I agreed were the primary points for child caregivers to consider: first, regulate yourself, and then reassure your children that they are safe and that the world will go on.

A week later, I have had other thoughts, largely in response to the efforts of President Obama and many other liberals to reach out to Trump in a constructive way and to extend themselves to his supporters. In some respects, I thought this was a good thing. Yet, I also felt there was something not quite right about this, that there was something missing or being lost, and I reflected on it.

I realized that in addition to helping child caregivers reassure their children about their safety, there was something else I wanted to say, and it referred to one of the familiar subjects in my blog – “family values”. The election provides parents with a unique opportunity to teach their children about their values and reinforce the values they want their children to carry into adulthood. I will suggest only 4 here – truth, responsibility, respect, and protest, or the constructive use of anger.

Truth – There is value in telling the truth. Many of us stress this with our children. Sometimes people stretch the truth or even occasionally deny the truth when they are frightened or ashamed. We teach our children to try not to do those things, because honesty is an important value. However, stretching the truth or occasionally denying it is very different from having no regard for the truth, for saying whatever you think will serve your purposes without any evidence of conflict or shame. This is what Trump did during his campaign. That is not what we want to teach our children.

There is another aspect of truth that has to do with what is true. People are often quick to accept simple answers that make them feel good or that affirm their beliefs. That is understandable, but it is not the best we can do. It is hard for all of us to push beyond our cherished beliefs, to challenge ourselves by exploring what is foreign to us. Extreme elements of the press tell their audience half-truths or falsehoods in order to promote a set of beliefs. That is not only bad journalism; it undermines the value of honesty. It is important to teach our children that we must always search for truth, no matter how unpleasant, frightening, or confusing the search, and no matter that we can never actually reach “truth”.

Responsibility – one must take responsibility for one’s actions. That includes the words one speaks. It is not OK to say hurtful, insulting, or false things at one time and later say, “I didn’t say that,” when you did, or “That was then and this is now.” It is insulting to hear Donald Trump’s cruel remarks and lies be referred to as “campaign rhetoric” or “distortions of the liberal press”. Videotape evidence exists to show that he did say these things. The people who maintain that Trump did not say them either avoid that evidence or knowingly deny it. If we accepted it when a child said, “I lied and said hurtful things to get what I wanted. Now that I have what I want, I ‘take it back’,” we would not be teaching our child good values. Actions must be accounted for, and speech is action.

Respect – The belief that all people were created equal is an important part of who we are as Americans. Attacking groups of people and devaluing them or mocking them – Muslims, women, African Americans, the disabled – is wrong. Again, it is not something you can “take back”. To say, as we have heard some Trump supporters say, “That is not the Donald Trump I know” is hardly reassuring. Do we want to teach our children that we will ignore their bad behavior if sometimes they behave well? Do we want to teach them that if they are bullies sometimes it is OK if other times they are not? No. We want to teach our children respect for all human beings.

Protest – anger is not in itself a bad thing. It is what you do with your anger that counts. If in response to your anger at feeling like a loser you attack someone weaker, then that is being a bully and that is wrong. If you use your anger to motivate constructive action – peaceful protest, searching for answers, fighting for rights of others – then that is what the civil rights workers, the suffragettes, and reformers across the ages have done – and that is good. That is what we want to teach our children.

It is distressing to hear the claim that it is “unpatriotic” to wish Donald Trump’s presidency will fail (Bret Stephens, Wall Street Journal, p. 10, Nov. 16). I agree that we should respect the electoral process, something that Donald Trump did not do when he refused to say that he would accept the results of the election if he did not win. I agree that it is good to hope our country grows in a healthy direction for all its people; I do have that hope. However, to celebrate a government that won by insulting the values of honesty, responsibility, respect, and constructive protest – not to mention generosity, humility, and compassion – would to my mind be essentially unpatriotic. That is not what we want to teach our children. The values that guide our behavior towards others and that help us know ourselves – these are precious. If the country we belong to elects a leader who scorns these values, we lose something. Many of us feel that loss. We must now grieve the loss and try to learn from it. That will be something good we can do for our children.

Stress Regulation: From Theory to Practice

Shantudraw05

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Stress Regulation: “From Theory to Practice”

Perry’s ideas about stress regulation are particularly important to me in my clinical work. In contrast to the negative cascade stress can cause in a sensitized child, helping a child grow his stress regulation system may initiate a healthy “cascade” effect.

In my practice, if a child gets better at calming herself, she can pay more attention to my ideas about the motivations for some of her problem behavior and consider trying more adaptive ways of behaving. For example, if a child is poorly regulated, she will not be receptive to my observations that when she starts out with “loser feelings” she cannot bear to play competitive games with her peers. She is more likely to use psychological defenses such as denial and avoidance to protect herself from the stress of acknowledging her painful feelings. If, however, we begin by my giving her a “handicap” that makes it easier for her to win, and then emphasize the rhythmic, repetitive turn taking patterns of the game with my actions and with my voice, she may be able to establish and maintain a receptive, alert position in relation to my communications and even allow me to scaffold some self reflection. In play sessions with one child, I would ask her at the beginning of the session whether it was a “bad guys in” or “bad guys out” day for her before we settled into a game of Candyland. If it had been a hard day for her, we would take all the cards that send you backwards out of the pile. If it had been a good day, we would leave them in. This small ritual allowed us to play the game together, while also helping her begin to reflect on and identify her feelings, and eventually appreciate the link between her temper tantrums and her sense of herself as a “bad girl”.

In psychology and psychoanalysis we refer to “respecting the child’s defenses”, something that Anna Freud talked about. That means not overwhelming a child, usually by avoiding confronting him with information he is not ready to receive. Perry’s idea of “dosing” and “spacing” adds a new dimension to the concept of “defense”. It brings the body into the equation in an important way. Thinking in these terms helps us organize our interactions with a child in time and space. It helps us put the music and dance into our clinical work. Because I study videotapes of my work with children, I see the nonverbal communication, what I call the “music and dance” of psychotherapy, both in a standard time frame and in a microprocess, second by second, time frame. In the microprocess, you can see this dosing and spacing even better than in real time. For example, in one session with a 4-yo boy, you see me introduce an idea about something scary to him; I deliver my communication in short (2 sec) vocal turns defined by short internal pauses (“dosing”) and then, right after I finish, I sit back and fold my arms across my chest. This is “spacing”. When you look at the film in slow motion, you can infer my (out of my awareness) intention of giving him space, giving him a turn.

“Dosing” adds the factor of measurement, of size, which I think is very useful to keep in mind. I remember playing with a little boy who felt the need to exert extreme control over me in the session. In order to help him grow, move him towards reciprocity, I had to stress him by interrupting him sometimes, declining to jump to comply with an order, or by adding a detail of my own to the narrative that he was spinning, any of which could make him mad. Sometimes I “dosed” my contributions by adding humor, sometimes I made them very short, and other times I acted a little confused. Slowly, using dosing in that way, he began to give me a turn now and then.

Spacing is another very helpful perspective. “Spacing” is even closer to the theory of psychological defenses than “dosing”. I was observing the need for “spacing” when I sat back and folded my arms across my chest in the previous example. Another example is my work with a child who lost a parent. When he saw me in the preschool classroom, he would “pretend” reject me by playfully pushing me away or telling me in a loud voice to go away. I would play along, sometimes moving back a few inches, but not going away until it was time for me to say goodbye. When you think about it, there is a lot of communication in our behavior. He is telling me he needs to know if his behavior can cause me to disappear forever, and I am telling him that his behavior is unrelated to when I come and go. My leaving the classroom was a dosing experience for this child. One day after many months of this daily play (“spacing”), I stood to leave, and the boy approached me sideways, without giving me a direct gaze, and leaned against me. I stroked his hair and he didn’t move.

In addition to dosing and spacing, Perry’s thoughts about “distributed caregiving” have also been helpful to me. Actually, what has happened is that my own clinical experience has been moving me further and further from thinking in terms of categorical diagnoses and “clinical” interventions. Instead, I think about children’s problems more often in dimensional terms and tend to move to support the child’s caregiving environment before immediately beginning an individual psychotherapy. Supporting the child’s caregiving environment means working with the child’s parents and teachers. One of my favorite ways of intervening is to work in the preschool. Then, I not only have a chance to offer the very capable teachers an insight now and then about a particular child. I also have the chance to “be there” for certain children when and how they need me. This is what Perry means by “distributed caregiving” – allowing a child to initiate a particular kind of interaction with each caregiver in a group available to him. This kind of thinking moves away from formulations about pathology and towards developmental goals. For example, Perry talks about how after the Waco disaster, the traumatized children seemed to identify particular caregivers for specific needs of the child – one for help with schoolwork, another for rough housing, another for snuggling. I have seen the same kind of distributed caregiving activity in the preschool classroom with healthy children.

I realize that psychotherapists and even psychoanalysts like me sometimes consult to teachers in schools by sitting down with them and listening to them talk about the children and answering their questions, and even by entering the classroom to observe certain children pointed out by the teachers. What I prefer to do is “live” in the classroom so that I can see the children in action and sometimes engage directly with them, while at the same time trying from time to time to identify what the teachers can do even better. For example, I might see a little boy who seems more fearful than average and begins tentatively to play with a toy car. I might suggest to the teacher that she encourage some gentle crashing games if the child initiates them.

In closing, I would like to emphasize the importance of rhythmic patterned activity that is repeated over and over again in helping people grow. This is very different from what I learned in psychiatric and psychoanalytic training. It is not that I have not engaged in that kind of activity in my clinical work; I have. On the other hand, now that I have integrated it into my theory, I do it more, and I do it better.

Stress Regulation: Bruce Perry

swati-and-son

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Every time I hear Bruce Perry speak, I hear something new, and I take a step forward in making sense of my experience with children and families. On September 16, Bruce talked to our IPMH course about his “theory of change” – Change is created by an intentional act that is repeated in a way that will influence the system in the brain relating to the function you are engaging in the action.

As always, he grounds his remarks in the science of the brain – although he is careful to remind us that all “models” of the brain are gross oversimplifications and only useful in so far as they help us understand how the brain works. That is because the brain is unbelievably complex. There are approximately 86 billion neurons in the human brain and many more glial cells. The brain is hierarchically organized both in terms of architecture and function. The most “primitive” part of the brain – the part that is most like the brain of primitive animals – is at the base of the brain. This part, including the brainstem and cerebellum, maintains bodily equilibrium – body temperature, heart rate, blood pressure, and respiration. Above that is the diencephalon that regulates functions such as appetite and sleep. Then there is the limbic system that deals with basic emotions such as anger, fear, and happiness, and also affiliation, and reward. Finally, there is the most uniquely human part of the brain, the cerebral cortex, that produces abstract though and the more complex emotions of guilt and shame. Yet, every time we introduce a model of the brain we oversimplify; these anatomical parts of the brain do not relate precisely to the functions described; it is complicated.

In addition to “intrinsic neurons” that make primarily local connections, there are neural systems in the brain that have wide distribution throughout the nervous system. These systems, such as the ones of the neurotransmitters norepinephrine, serotonin, and dopamine, are crucially important in managing stress. The stress response systems connect the lower parts of the brain with the cortex and also connect the brain to the autonomic nervous system and to the endocrine system, the immune system, the musculoskeletal system, and the internal organs.

As we have noted in other blog postings, the lower part of the brain forms earliest in intrauterine life when the brain is growing most rapidly and is most subject to influences from the environment. Although “neuroplasticity”, or brain growth, occurs throughout life, the most rapid and profound changes occur in the first few years. That is why students of development stress the importance of a good early caregiving environment. An adequately responsive, consistent, and predictable caregiving relationship can modulate the effect of adverse experiences on the developing brain.

When an infant experiences an adverse event – such as exposure to toxins in utero – there can be a “cascade” of effects. The lower part of the brain may be primarily affected, but because the child then becomes compromised in his ability to regulate stress, subsequent development of all the interrelated parts of the brain and body may be affected. That is the reason why children born into homes that suffer chronic poverty, domestic violence, and substance abuse, for example, are more likely to have problems with their emotions, their relationships, and learning.

The neural networks of the stress response system are in dynamic equilibrium. Too high a level of stress-inducing novelty will activate the system in order to lower the stress. Too low a level of novelty will cause the system to increase stimulation to restore alertness. When a child experiences repetitive, unpredictable, stressful events, her stress regulation system will be sensitized, lowering her set point and causing her to be more vulnerable to similar stresses in the future and to react with a more extreme response. A child may be sensitized by a chaotic or violent home environment. He may also be sensitized by vulnerability caused by inherited developmental vulnerabilities or serious childhood illnesses. For example, a child who inherits genes associated with “autistic spectrum disorder” (I put this in quotes since I consider this a highly problematic diagnostic category.) may be highly stressed by making eye contact with another person. A child with this inherited vulnerability is sensitized early in life and will inevitably have multiple repetitive adverse experiences while living in what for another child might be a comfortable home life.

In order to change the regulatory set point of a stress response system in a healthy direction, it is necessary to activate the same system with small repetitive stressors that are organized in an appropriate pattern of dose and space. The last time I wrote about Bruce Perry, I introduced his idea of “dosing”, one that I find very important in my therapeutic work. This time Dr. Perry introduced another important concept, that of “spacing”. Dosing means that you apply a stressor but not in a dose that is beyond the capacity of the child to manage; you do not overwhelm him. Spacing means that you time the doses so that the child is prepared for another challenge. For example, if I am working with a child who becomes easily dysregulated by negative affect states, I am likely to accept her protestations that she really loves her little brother for some time before gently questioning them.

I will continue the discussion of how I use Bruce Perry’s ideas in my work with young children in my next blog, “Stress Regulation: From Theory to Practice”.

Bruce Perry, Lecture, U Mass Boston Infant Parent Mental Health Course, September 16, 2016