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Archive for the ‘posttraumatic stress’ Category

I’ve just fielded a question on the Talk page of the Wikipedia article on PTSD. It’s a good question (a couple, actually), and my answer might be useful to repeat here. The visitor asks why the article says this:

“Children may develop PTSD symptoms by experiencing bullying or sexually traumatic events like age-inappropriate sexual experiences.”

The concern is the reference to “age-inappropriate sexual experiences” rather than “rape”.  “Why does it say that instead of simply rape?  The Webster dictionary defines rape is having sex with who is below a certain age [http://www.merriam-webster.com/dictionary/rape%5B3%5D].  And what does age-inappropriate mean?  Would it be less dramatic if the person was their own age, instead of significantly older?”

My response (edited very modestly, for this venue):

I don’t have time to provide you with the reference citations which I’d like to offer, in responding to your questions, but  will respond using the knowledge I’ve acquired from many trustworthy sources in over 30 years of work in clinical and research psychotherapy, involving adults, adolescents, and children, many of whom had experienced what we call age-inappropriate sexual activity, often with negative consequences. I hope you’ll forgive my not backing up what I say with proper sourcing.

First, your questions are excellent ones. Please understand that casual language is often sloppy, and this won’t help us here. What the law, or the dictionary, defines as rape may well be different in important ways from a medical or psychological definition. The dictionary you cite appears to be giving a pseudo-legal definition. There is no “right” definition. Linguists write definitions (and dictionaries which contain them) on the basis of how people USE words. Philosophers and other thinkers are free, of course, to ”stipulate” definitions, as well. In formal, thoughtful writing, we usually stipulate definitions so that they help us with our thinking. They become tools, used to accomplish goals. That’s why legal people see “rape” differently than, say, anthropologists, or therapists. And note that even in groups of professionals in the same field, definitions can differ significantly.

So, let me begin by saying simply that from my perspective rape is always inappropriate (!), and is AGE-inappropriate when it involves a sexually immature individual. Note that physiological sexual maturity bares only a loose relationship to legal sexual maturity, and for good reasons (which I won’t take up here). If only some rape is ”age-appropriate”, as opposed to simply ”inappropriate”, it is also true that not all age-inappropriate sexual behavior is rape – which I think should be obvious, upon a little reflection. Inappropriate touching, for example, isn’t necessarily rape.

Age-inappropriate sexual experiences, in psychology/psychotherapy are those generally seen as those which involve an individual doing something sexual which is clearly not usual or expected for their age. This can be tricky to distinguish, however. Clearly, many, if not all, infants and children explore their sexual organs, and each others’, as well. This is normal, and generally harmless. At what point is something age-inappropriate occurring? There is no clear dividing line. It not dissimilar to the problem of distinguishing pornographic literature from erotic literature. I can offer no easy solutions to these problems.

That said, the key concept here is that sexual experiences involving children/adolescents who are not sexually mature ”can” have immediate and/or delayed long-term negative consequences. This is clearly cause for concern. It is very important to note that not only are not all sexual experiences children have inappropriate, not all of them cause any problem at all. Event consequences are driven by the degree of involvement, the nature of the act, whether or not there was coercion, how the child felt about it at the time, the reaction of adults who came to learn of the event, and so on. Many factors influence the consequences of a sexual experience involving a child.

We should never simply stipulate that something MUST be a problem (although this is commonly done in courtrooms). Rather, when we let the individual involved tell us of their experience and what it means to them, then we can know the real psychological consequences.

Well-meaning people can create a problem where none existed, with a child. Some individuals come through quite serious experiences with very little if any damage. Others are greatly hurt by what appear to be modest experiences. And, regardless of the consequences, those of us who come to learn of a given experience may have good cause for concern. It would be nice if we could view all this in simple terms, but I don’t think that would be accurate, useful, or intelligent.

Among the problematic consequences of age-inappropriate sexual behavior which we deal with in clinical psychotherapy are these:

* Lose of a child’s sense of safety: Loss of control over what’s done with your body is at the least unpleasant, and at worst traumatic. It may be difficult to feel safe in the world for some time after such an event.
* Loss of trust of key individuals in a child’s life: A sexually inappropriate relative becomes an untrustworthy relative. Children need families they can trust. A sexual abuse incident is one way to lose a functional relationship with a sibling, or a parent, or a grandparent. This can have long term consequences.
* Outright psychological trauma: When there substantial levels of fear involved, and the child is unable to resolve these feelings. enduring trauma may result. This is how once acquires PTSD.
* Premature sexualization of the child: This is the problem non-professionals usually forget or ignore or have no awareness of. Children introduced to sexual experiences before they are ready or desirous of them, may come to think that sex is a part of emotional intimacy. This may lead them to be sexual with other children, or other adults, in unwanted and unacceptable ways, and in ways that can damage others as well. I once knew a very pretty, charming 10 year old girl who had been removed from a succession of foster homes because she couldn’t keep her hands where they belonged. She had been “prematurely sexualized”. She thought what she was doing was OK, and her behavior led to repeated social rejection. This sort of thing is far more common than most people realize, and definitely one of the reasons why we’re concerned about age-inappropriate sexual behavior. It can lead to an child’s experiencing themselves as unacceptable to others in general, which can lead to depression, self-medication with various psychotropic substances, and other long-term damaging consequences.
* Disturbance to individuals associated with the child: Even when inappropriate sexual experiences are not a problem for a child, they can be for others. I dealt with a 9 year old boy once whose parents were quite upset because his female babysitter (age 13 – and not a relative) had climbed into bed with him late at night. They couldn’t imagine that he wasn’t somehow injured by this experience – clearly (one would think!) age-inappropriate sexual behavior. It turned out that he was only annoyed. He couldn’t make sense of what she was doing, and got up, went downstairs, and slept on the family sofa. Problem solved. All I had to do was calm down the parents, so they wouldn’t continue to disturb their son.

This is not intended to be a complete list, but I do believe it addresses most major issues.

Relative to a hypothetical age-inappropriate sexual experience, you ask “Would it be less dramatic if the person was their own age, instead of  significantly older?” It could well be, although “drama” is not the issue, as I’m sure you realize. The problem with older individuals is their misbehavior can lead to a needless and inappropriate distrust of all older people. Also, older individuals are likely to initiate more mature (and thus age-inappropriate) activities with younger individuals. At the same time one must note that in most cultures it is deemed appropriate for young, sexually mature hetersexuals to pair off such that the male is older than the female – one major research effort determined that the age difference deemed ideal by many cultures was about 3.5 years (with the male being older).

I will conclude my remarks by saying that I’m concerned about the tendency in some families, communities, and schools, to pathologize the normal. Two six year old girls simulating intercourse, because they are curious and cannot make sense of why adults would do this, do not really need a semi-hysterical, or punitive, or any other negative reaction from adults. I could cite other cases, many of them not so easy to think about…and that’s my point. A thoughtful examination of an event is a far wiser response than is a knee-jerk negative reaction of any kind. I prefer to act from knowledge rather than pre-drawn conclusions based on some principle rather than good data. It think that we don’t yet have all the knowledge about age-inappropriate sexual experiences that we’d like to have. The situation is clearly better than it has been in the past, without doubt, but we’re not finished out work, so to speak.

I hope my responses are useful to you. Thanks for your great questions!

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Many of the people I work with as a psychotherapist have been very seriously impacted by their life histories.They did not ask for this. It’s like a rock that falls out of the sky, striking them for no discernible  reason. It’s our task to go forward and make their lives work better. Sometimes rather simple tools yield powerful results, as I relate here.

The problem: getting control of intrusive symptoms

Many of my clients have Post-traumatic Stress Disorder. This is usually quite treatable, but success in treatment often isn’t simple. Sometimes I’m faced with a client whose symptoms interrupt their life so much that it makes ongoing treatment difficult if not impossible. This is (obviously) a show-stopper. We simply must moderate the impact of those symptoms if we are to get treatment launched (which will, of course, we expect to make the symptoms go away).

An example: I have a client whose depression, social isolation, high degree of distractibility, and intermittent flashbacks all result in their having real difficulties in remembering appointments, much less actually showing up for them. Symptoms of their disorder are effectively blocking treatment, so we must achieve real symptom management if we’re to accomplish anything significant.

The intervention: tracking symptom intrusion events

So, we recently started formally tracking commitments he makes – for phone calls with me (in which I do brief counseling), as well as psychotherapy appointments. We use an online Google Docs spreadsheet to track both individual commitments he makes AND, should he fail to keep a commitment, the disruptive symptom(s) which impacted him and caused the problem. The purpose of this is help us both focus on identifying and improving management of specific symptoms which are making his life dysfunctional. To both of us, this direct, straightforward, utilitarian approach appears to be working.

It’s about behavior change, not moral re-tooling

There’s also an important implicit message being conveyed here: when you don’t keep a promise, there’s a reason. Something’s happening in your brain which is not serving you well. It’s not about moral failure, or flawed character, or anything remotely related to that outdated, conceptually limited, seventeenth century way of thinking about human behavior. It’s just a programming glitch, pure and simple. We need to isolate the “bug” in the brain program, and fix it. Since we cannot directly access the program, we go at it indirectly, using known psychological principles[1]. This is indirect access is not ideal, but it’s the only access we have, and its good enough – it will get the job done.

So, looking at my client who has trouble keeping promises, we are not going to do a moral analysis of the situation. We’re going to use our best knowledge to make sense of it, and to change what’s happening. Since we understand (I hope – see note 1 below) that a psychological principle CANNOT be Mosaic (absolute or deterministic)  in nature, just what IS it? It’s a pragmatic description of what is likely to happen in a situation, to the best of our knowledge. It’s a probability statement, a kind of “bet”, if you will.

Watched pots boil faster – how the eyes of a group can help an individual

The key psychological principle on exhibit here is social facilitation.[2] It has been noted in psychology, for over 100 years, that people perform better when observed. Modern updates on this note that this is true, generally, with simple behaviors, but can be quite the opposite with complex behaviors.

What I’m trying to do with my client is increase his sense of being observed, both by me and by him (but not by anyone else, as the Google Docs spreadsheet is not accessible to the public), with the expectation that the mere fact of increased observation will improve BOTH his and my management of his intrusive symptoms.

For every intrusive symptom we’ve identified, I’ve suggested to him (IN the online spreadsheet) a simple cognitive-behavioral management intervention. Because the interventions are simple, they ought to be better utilized when his sense of being observed increases. It’s a reasonable bet. Whether the bet pays off or not will be tracked in the spreadsheet. Both he and I contribute to the spreadsheet. His participation is critical. It’s visible manifestation of his very real motivation to get his life in order. He defaulted on a promise last night, and he himself entered that fact into the spreadsheet (it was his first such default, by the way, since we started spreadsheet tracking).

So, this shared spreadsheet functionality make it possible for him to be more visible to himself, and we’re already seeing improved results – dramatically so. Awareness tends to confer increased choice (another practical psychological principle). Because his behavior is improving, his hope for real change in his life is growing. It’s all a simple thing to do, but has already had a  large effect on his life.

An event in progress

We are early in this intervention effort. It may yet fail, even if it surely hasn’t so far. If it does, we’ll simply assess the situation, redesign interventions, re-engage, and continue tracking outcomes.

Today, however, I’m totally pleased with our results. Our use of the Internet as a private computer network may be a little unusual, but…it’s working. and that’s no small thing – not to my client, and certainly not to me. I like to win. We’re winning.

Notes

1. I need to explain what I mean by “known psychological principles”. I am NOT referring to  “principles” that are Mosaic in nature (i.e., those which have the authority of Moses, of “Ten Commandments” fame). While the existence of such principles have long been asserted, to assert is not to validate. Saying that, I must clarify that in our times truth is NOT validated by reference to authority, but by demonstration in the real world. Obviously, not everyone accepts this, but the scientific psychology/psychotherapy community does, and it is from that point of which which I write.

In the nineteenth century, our best thinkers thought we’d finally located  principles of at least near-Mosaic quality –  in the magnificent Newtonian universe of mathematically describable mechanics and thermodynamics. But, with the emergence of Einstein’s relativity and quantum physics (with which Einstein never made his peace), that all fell apart. This new world-view, essentially in place by the early 20th century, is with us still.

Educated people now generally now that we live in a world imbued with uncertainty (probability), not principles (determinism) of the old sort. “Principles” exist only in the simplicity of casual speech and informal thought, the real world does not appear to offer such principles. One can certainly assert the existence of a “principle”. That’s easy enough. It’s demonstrating its validity – its truth – that always proves surpassingly difficult.

People who exuberantly talk about their “principles” and their “values” as if their veracity were beyond doubt are exhibiting intellectual dishonesty. They give us the conclusion of an argument (thought process), but not the argument itself. It’s as if I said, “I’m simply going to believe that what Newton described to us his Principia is true. Because I trust this document, I know that the world is inherently mechanical, because the Principia says so! Mechanistic determinism is true, else Newton wouldn’t have devoted so many pages to its description!” As a medieval philosopher might dryly say, “non sequitor” – nonsense.

The question here is not whether a mechanical view of the universe is good and true, but whether the assumption that Newton got it right in his Principia is supported (and it is not, in the argument I give here). The “values” crowd invariably makes a gratuitous assumption sabout some source document or idea, then deductively derive propositions from that assumption. It’s child’s play, and we’re not going to do that with real people in the real world. What we think has consequences, so we’d better get it as right as we possibly can – demonstrably right.

2. The referenced article is brief, but well summarizes the concept.

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Since about November, 2008, I have been slowly working to improve the Posttraumatic stress disorder article at WikiPedia. It’s been fun, though at times inordinately time-intensive. Much of the article awaits my planned revisions, and I’m the only MHP (mental health professional) working on it, at the moment. As far as I can tell, I’m the only one who ever has. (More about that later…)

A few of the article’s sections are looking rather good. Medication (which took me 3 days!) is great, and Epidemiology is about 90% there. Other sections aren’t bad, but lack adequate references, or need their references checked (people can be incredibly sloppy). Some need a complete rewrite. Overall, the whole article needs some basic reorganization, which it’s about to get.

Wikipedia has enormous exposure on the Internet. It’s among the top 5 most-visited sites on the Internet. Of those, it’s the only one that’s non-profit. Its influence on a large segment of Internet users and various organizations and publications is truly impressive, and well surveyed here.

It’s also enormous. Nine years old, it currently has 14 million articles. Not words. Articles. Whew. Someone has a lot of free time, yes? In truth, I think it’s more about the passions of a small group of individuals, and the desire to share, than about free time.

It’s written collaboratively. You can go write there, if you like, but…you’ll have company. You’ll have to learn to work cooperatively, and to take the time to learn a little of the culture. There definitely are some rules and traditions you’re expected to play along with. Pretty much all good stuff, to be sure, but with some particulars you do need to know.

A certain amount of it appears overly influenced by popular culture, and an almost (heck – distinctly, at times!) adolescent point of view. But, for all that, there are reams of articles there which are very carefully written, meticulously documented, and flagrantly informative, if I may put it that way. A recently published study found its accuracy compared quite well with that of the Encyclopedia Britannica.[1]

When needing some quick information about some serious topic, Wikipedia is often the first place I turn. If nothing else, the references and links at the end of an article will quickly point me to some excellent information sources. But I usually get  much more than that.

Still, quality varies broadly, so it’s best that you know a little about your subject before reading a Wikipedia article, so you can filter the rocks out of the humus.

So, when I found that one of my clients with PTSD was reading about it there, I reviewed the article, and I was both intrigued and bothered. Some material in the article was excellent, but other major parts were poorly written, dubiously sourced (i.e., using shabby references), or simply irrelevant. I was annoyed. After some thought, I decided to try to fix it. But…I was totally new to Wikipedia, so I started slowly.

I hung out at the article’s Talk page for a while, and wrote some rather long and detailed answers to various questions. Suitably warmed up, I began contributing to the article itself. Slowly it dawned on me that I basically had no competition. There is only one other health care professional  involved with the article, at times, but he’s not a mental health professional, much less an anxiety disorders specialist. So, as it turns out, as long as I do my work according to accepted conventions (write clearly, make sense, and source major assertions with obvious authoritative references), I’m not challenged.  And, because of Wikipedia’s exposure and influence,  I’m feeling like I’m making a real contribution. At the very least, I can begin to stop worrying about what my clients might be learning about PTSD at Wikipedia!

So why am I so alone, as a major contributor to the article? I can only conjecture. In my personal experience, my MHP peers are a very caring, committed, and somewhat narrowly focused group of folks. Granted, work + family = little free time for many people, but that doesn’t tell the whole story. Many MHPs don’t write much, if anything at all. Many are not exactly enthralled by research-oriented psychotherapy. Few have much interest in community education or outreach issues. So, who’s left? Apparently, not many people at all.

I recently appealed for help on an Internet Discussion list I started some years ago. It has about 200 members, and a number of them are quite serious folks. I got no takers. OK…I guess I’m on my way to being the sole professional source for Wikipedia’s PTSD article. I do hope to have company at some point. It can only work to improve the article. However, I’ll stay with it until it meets my standards, which are definitely demanding. How demanding? Well, my Masters thesis in Counseling Psychology ran 385 pages, and I was told I’d written a dissertation. Didn’t get a Ph.D. for it, though.

Notes

1. Jim Giles (December 2005). “Internet encyclopedias go head to head”. Nature 438: 900–901. doi:10.1038/438900a. http://www.nature.com/nature/journal/v438/n7070/full/438900a.html.

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I recently added the following section (notes are at end of the post) to the Posttraumatic stress disorder article at WikiPedia (see my next post, for more on this). The information is completely up to date, and rather interesting – although probably only to other MHPs who treat significant numbers of clients with PTSD, which is my specialty –

Proposed changes to current DSM-IV criteria

(Note: the “DSM” is the Diagnostic and Statistical Manual of the American Psychiatric Association – the compendium of established mental illness diagnoses which mental health professionals in the USA, and a few other places, use. The fifth major revision is in preparation, and will be published soon. It’s a Big Deal, at least for some of us.)

On February 10, 2010, the American Psychiatric Association placed online for comment the draft diagnostic criteria for mental illness diagnoses which are proposed for the upcoming DSM-V. After a public comment period closes on April 20, 2010, the criteria will be field tested for two years, prior to final revisions and publication in May of 2013.[1]

The draft PTSD diagnostic criteria contain some noteworthy changes:[2]

  • Criteria A (prior exposure to traumatic events) is more specifically stated, and evaluation of an individual’s emotional response at the time (current criteria A2) is dropped.
  • Several items in Criteria B (intrusion symptoms) are rewritten to add or augment certain distinctions now considered important.
  • Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This is especially evident in the restated Criteria B – intrusion symptoms. Development of age-specific criteria for diagnosis of PTSD is ongoing at this time.
  • Criteria C (avoidance and numbing) has been split into “C” and “D”:
    • Criteria C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in descriptions.
    • New Criteria D focuses on negative alterations in cognition and mood associated with the traumatic event(s), and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria.
  • Criteria E (formerly “D”), which focuses on increased arousal and reactivity, contains one modestly revised, one entirely new, and four unchanged symptoms.
  • Criteria F (formerly “E”) still requires duration of symptoms to have been at least one month.
  • Criteria G (formerly “F”) stipulates symptom impact (“disturbance”) in the same way as before.
  • The “acute” vs “delayed” distinction is dropped; the “delayed” specifier is considered appropriate if clinical symptom onset is no sooner than 6 months after the traumatic event(s).

Finally, the inclusion in the DSM-V of a Developmental Trauma Disorder is still under discussion, at the time of the draft publication.[3]

Notes

1. Gever, John (10 February 2010). “DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses”. http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/18399. Retrieved 10 February 2010.

2. “309.81 Posttraumatic Stress Disorder – proposed revision – rationale”. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165#. Retrieved 11 February 2010.

3. “Conditions Proposed by Outside Sources”. http://www.dsm5.org/ProposedRevisions/Pages/ConditionsProposedbyOutsideSources.aspx. Retrieved 11 February 2010.

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I was a college kid during the time of Vietnam. My bad eyes kept me from going. I watched others my age come home, and some of them stumbled. I read about the psychological wounds of war. And later I learned that it was this war which finally forced us to formally recognize Posttraumatic Stress Disorder (PTSD) as a formal diagnosis.Fast forward, past the Persian Gulf war (some war – we had bombers, they had trenches), to today. I’ve been aware for some time that we aren’t dealing adequately with the PTSD coming out of Iraq in the minds of our veterans. I don’t even want to think about what’s happening to the civilians left behind in Iraq.

The Washington Post has initiated a series of articles on the current situation with handling of the PTSD coming out of the Iraqi conflict, by the Veterans Administration. You should read it:

Sunday, June 17: The War Inside: Troops Are Returning From the Battlefield With Psychological Wounds, But the Mental-Health System That Serves Them Makes Healing Difficult

Monday, June 18: Little Relief on Ward 53: At Walter Reed, Care for Soldiers Struggling With War’s Mental Trauma Is Undermined by Doctor Shortages and Unfocused Methods

Have a look at these (there may be more coming in this series – I can’t really tell), then do something patriotic: call the office of your local Congressperson or Senator – or both. Or email them. Be polite, but clear. Tell them, in your own words that it’s time to cut the pseudo-patriotic crap and so something real: get emergency funding into V.A. system so that military PTSD can be dealt with. Let’s support our troops AFTER they come home as well.

I hope you never have to see PTSD, much less live with. I treat it, so I’ve seen a lot of it. I’m outraged by how badly we’re treating our veterans who have it. I hope you are too.

Make that call. Just do it.

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INTIMATE CONNECTIONS MAKE US

“She doesn’t understand me!”

“Nothing I say seems to get through!”

“He seems to be in his own world. He never really hears me…”

I seem to be hearing this from a number of people I work with, lately. I’ve heard it for years, actually, and I think there’s more going on with these complaints than is immediately apparent.

We all want to be understood, most particularly about matters which seriously concern us. For some people, it seems to be an especially critical issue. Why is this? The reasons usually aren’t obvious, but I think I know what’s going on in many cases.

Who we are, to ourselves – how we “see” ourselves – is intimately related to how others see us. First of all, we’re inherently social animals. Our brain finds other people just about the most intensely stimulating, meaningful, and valuable source of meaning available anywhere. This is true for many animals, but quite possible for none more than for us.

Our connection to other people goes far beyond this, however. Other people literally make us. Without our ever realizing it at the time, they tell us who we are in our earliest years of development – a time when we are intensely vulnerable, impressionable, and hungry to have a sense of ourselves that can be relied upon. From our primary caregivers, as we grow up, we learn behavior, language, how to dress, what to eat – all the details of being human. But more than this, we learn about ourselves: Are we worth listening to? Is what we want of any importance? Do our thoughts, our feelings, our actions have value to those who mean so very much to us?

These are absolutely vital, absolutely unavoidable questions. And they do get answers. Sadly, the answers too often are not good ones – not accurate, not useful, not even tolerable. Without our having any real say in the matter, we can too easily get inaccurate, damaging answers to these questions, when we are very young. This can cripple us for a very long time – perhaps forever.

Recently, in developmental psychology, there has been a growing interest in “the social construction of the sense of self”. It’s not a new idea, but recent research on what happens when a baby and its main parent don’t get along has shed new light on the matter. The topic has become particularly important in psychotherapy, for as we’ve better understood how critical is the relation between very young children and their parents we’ve also come to better understand some of the disorders we treat in adults.

THE CONSEQUENCES OF NOT BEING UNDERSTOOD

What has this to do with someone’s having a sense of urgency about being understood? Well, consider what happens when we are NOT understood when expressing something important to us. When we were small, if we said “Mommy, I’m tired. I want to go home,” or “I don’t want to eat that!”, did we discover that we were understood when expressing ourselves? Did we feel respected?

As a small child, when we don’t feel understood, we tend to feel isolated. We may also feel devalued. In a worst case, we may feel intensely threatened. It is as if we are calling for help, and no one seems to be hearing the call.

This is precisely what has happened to anyone who’s had to endure parents who are unaware, insensitive, resistant, or absent, for sustained periods of her/his childhood. What they come to know is something no child should have to learn: they can be overlooked, ignored, and inappropriately left to their own resources. This feels bad because it is bad.

Certainly it is a simple fact that every child wants to grow up, to “do it myself”, in the immortal words of every feisty two year old. Yet at the same time, much of life is beyond their ability to manage, for years, and THAT part of life is the responsibility of their caregivers. What we cannot do for ourselves must be understood by our caregivers, and responded to.

Perhaps we can express ourselves about the matter, and sometimes we won’t be able to. In both cases, a caregiver needs to “get it” and to respond adequately to the need at hand, if a child is to grow up feeling like their universe is a good place for them.

SOLITUDE CAN TRAUMATIZE

We start our lives in relationship – literally bound to our mothers. After birth, we continue to be bound, in a link of utter dependence, which slowly diminishes, over the years. If, while we are young (say, in the first 5 years of life) a mother or other primary caregiver is too depressed, or angry, or distracted, or drunk, or distant in any other way, to respond to our distress calls, what happens?

We become frightened, and even terrified. Children in such a situation have lost their moorings, and they simply cannot cope. Left too long in this condition, or allowed to experience this too often, a child is at real risk for becoming traumatized. Many of my clients have had this experience. It’s effect on them has been bad – often profoundly bad.

Now, let’s return to the need to be understood. People who’ve experienced inappropriate parenting (and this term encompasses both neglect and abuse) know just how bad it can get when one is not understood. Everyone’s life experience is to a real degree unique, but the terror of being invisible to parents who SHOULD be seeing you and responding to you, is the same: it’s awful, traumatizing, life-changing, and unforgettable. Its effects can often be healed, with competent psychotherapy, but the learned sense of urgency about being understood may well remain in some form, for a long time.

BREAKING FREE FROM THE CONSEQUENCES OF NOT BEING UNDERSTOOD

What works is for an adult to come to understand that their vulnerability, should they NOT be understood in their present adult life, is not the vulnerability they endured in childhood. Their childhood really IS over. If they’re still responding out of a sense of BEING that neglected child, they cannot achieve this understanding. If their memory of their hurtful childhood is still capable of emotionally disturbing them – which will be seen should any current event “trigger” that memory – they WILL respond as if they were still that neglected child. They will be overtly dysfunctional, and they won’t have any choice about it – not at the time it’s happening.

However, when their memories are permanently quieted down (both recallable memory and that other kind – the memories we all have which can be triggered but not willfully recalled), they are free to experience their present safety and the full range of options of their adult existence. Such a “quieting down” is the goal and outcome of good psychotherapy.

Adults who have experienced this may still have to spend a little time training themselves, however. Once a child learns not to fall down when walking, they still have to learn to run. Once an adult no longer feels at times like a wounded little child, they still have to learn how to act and feel like a competent adult, in the context of communication which is not being heard (much less understood).

WHAT ADULT COMPETENCE IN EXPRESSIVE COMMUNICATION LOOKS LIKE

Competent adults give priority to expressing their own truths accurately and plainly, and THEN to being understood in their expression. Having made a reasonable effort to do this (and what is “reasonable” often has to be learned), they stop. Their work is over. Understanding takes two people, and at this point the other person’s work begins. The “other person” needs to be left to do it. The speaker doesn’t control the listener, and doesn’t need to, in fact.

If we were not understood in childhood it is usually because of the incompetence of our parents – and this incompetence is admittedly often accidental. Parents are people, and they have very real limits in their abilities, like all of us. Not all parents “show up” ready to function as competent parents. People with active drug/alcohol abuse issues, people with active mental illness (including depression, and unresolved childhood trauma issues of their own), are quite likely not to be able to achieve parental competence. They won’t adequately understand their child because they cannot or do not want to. The only option the child has in this situation is to keep trying to be understood. THAT is where they will likely learn to be obsessed with being understood, an obsession which they can very easily carry into their adult lives..

As a competent adult in an adult world, we will sometimes not be understood. It’s unavoidable. If one has made a reasonable effort to express oneself – to speak one’s truth in accessible language, then a failure to be understood is likely to be due to inability on the part of the listener: they cannot or do not want to understand.

So, if you’re having a problem being understood, take time to understand why. It may well have nothing to do with you at all, just as it may well have had nothing to do with you in childhood, if you had this problem then. Acquiring and maintaining an appropriate sense of personal accountability and responsibility (not the same thing at all) is a good part of being a competent adult. It’s worth working on until you get it more or less right. The secret is to do what is yours to do as well as you can, and to let others do the rest. Most of the time this will work. It can be trusted. It’s good to know this.

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US SOLDIERS SEEKING MORE MENTAL HEALTH TREATMENT

Today’s Journal of the American Medical Association has a report on a new study of mental health services used by recent military veterans in the USA. About a third of them seek help in the first year of their return. Most of them did not receive PTSD or similar diagnoses when assessed prior to treatment.

A NY Times summary of the report states that since 1995, use of VA mental health services has increased 60%. This is largely due to increased numbers of Vietnam veterans seeking PTSD treatment. It doesn’t state what many of us are aware of – that virtually no one treated PTSD until well after 1995. Surely part of the increase may be accounted to that fact.

TREATMENT NEED UNDERESTIMATED

VA clinics have, so far, treated 50,000 Iraqi veterans. Estimates of how many more may be treated vary significantly.

This is a greater number seeking help than the military planned for – in fact, most of those seeking help after their return to the states had not been seen by military screeners as having mental health problems at all! Part of the problem appears to be that coming up positive on the military screening means delays in release or return, and the soldiers know this.

There are additional factors at work, I suspect. Minimization of PTSD and similar responses to stress in the military has long been reported. Civilian police and firemen appear to do the same thing, so this isn’t surprising. Real men don’t suffer emotional hurt – that appears to be the belief. But they, do, of course.

GETTING IT RIGHT IS JUST TOO EXPENSIVE – APPARENTLY

Our military is financially strained right now. Iraq has been expensive on all fronts. The last thing the military needs is a mushrooming PTSD problem. So, underestimating the problem works to minimize costs at the front end. Why make it easy for the soldiers to get treatment? It’s not like handing out aspirin, after all. Deny and delay, and probably some of them just won’t come in for help.

A local PTSD treatment contractor with the VA here in Washington state (USA) tells me that financial constraints on treatment are so severe that most vets with PTSD are allowed 30 minutes of individual treatment a month. The rest of the time they have group therapy (which is NOT a validated treatment for PTSD). I rest my case.

Support our troops – until they become invisible to us. It’s the American way. It shouldn’t be.

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