Image

Dispatch from the front lines: A week in Head Start

I spent a rather frantic week in Iowa last week. I know, that does sound sort of paradoxical. I’ll explain: I was collecting the last bits of data for a study I’m conducting in a collection of Head Start spots in Iowa. This required a lot of riding around town, zipping through various schools and agencies with a formidably energetic and connected special education interventionist, plus a good deal of running around (literally) behind preschool teachers begging for interviews. It was a grand time. We have some good-looking data, which we’re hoping shows the promise of a play-based intervention we’ve been using for eons but haven’t ever bothered to quantify before.

In any case, while running to and fro last week, I had some remarkable moments with preschool students and teachers.

  • A miniature United Nations (one boy from Somalia, one from an Arabic-speaking middle eastern country, and one White U.S. born) of preschool boys managed to agree on and build a huge tower of blocks, and did not fall into cultural divisions when it all fell apart.
  • The terror! A three year old boy expressed great horror at the “yellow spider” his teacher drew on the white board. The fact that she called it a sun made little impact.
  • The tenderness and care children can take with each other when taught how to do so.
  • Enormous numbers of smiles and hugs that greeted us in every place we visited.
  • Surprise when I found a man(!) working as a teacher in one of the rooms. The children clearly loved and respected him, and he clearly reciprocated.

At the end of the week, all worn out from getting up and down from the floors of various classrooms, running around town, and investing great amounts of energy and worry into the examination of raw data, I was once again reminded how important Head Start is to the educational system in the U.S. Head Start is celebrating 50 years this year. It was one part of the vast War on Poverty instituted by President Johnson in 1965, and is arguably the most successful of the programs begun then. It’s certainly impacted the greatest number of poor Americans of any of those original programs.

In more recent and less charitable years, HS, along with every other educational or human services-oriented government endeavor, has met with funding cuts and reductions in support by politicians. We’ve had a period of austerity of compassion for about 20 years, off and on. Head Start has demonstrated its importance hundreds of times over 50 years, including studies that show better educational outcomes in adulthood for kids who went than for those who didn’t. But these programs are expensive, according to our current batch of elected officials. Never mind that the entire budget of Head Start is less than some of the line items including in the defense or federal prisons budgets, it’s still been a target for cuts lately.

Just this week, Pope Francis moved Oscar Romero along the path to sainthood, and he had a little chat in his office with a liberation theologian. Liberation theology has been unfashionable for about 30 years now due to its emphasis on possibly communist ideas like helping the poor and needy. Although His Holiness isn’t an elected official in the US, I’m hoping that the return of the Vatican’s attention to the poor and least signals a larger cultural sea change in the gaze of the public, from the austere and uncharitable Bush II years to a more pro-people focus redolent of the 1960’s, except with data and technology.

The Vatican seems an odd place for a revolution against greed and repression to begin, much like Iowa seems an odd place for a vacation. Let’s not count either one out just yet.

Image

Self-regulation, toxic stress, and Baltimore.

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

So, let’s break it down.

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

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

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

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

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

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

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

Image

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

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

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

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

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

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

Image

Repotting time

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

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

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

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

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

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

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

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

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

Image

Thump thump thump….here come the helicopters (parents)!

One of the great joys of being a professor in a graduate program is watching as young adults grow into creative professionals from being ex-college-students. Every fall, we welcome a group of twelve or so young people, most of whom graduated from their undergraduate programs mere months prior, to campus. Over the next two years, we do the sometimes difficult work of molding them into capable, responsible, and confident beginning therapists. When they leave after graduation, most of them go on to lead rewarding, full, and pro-social lives.

The two years between the arrival of newly-minted B.A. holders and the departure of newly-minted M.S. holders can be tough on everyone involved. Learning to be a competent therapist isn’t easy. The content material; diagnostic categories, pharmacology, neuroscience, counseling skills, theories, and techniques can be overwhelming. Learning to make meaningful connections with total strangers who have lives very different from your own can be exhausting. Developing an identity as both an adult and a professional can be the most difficult aspect of the entire process, especially for 23 year old students whose parents don’t identify as professionals.

The notion of professional identity has been belabored for years in the counseling literature. How do you “be” a counselor? How, if at all, is that person different from who you are at home or with friends? How do you put on this new identity without loosing sight of your former self? Students can struggle mightily with all of these issues, and as much as faculty and supervisors want to help them, it’s a battle each person must face on his or her own.

An interesting cultural turn has recently made this struggle more difficult and less likely to resolve by the time the students leave us. Their parents are now jumping into the graduate program, sometimes at the invitation of the student, but just as often not. Comedians and pundits have talked for years about the silliness of millennial parents over parenting their children to the point of the absurd. Children are no longer left alone to explore the outdoors, even in safe neighborhoods. Parents go to high school dances. They go on graduation trips. They heckle college professors who “give” their child a B or lower.

And now they’re coming to graduate school.

I’ve heard from colleagues around the U.S. that they’re now being contacted by the parents of students about a range of issues, from admissions to internship placement to graduation requirements. Last week, I had my first experience with a parent of a graduate student interfering in the student’s educational experience. I was stunned, to say the least.

And now I’m sad, mostly for the student. The early twenties aren’t easy for most people who are making big transitions from a late adolescent stage, which is drastically extended in modern culture by the university experience, and early adulthood. At the point in their lives when young people most need to wrestle with issues related to independence, freedom (and it’s twin, responsibility), and adult identity, parents are figuratively putting their feet in the doors of development, halting or delaying the process of maturation immeasurably.

I am glad this student’s parents love him/her and are supportive of the journey of higher education. I wonder if they realize that without allowing any struggle at all on the part of the student, they are effectively retarding his/her transition into adulthood. I’m hoping that the parents will learn to allow the child to work through the difficult passages of life with much less interference in the future; I can’t imagine mom or dad calling the boss about a workplace issue, but I guess it’s very possible in the current climate.

It’s my own generation of parents that are crippling their children by eliminating rehearsal for adulthood by removing all obstacles. And it’s us who will have to live with the way we’ve so poorly tended our duties. I’m left hoping not to have to talk to the parents of my doctor before s/he will give me my pills in the old lady’s home.

It’s our mess, X’ers. We need to fix it before it ruins us all.

Image

Common factors versus specific ingredients in therapy: Who wins?

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

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

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

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

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

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

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

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

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

If one Sunday morning they should ask you

the only thing that matters after all,

tell them the only thing you know is true.

Tell them that failing is an act of love,

because like sin,

it is the commonality within.

How failing together we shall finally pass.

Image

Journey-Making

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

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

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

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

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

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

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

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