The Child Mind BlogBrainstorm
Fear of Vomiting and Exposure Therapy
Feb. 25, 2014 Caroline Miller
The fear of vomiting is a very, very common one in the world of anxiety disorders. Scott Stossel, in his bestseller, My Age of Anxiety, makes it clear that it's not just a matter of feeling queasy at the thought of vomiting (who doesn't feel that way?) but an anxiety so toxic you find yourself arranging your life meticulously, painstakingly to avoid it. The challenge is that this phobia can ambush you practically anywhere—if you think about it, where could you not, hypothetically, vomit?
So it's not surprising that one of the most dramatic parts of the book (and, in shortened form, the Atlantic excerpt) is Stossel's account of his misadventure with what he calls exposure therapy, designed to rid him of his vomiting phobia. It turns into a disaster when the ipecac he takes to make him vomit—in order to diminish the massive anxiety attached to it—fails to make him vomit. Instead, it just makes him violently ill, curled on the floor of a clinic bathroom for hours on end, and more anxious than before. (He notes, by way of humor, that the fiasco did succeed in making his therapist vomit.)
I mention this because the scene is so vividly memorable that I worry that it will give exposure therapy a bad name. And it's so unlike the kind of exposure therapy we're familiar with at the Child Mind Institute that I asked Dr. Jerry Bubrick, an expert in treating anxiety, what might have gone wrong in Stossel's case.
Dr. Bubrick notes that most exposure therapy works by introducing the source of the fear in tiny increments, so that the patient learns to tolerate them one at a time, and doesn't move from one to the next until he is so over being anxious at each step that he is actually bored. The patient and doctor create a hierarchy of fears that run from, say, writing the word vomit to watching a video of someone vomiting, and the patient becomes habituated to each before moving on to actually doing the things that he associates with vomiting—let alone vomiting.
Dr. Bubrick showed me a piece of paper covered with the word vomit that was the work of an 8-year-old he happens to be treating right now who shares Stossel's phobia. This little girl was so anxious at the outset that just hearing the word vomit made her curl into a ball and check out of the session, so Dr. Bubrick said he backed up and started with something easier, having her write the word vomit, first in tiny letters and then progressively bigger—and finally in purple.
There are clinicians, Dr. Bubrick said, who believe in extreme exposures—"going to the top of the hierarchy as quickly as possible." But that could only work, he said, if the patient really buys into the model, has confidence that he will be able to handle the anxiety and habituate to it. That confidence, along with trust in the clinician, generally comes from those earlier baby steps, and it's clear from Stossel's account that he didn't have it.
It takes time and patience. "You can't expect someone to face his worst possible fear and get bored quickly," he notes. "But when I expose patients to things much lower in intensity, that cause much less fear, and they understand the mechanics of exposure, time and time again, and it's working more and more, they'll be much more motivated to face their biggest baddest fear and it will be much more effective when we do it."
Dr. Bubrick notes that he got a picture the other day from the mom of a 10-year-old boy who graduated last fall from treatment for a vomiting phobia. It was a picture of a pumpkin her son had carved for Halloween—and the pumpkin was vomiting.
Dr. Bubrick, by the way, would love to treat Scott Stossel.View Comments | Add Comment
Inside a Parent Training Session
Feb. 25, 2014 Caroline Miller
Practice, practice, practice. It's what parents find themselves urging (or cajoling or harassing) their kids to do when it comes to the piano or tennis. But practicing is also what parents do when they go through parent training. And it's practice that's the secret of the training's well-documented success at diminishing kids' problem behavior.
In a terrific article in the magazine Scientific American Mind, Ingrid Wickelgren takes us inside a session of Parent-Child Interaction Therapy (PCIT) with Dr. Steven Kurtz at the Child Mind Institute. We get to look in on a mom playing with a six-year-old boy who has serious behavior problems. We see what happens when he responds to her commands (lots of very specific praise) and when he doesn't (lots of time in the time out chair, and the back-up time-out room). By the end of the session, everyone is exhausted—but also excited by the progress they've made. In a related blog, you can even hear Dr. Kurtz coaching a mom, via an earbud, from the other side of the one-way mirror.
Wickelgren also takes us back to the origins of Parent-Child Interaction Therapy in the early 1970s, when a clinical psychology named Sheila Eyeberg, who was treating children with play therapy, noticed that in sessions the kids seemed to calm down, self-correct, and try to please her. But they weren't doing the same things for their parents, and the behavior changes didn't carry over at home.
The evolution of the treatment and range of things it's been used for are fascinating. And—to get back to practice—an analysis of many studies into parent training programs, Wickelgren writes, found that "requiring parents to practice the appropriate actions with their children during the training sessions seemed to be critical to correcting parent behavior."
And changing parent behavior, we know, can be the key to changing children's behavior.View Comments | Add Comment
An Intimate Look at Anxiety
Feb. 17, 2014 Caroline Miller
You don't have to be a seriously anxious person, or the parent of one, to find Scott Stossel's new book, The Age of Anxiety, (and the excellent excerpt in the Atlantic) riveting. Stossel's account of his experience with anxiety is so vivid and so candid that it's almost unnerving.
There's the cocktail of Xanax, Inderal and vodka he consumes before making public appearances, to keep from bolting from the stage—which he says he's done. The panicked search for restrooms on a trip to Rome, including one at a gelateria near the Trevi Fountain, "where a series of impatient Italians banged on the door while I bivouacked there." He describes standing at the altar at his own wedding, drenched in sweat, shaking so badly that he has to hold on to his wife to keep from keeling over.
Stossel's anecdotes, which the New York Times reviewer calls "bravely intimate," are valuable in a couple of ways to parents of very anxious children. First, they're a powerful reminder of how physical anxiety is, how overwhelming and debilitating it can be whether you're 5 or 45 years old. They're a reminder of how real the anxiety is, even if the fears that generate it—and Stossel's list of phobias is very, very long—seem absurd. They're also a reminder of how many anxious children (and adults) hide their anxiety and manage to function—even function exceptionally well—at great cost in suffering.
But Stossel also explores all the thorny issues surrounding how we think about and treat anxiety. Is it inherited? Is it learned? Is it a condition of life in the 21st century? In his own family he sees an inherited predisposition to anxiety on his father's side, and in his mother's family, a proudly held conviction that emotion should be avoided at all costs. "Thus, me," he writes: "a mixture of Jewish and WASP pathology—a neurotic and histrionic Jew suppressed inside a neurotic and repressed WASP. No wonder I'm anxious: I'm like Woody Allen trapped inside John Calvin."
In writing about Stossel, Donna Wick, a clinical psychologist and founder of Mind to Mind Parent, notes an interesting thing about the heritability of anxiety. What's actually inherited seems to be what researchers call a "highly reactive temperament," but that doesn't always lead to an anxiety disorder. When parents respond to a highly reactive baby by figuring out how to soothe him, it can "have lasting, long term effects, as we now know that relationships can change the way the brain is wired," she writes on the Huffington Post. On the other hand, parents whose highly reactive babies make them anxious can inadvertently escalate the child's anxiety, and there is more suffering all around.
But Dr. Wick and Stossel both write about the positive effects of anxiety, which can be a powerful motivator towards achievement of all kinds. "So in addition to treating unhealthy levels of anxiety," Dr. Wick writes, "don't forget to appreciate, and even more importantly, teach your child to appreciate the other side of the coin. It will help him understand, value, and ultimately manage aspects of his personality that might otherwise appear 'bad' or negative."View Comments | Add Comment
Lindsey Vonn, 'The Biggest Loser' and the Fat Police
Feb. 11, 2014 Beth Arky
Attacking women's bodies—and self-esteem—seems to be a sport that's never out of season. The latest salvo (and one of the more unusual ones) comes from American Olympic gold medal skier Lindsey Vonn, who is out of the competition in Sochi with an injury but still in the spotlight for bashing women she deems to be too thin and not athletic enough.
In an interview with Self that's getting a lot of attention on tabloid websites, the Olympic gold medalist criticized movie stars' bodies after attending a gala last May with the likes of Gwyneth Paltrow, Jennifer Lawrence, Beyoncé and Ann Hathaway:
"It was hard to go to the Met ball with people who eat lettuce and a Diet Coke for dinner. It's difficult to be at events with a room full of women who weigh half as much as you do. That's always tough. I don't envy them, though, because so many of them are skinny-fat. They have more cellulite than most people. I feel like I need to give them a cheeseburger. It's sexy and beautiful to be strong."
Vonn may think she's speaking out for being healthy, not model-thin, but what she's really doing is trashing other women for cellulite (!) and for not making the same choices she has. It's too bad because her important message about her depression (she's "normal again, now that I'm on medication") was drowned out by her nasty pot shots.
The Vonn story comes days after the uproar over the extreme weight loss of Biggest Loser winner Rachel Frederickson, who shed 60 percent of her body weight from her 5-foot-4-inch frame to go from 260 pounds to 105 pounds. The focus on Fredrickson's "scary," "shocking" loss again diverted attention from the more salient point.
We live in a culture where thin is the goal. Let's be clear here: Loser, which just wrapped its 15th season on NBC, is not a weight loss show, where contestants work to maintain a healthy lifestyle; it's a game show competition where participants battle like Roman gladiators to lose the most weight.
As one style blogger wrote: "Therein lies the whole problem not only with the concept of the show, but the whole cultural dieting complex: This shallow obsession with numbers has more to do with appearance than with actual health, despite protests to the contrary. And that preoccupation with and scrutiny of appearance—even when it's well-intentioned, as in the case of all the Twitter users expressing "concern" over Fredrickson's reveal—ultimately undermines healthy weight loss."
It's a case of your damned if you do, damned if you don't. Don't be too fat but don't be too skinny. And if you think everyone is finding fault with your body, you're right. That's exactly what makes it so hard for girls struggling with eating disorders to recover successfully.View Comments | Add Comment
NFL Prospect Michael Sam: I'm a Lineman, Gay, and Proud
Feb. 11, 2014 Harry Kimball
The Super Bowl may be past, but now we have the more exciting, potentially groundbreaking story of Michael Sam, a top defensive player for the University of Missouri football team who is widely expected to be drafted by the National Football League. Sam just came out in an interview published yesterday in the New York Times. Though professional athletes have come out after their playing days were over, should Sam be drafted he would be the first NFL player to enter the league as a publicly gay man.
There are two ways that Sam's actions can help young people and our culture at large. The first is as a civil rights issue. As Joe Posnanski shows brilliantly in a piece on NBC Sports, the situation Sam finds himself in is eerily similar to that of Jackie Robinson in 1947. Many sneakily pragmatic arguments have come from the NFL coaching establishment as to why Sam wouldn't be a good fit in the pros or the clubhouse—they've all been said before, and they were all proven to be not only prejudiced, but ludicrous. The fact is, the inclusion of minorities in our nation's popular pastimes has had real and society-changing outcomes before, and we don't need to wait until "ten years from now," where one GM put the timeline for change.
But there's one important way in which sexual orientation is not like skin color. Jackie Robinson was not able to be in the closet. And here is where Sam can be another kind of hero—as a role model for kids who struggle with their sexuality and with being honest about it.
We know that kids who don't feel accepted for their sexual orientation are at risk for depression and suicide. And for many of them it can seem impossible to find a mentor who understands. Without guidance and good information, it can feel like peers are not on the same planet. And isolation can be a young person's very worst enemy.
Enter Sam. As a public figure, he is aware of the uncertain future he has brought upon himself in a sport that has been hostile to even the idea of homosexuality. "I'm not naïve," he told the Times. "I know this is a huge deal." And he is also aware of how the media can twist your words, even your persona. "I just want to make sure I could tell my story the way I want to tell it," he continued.
But it is his story about coming out to his teammates, about finding people he could trust and being himself with, that I hope rings true for young people who struggle with a hidden part of themselves. "Once I became official to my teammates, I knew who I was," he said. "I was so proud of myself and I just didn't care who knew."
Thanks to Sam it seems inevitable that some people might soon find it easier to believe that a football player can be gay. Others, that a gay man can be a football player. Both are big steps forward. After he came out to his team, he said, "If someone on the street would have asked me, 'Hey, Mike, I heard you were gay; is that true?' I would have said yes."
That didn't happen, Sam said, for an understandable reason. "I guess they don't want to ask a 6-3, 260-pound defensive lineman if he was gay or not." Here's hoping that it just got a little better for young people of any size who struggle with who they are.View Comments | Add Comment
Lifetime Revives Tired Stereotypes About Bipolar
Feb. 10, 2014 Beth Arky
For every Silver Linings Playbook, there is, unfortunately, a Girl He Met Online. While the Oscar-winning Playbook destigmatized bipolar disorder as a chronic yet treatable mental illness, Lifetime's recent Girl featured a vilified bipolar character whose "anger knows no bounds."
It's stunning that a show so regressive would be made at a point when so many people have moved beyond this stereotype. The main character, named Gillian, attracts suitors, then scares them off, then goes ballistic when they dump her.
In a post that's gotten a lot of attention, blogger Elaina J. Martin wrote that Girl was egregious in part because it's such a tired, clichéd portrayal. "They made Gillian dangerous and they made it appear that her bipolar disorder was the cause of this," Martin wrote. "Don't get me wrong. People like me with bipolar disorder do get irritable. I have admitted to getting angry myself. But I don't kill people. (Obviously). I don't strangle people. I don't drug people with sleeping pills." In fact, people with mental illness are much more likely to hurt themselves than others.
The character of Gillian brings to mind Glenn Close's bunny-boiling Alex in Fatal Attraction. Some 25 years after making that movie and in Newtown's aftermath, Close said she regretted that her role increased the stigma around mental illness. In fact, Close's sister has bipolar.
As for Girl, "They portrayed Gillian to be the general population's expectation of 'crazy' and it isn't fair," Martin wrote. "It isn't fair to people like me, who live and thrive with this disorder, to be compared to someone like Gillian. This is the reason there is so much misunderstanding about mental illness—because the media feeds us bullshit."
It would seem Lifetime is creating something of a franchise based on the dangers of internet dating. We can only hope the network doesn't continue to perpetuate cartoon stereotypes about people with mental illness, who need our understanding, acceptance and help.View Comments | Add Comment
Philip Seymour Hoffman and the Long Arms of Addiction
Feb. 4, 2014 Harry Kimball
Philip Seymour Hoffman's stunning death on Sunday from an apparent overdose of heroin has been a painful wake-up call not only about the power of addiction, but also the resurgence of heroin use in the last few years.
There is a complicated story here of the rise of prescription painkiller abuse, the attempts to fight that scourge with stricter regulations, and the resurgent popularity of illicit alternatives like heroin. This shift does not only apply to long-sober addicts like Hoffman, who checked himself into rehab last year after what he said were 20-plus years clean. As a DEA official tells the New York Times, "the addicts you see a lot are young suburban kids starting on prescription drugs, and they graduate to heroin."
There are also troubling reports that a rash of deaths—including speculation about Hoffman's—were caused by heroin cut with a terrifyingly potent synthetic opioid called fentanyl, greatly increasing the chances for accidentally overdosing. Let's just say that heroin and pills can both ruin lives. As an addiction specialist tells the Times, "It's not easy to get the opioid genie back into the bottle."
But Hoffman did for a while. According to interviews, including a CBS profile from 2006, he had been sober since he was 22. As a young actor, he said, his taste for drugs was insatiable. "It was anything I could get my hands on." And that scared him. "You get panicked," he said, "and I got panicked for my life."
It is a testament to Hoffman's strength and to the terrible strength of opioid addiction that he was able to make that decision at that age and maintain it for so long, only to relapse. It is a testament to his strength that he saw what was happening last year and returned to rehab. It is a testament to these dueling powers that he is reported to have had a substantial amount of heroin in his apartment at the time of his death, as well as a prescription for buprenorphine, a drug used to treat addiction.
It is difficult to extract lessons from the lives of those we've lost—lessons they could not benefit from themselves. But like Ned Vizzinni, the author who recently committed suicide after giving hope and advice to so many depressed young people, Philip Seymour Hoffman still has a gift to give beyond his performances. This gift is the knowledge that young people struggling with addiction can take control of their lives if they ask for help, and they can still accomplish awesome things. And that they can never stop being vigilant.View Comments | Add Comment
Why Raising Kids Is 'All Joy and No Fun'
Feb. 4, 2014 Caroline Miller
You might think from the title—All Joy and No Fun—that Jennifer Senior's new book about parenting is basically a long complaint about how tough it is to raise kids these days. But it's not. It's a nuanced and emotionally acute look at how kids affect parents—how they make you feel and why.
The title reflects the fact that just because children are rewarding and important doesn't mean they're always (or even usually) fun. But there's a lot more here: It's not the kids themselves that make a good deal of parenting such a pain. Senior's argument is that the particular concept of parenting that's developed since World War II has made raising kids more fraught with confusion and anxiety than ever before.
Ever since children stopped being seen as economic assets—as cheap labor on the farm or in factories—they've become emotional assets. They don't work for us, they complete us. That means that there is no limit to what we feel we should do to nurture, protect, and perfect them. We're working for them now. And there's very little time off—except perhaps when we escape into our other jobs.
The problem, Senior writes, is that we've taken on the responsibility of making them both successful and happy. Instead of sending them outside to play or forage for friends, we now have to arrange play dates or feel we have to play with them ourselves. We need them to do well in school, because we know options are limited for those who don't. Their homework has become our homework.
With the economy changing so fast that we have no idea what skills will position them best for the future, we find ourselves desperately trying to make them successful at being successful—hence the veritable "arms race" of activities, from athletics to coding to Chinese. And as for happiness, anyone who has a child with emotional problems knows how painfully elusive that can be.
All Joy and No Fun is a terrific read because it puts the insecurity and ambivalence we often feel about our kids into a liberating context. And Senior never loses sight of how much we love these kids, and how kids keep us grounded. As Americans in the 21st century we can, and do, change our jobs, our communities, and our spouses. But we can never change our children. "They are the last binding obligation," she writes, "in a culture that asks for almost no other permanent commitments." That might not always be fun, but it may be the best thing about us.View Comments | Add Comment
One Teacher Fights Violence by Helping Kids Connect
Feb. 3, 2014 Beth Arky
Momastery blogger Glennon Doyle Melton went to meet with her son Chase's fifth grade teacher to get some math tutoring—not tutoring for her son, but help for herself, so she could understand his homework better. The teacher 's willingness to do this was pretty great, but while they were talking Melton discovered something else that moved her even more, and it's moved millions of others since she posted it on Facebook last Thursday.
In "Share This With All Schools, Please" Melton writes about the teacher's strategy to make sure that all the children in her class are also learning how to be part of a community.
Each Friday she has her students write the names of four kids they'd like to sit with the next week and asks them to nominate one student for exceptional classroom citizen that week. After the students have left for the day, the teacher studies the slips of paper, looking for patterns:
"Who is not getting requested by anyone else?
Who doesn't even know who to request?
Who never gets noticed enough to be nominated?
Who had a million friends last week and none this week?"
It turns out that this creative teacher is not really looking for exceptional citizens. She's looking for lonely children. "She's looking for children who are struggling to connect with other children. She's identifying the little ones who are falling through the cracks of the class's social life. She is discovering whose gifts are going unnoticed by their peers. And she's pinning down—right away—who's being bullied and who is doing the bullying."
So how long has this teacher been doing this? Every Friday afternoon since Columbine.
"As a teacher, parent, and lover of all children," Melton writes, "I think that this is the most brilliant Love Ninja strategy I have ever encountered. It's like taking an X-ray of a classroom to see beneath the surface of things and into the hearts of students. It is like mining for gold, the gold being those little ones who need a little help—who need adults to step in and TEACH them how to make friends, how to ask others to play, how to join a group, or how to share their gifts with others. And it's a bully deterrent because every teacher knows that bullying usually happens outside of her eyeshot—and that often kids being bullied are too intimidated to share."
The response to the blog has been overwhelming. Since Thursday, there have been nearly 3 million Facebook shares, 15 ,000 tweets and 1,400 comments on the blog alone.
On the blog, one mom commented, "My son certainly could have benefitted from a teacher such as this. Too often the children who have social difficulties are overlooked. We need more teachers with this kind of insight and administrators who care about the students as whole people instead of statistics on a standardized test roster."
One commenter on Facebook wrote: "To me, the beauty wasn't just in the system the teacher created. The beauty was that the teacher identified a problem and found a way that she could address that.... THAT is why teachers are valuable! There are millions of teachers doing little things like that, every day, that we know NOTHING about. Her work and the work of countless other teachers is disparaged often by many who fail to see the value of spreading good."
This teacher's strategy recognizes that violence like school shootings begins with disconnection, Melton writes. "And so she decided to start fighting violence early and often, and with the world within her reach. What Chase's teacher is doing when she sits in her empty classroom studying those lists written with shaky 11 year old hands is SAVING LIVES. I am convinced of it. She is saving lives."
I only take exception when she puts the responsibility solely on teachers, calling them our "ONLY hope for a better world." It's also up to parents, clinicians and anyone else who comes in contact with children and teens to have their antennae up to detect the child who is lonely, or angry, or depressed. Only then can we begin the healing process.View Comments | Add Comment
60 Minutes Highlights Lack of Care for Kids in Crisis
Jan. 27, 2014 Caroline Miller
Sixty Minutes aired a powerful piece last night about an urgent lack of mental health care for young people in crisis. The figure at the center of the piece was Virginia State Senator Creigh Deeds, whose still-livid scars bear witness to the problem. Four weeks earlier, Sen. Deeds' 24-year-old son Gus, who had struggled with bipolar disorder for years, had slashed his father's face and stabbed him repeatedly, just hours after being turned away from the local hospital because there were no psychiatric beds available. Then Gus Deeds killed himself with a hunting rifle.
Senator Deeds' frustration was echoed by other parents, including a support group of seven Connecticut mothers of seriously ill children who testified to a similar "revolving door" care since insurance usually pays only when a child is at "imminent" risk of hurting himself or someone else—for no more than 3 or 4 days. And when they are released there's nowhere for them to go but home.
The lack of beds leaves the ER as the last resort for many. "Every day, we have 10 to 20 kids with psychiatric problems come into our emergency department, kids who wanna kill themselves, who've tried to kill themselves, who've tried to kill somebody else," says a nurse-practitioner at the Yale-New Haven Hospital. "We have 52 psychiatric beds here at Yale. And right now, all 52 are full. And so the seven kids that are here in the emergency room are waiting for an open bed."
Among those seven when he was interviewed was a 17-year-old who hears voices who had slashed his own face. His father, in tears, said the ER was his only option; he had called a psychiatrist but was told there was a three-month wait for an appointment.
Creigh Deeds sums up the segment when he says, "There's just a lack of equity in the way we as a society, and certainly as a government and insurance industry, medical industry, with the way we look at mental health issues."
Or as 60 Minutes correspondent Scott Pelley paraphrases: "Don't want to fund it. Don't want to talk about it. Don't want to see it."
The segment ends with this fact: "Nationwide, since 2008, states have cut $4.5 billion from mental health care funding." You can see it here.View Comments | Add Comment