Sunday, July 29, 2012

Crazy Violence

It's been more than a week since the shootings in Aurora and one thing at least is clear:  James Holmes is either crazy or pretending to be, and he can do so because we not only expect someone who shoots innocent people to be mentally ill, but we know they often are from now-long experience.  In fact much of the violence perpetrated within our society is by people with mental illness because, lo and behold, the majority of Americans have one or more diagnosable psychiatric disorders, from ADHD to autism to agoraphobia.  There's hundreds of varieties in the diagnostic handbook, DSM-IV.  I currently have a relatively mild but still problematic Adjustment Disorder that's either a consequence of my head injury or the length of time it's taking me to recover from it, but like the vast majority of mental illness diagnoses it doesn't make me any more prone to violence.
site of Aurora shootings

The disorders that are most often linked to violence are those that alter one's sense of reality--psychosis or the flashbacks associated with PTSD--or severe impulse control or antisocial personality problems.  Teasing apart the reasons someone has done or threatened violence to themselves or others is typically done by mental health professionals, and if it's serious enough, done in locked psychiatric hospitals.  It's hard work.  And what I've learned from doing this work for twenty-five years is that there is, even in the most deranged individual, an interior logic to what they do.  No one acts entirely randomly, putting their shoes on their feet one day and on their hands the next.  We act in predictable enough patterns that once someone has given us a cue to their interior logic--once they have done or threatened harm to to themselves or others--we can almost always figure out what mostly drove that behavior, if they cooperate with trying to stop it.  The thing is, bad things happen before we pick up on those initial cues, and they don't always cooperate with the mental health help offered.  Maybe both those things happened with James Holmes.

Product DetailsA book I read and loved this week, This Bright River, starts out with what is likely a murder, and in the next chapter we are told there has clearly been a death.  This is a pivotal event for one of the two main characters as the death is of his cousin who, it turns out, was in some ways crazy.  The book is really good and about more than this, but since it is written in the first person from multiple points of view we get more than one glimpse into the interior logic of a violent individual, one so graphic I could not read it.  It wasn't work--I didn't have to.

My daughter Caitlin works in a school for autism-spectrum kids and had a rough week.  One of the students developed a new "chain," a murky pattern of behavior that led to headbanging and self-injury, and then to aggression towards the adults trying to stop him.  Despite trying to change everything that might be fueling the chain it was getting worse, in part because the changes they were making to break the chain were highly distressing, and Cait got hurt.  When I saw her on Friday night she looked battle-weary, injured by her efforts to help a violent individual.

It didn't help that her week had started with violence at home.  One of our sons has a psychotic disorder and chronic depression.  He got his Xbox back more than a year after he became obsessed with shooter games (like Call of Duty) and became violent when we tried to limit his use.  He posted advice on his Facebook account (which he hadn't had access to in all that time) not to go after one's parents if one still had to live with them.  Sound advice, and the kind of very strange logic I'm talking about.  He gets a lot of help from said professionals, and parents--and Caitlin "liked" this statement on his wall, though I couldn't make myself do it.  He got his Xbox back sans shooter games--he wants Minecraft, which we've agreed to.  He will likely still get obsessed.  We'll see if that's the main factor, or the violence in he games.  Sometimes it's trial and error.

But that's not the main event in terms of violence at home this week.  On Monday night, as my husband and I were watching Lizzy and her team win the state championship (woo-hoo) another of our adult sons was doing his own chain.  He was caught sneaking candy from our room, where we keep little potty treats for our two-year-old granddaugher, and sent to his room for a time-out.  He swore at her for stopping him, then started to smash holes in his walls.  He has schizophrenia and mental retardation and this is his chain--do something, get caught, swear, get a time out, react violently.  By the time we got home he had smashed nearly through his door trying to get to her.

So while the vast majority of people with a mental illness are not violent, it is also my experience that for mentally ill people who are violent, they do an incredible amount of damage, and are deserving of all the treatments we have available, and more that we've yet to develop.  For all our sakes.

Sunday, July 22, 2012

Unbridled Enthusiasm

My daughter Lizzy is on a softball team that is on a softball team that is winning, which means they are still playing since this is all-star season in Little League.  People ask me if she's happy and I say yes, but in reality the parents' emotions are far more engaged in the win/loss equation.  The girls really have been happy just to be playing.

Milford Softball All-Stars winning sectionals
Photo by Stephen Ball
Have you been to a girls' softball game?  Or volleyball?  They're chanting sports because they're so team-oriented and the field (as opposed to soccer) is small enough that your chants have power.  It feels like a revival meeting sometimes with the calling out and answering, the girls all lined up against the backstop:   "Extra! Extra! Read all about it! Cally stole second and we're gonna shout it! CALLY STOLE SECOND! Noooo doubt about it..."  They dance in the infield, and smack their heels to denote the number of outs in the outfield. At the end of some games there's a pig pile on the pitchers' mound with both teams together.  It's a feel-good experience.

Now here's the caveat:  Lizzy's team has become more muted as they move up, and the chanting from the last game was largely from the parents, and it was borderline nasty.  Yelling at umps (our side).  A coach (their side) harassing his own pitcher with screaming aggressive chants of of "Dig Deep Claire!" and "You gotta want it, Claire!" and "Show 'em what you're made of, Claire!"  Dozens of times, over and over.  It was awful, actually.  I felt bad for Claire.  She's eleven years old.

The coaches of Lizzy's team are nearly perfect, which is a nice kind of cosmic justice--calm, caring, instructional, stern, smart.  They're also focused and hard-working and they've crafted this team of girls into their image and thus, less chanting over time as the stakes go up.  They're in the state championship series for their age group starting today and I don't expect a lot of noise by the girls, who have taken on a kind of warrior persona that's a bit daunting, actually.  No, now it's the parents gone wild, which isn't quite as much fun.  Always a devoted but lackadaisical spectator, I am no longer reading on the sidelines.  I jump up when Lizzy goes to the On-Deck circle in anxiety and excitement and leap and cheer if she gets a hit.  It can't be helped.

If she could see me, which luckily she can't, she would give me not the adorable thumbs-up of a year ago, or even a big, beaming smile.  No, once she turned eleven on Memorial Day weekend, she turned into a pre-teen and they, apparently, quickly master cool disdain.  She gives me the Look, which says "please don't embarrass me further, mother" that I am still getting in nearly-lethal doses by her fifteen-year-old sister Ciara.  It's not quite fair that when one's baby crosses this Rubicon there's no compensation given.  In April we went on an awesome baseball road trip where she kissed me not only good night but good morning, and sometimes good afternoon.  That golden era, of age 8 to 10 (my mother remembers it as 8-12 and maybe there are remnants for awhile.  She crawled into bed with me last night) when kids think their parents are the be-all, end-all destination for good times and wisdom. After games now when I ask her questions rather than wanting to discuss it with me she just looks out the window, probably thinking of her coaches' words instead.  Sigh.

Saying Hello (or Good-bye) at Camp Horizons 
No, for my own fan base I'm going to have to go back to Camp Horizons.  They seem to be the epicenter for unbridled enthusiasm in my world.  When I brought Billy to camp in late June there were dozens (I kid you not) of campers and counselors screaming his name as we arrived, dancing and jumping and they had never met him.  I thought it remarkable that they could exude such joy out into the universe of strangers-to-be-friends.  The culture was so incredibly positive that it carried me through the next few days of calls about problems he was having at camp, all of which had the same competent, caring, upbeat tone.  He can't wait to go back in a couple of weeks and, frankly, neither can I.  They cheered my husband and I when we arrived to pick up Billy as well, which Mark of course had a comment about regarding their motivation to get Billy home but I accepted as the shout-out that I'm sure it was:  you're great.  I'll try my best to return the sentiment in the forum they prefer (matching funds for their all-year expansion and an air-conditioned dining hall). If you want a lift, look through their photo gallery:

Because joy is contagious and preserving it hard.

Sunday, July 15, 2012

Better Living Through...

This month's Atlantic Monthly has a cover article I totally agree with called "Why Women Still Can't Have It All" that I read for validation, but remembered largely for the cover art of a baby in a briefcase.  This is old news, at least for me.  Though in my twenties I did go to grad school and work and begin to raise six of my kids, I knew it was a deeply precarious situation.  T. Berry Brazelton, who was the parenting guru of the day, put the stakes in stark contrast when he said parents stretched so thin would have to skimp somewhere.  "Skimp at work" he said, and it freed me to do so without shame, not to do a bad job or get fired, or even to leave at the end of the day when important work was yet to be finished, but rather to make choices, steadily and consciously, that put my family before my career.  My ambition thus muted since I had in fact made my choice by becoming a parent to so many so young, I've enjoyed a solid career that never threatened to flip the equation.  Women like me apparently blossom in their fifties work lives as their children no longer pull, which might be nice, though I have some limitations now, and also lots of other interests that I might substitute for the fifteen practices, games, rides to school and loads of laundry I do every week.  We'll see.
The Atlantic - June 2012
No, it was the month before's cover article, "The Perfected Self," that was significant for me, and if you read the article, it was probably in the entirely opposite direction they intended.  The author was writing about his brother, who had lost nearly half his body weight by tracking his food intake on a smartphone app, and they listed a few available.  The subtitle is "How the creepy science of behavior modification is reshaping our desires."  His point is that if we use smartphone apps to manage our money, our weight and our time to a near perfection, we've lost our free will.  Though it was undoubtably great that his brother was able to get back to the size he was at age 23 and get off his diabetes medications, if we see perfection as a realistic goal, and grind towards it like hamsters on the proverbial wheel, we can hardly give credit to ourselves when we reach those goals.  It's an interesting article.

What I took from it, of course, was that there were apps for my Droid that could help me reverse the backsliding I'd done with my weight since I lost 40 pounds at age 40 for a healthier middle-age.  Though I did all the things I was supposed to--track using my Weight Watchers logs, changing how I ate so that (my kids will tell you with disgust) there's nary an unhealthy food molecule in my kitchen, exercising the requisite hour a day--it crept back up, especially once I started again to get epidural steroid injections in my back this year.  My net gain on the weight loss (for this is how it always frames itself in my head) went from 40 pounds, to 30, to 20 this past March, and slipping.  I went directly from the kitchen where I read the article to the bedroom where my phone was charging and downloaded the app I now use, FitTracker. .  Better living through behavior modification.

As a psychologist I've always used behavior mod, and schooled others on ways to use it to improve their lives. I've tracked my own moods, pain levels, med uses, headaches, sleep cycles, pleasurable activities, skills use and exercise as well as my weight over the years, and it's always helped me get where I want to go.

The difference with the smartphone apps, and the reason they're so powerful, is the addition of immediate, specific feedback.  Each time I plug in a food, the daily nutritional goals that it sets based on my weight and activity level and weight loss goals are updated.  I can check back, with one wiggle of a finger, and see if I've had enough calcium, or protein, or too much fat.  It's exquisitely precise, giving me credit for 1% of my daily iron needs from a piece of licorice, and 117 extra calories to spend for a medium-intensity 30 minute walk with my dog.  I set it to lose a pound a week, and although the irrational part of my brain wanted to lose 2 pounds a week instead, I've lost...a pound a week.  Wholly unexciting, really, but 7 pounds in 7 weeks has made me oddly reinvigorated in terms of my free will.  See?  If I want to I can do it; my weight isn't an off-the-rails roller coaster to an uncomfortably (for me) abyss.  Which makes me wonder if, in a reverse psychology kind of way, this was one of the points of the Atlantic article.  Or whether it was simply cautioning me--don't get carried away.  Either way I've heeded that warning.  Beyond a simple tracker for my asthma peak flows that I assure you will thrill my doctor to no end, I've hunted no further for perfection, though a money tracker sounds might good.

It's made me attuned to the instant feedback I get in other ways.  Even your reading this blog changes what I write--there are three of my weekly posts out of the twelve I've written so far that are by far the most popular, and I've looked for the similarities between them, to see what strikes a chord in a reader.  It's like when I give a good gift, the the receiver smiles and squeals--instant reinforcement will make me do it again.   And yet, I can't get too addicted to it.  Sometimes a broader view is the key.

The walls of Lucca, Italy
My husband and I went to Italy a few years ago on a family trip with my mother and her cousins, and we stayed in a gorgeous corner of the world, the walled city of Lucca in Tuscany.  Each day we'd walk the wall, which was broad on the top, and filled with families during the late afternoon hours when shops were closed and working adults came home to spend time with their spouses and kids before going back to work for a few hours, all without a word from Dr. Brazelton.  What struck me most, however, was the way that it was hard to distinguish whose children belonged to which parent.  They were all instructed in almost identical ways, "stay close," "stop," "shh," all the basics, by whatever adult was nearby, and the chilrdren were almost uniformly well-behaved.  We walked for hours that week and marveled that despite the hundreds of children we saw, and the parents who were paying them little attention, focused as they were on their wife or father or best friend or whomever they were talking with, we never saw a meltdown.

I am entirely sure that if I walked into the McDonald's by my house I couldn't get out of there, even with no line,without witnessing at least one flaming tantrum of an out-of-control child and a frazzled parent, both yelling at each other, faces red with frustration and embarrassment, and everyone else looking away.  This is how it is for us--our societal norm is more chaotic, and individual.  In Lucca I daresay you could get away without going to church, but people would notice.  Maybe ask you if you were well, or ask your mother at church whether you were away, all with the intended effect of taking away the question, the free will, of the decision on Sunday mornings of whether to go to church or not.  It's mostly men that work, and women who run the homes and mind the children.  Men stay with their mother until they marry, because they need someone to cook for them.  Women resist bearing children because they prefer their freedom.  It's an imperfect culture, and the societal norms rigid.

But it sure is appealing in some ways, especially the ease with which they blend work and home, and even how limiting some choices frees your mind for appreciating other things.  They dress up when they go out--if I lived there I would too.  They take their kids to restaurants, and eat small portions of good food for hours with friends--how lovely.  They don't need their smart phone apps to stay thin, for the most part.  They have their culture.

Sunday, July 8, 2012

Saving Horseshoes

Today was the first time I walked my favorite beach path in two months and it was bittersweet because I missed one of my annual rites of saving horseshoes and I wonder what happened without me.

It was always almost equally stressful and satisfying.  Between April and July, but especially May and June, horseshoe crabs go mad with lust at the furthest beach I walk to, by the Audobon sanctuary in my town.  I am not at all sure what happens there at night, but by morning there are pairs and trios and whole piles of horseshoe crabs still attached to each other by their sex parts, crashed over each other's shells, tails and other parts all akimbo.

This is amusing, but not the problem.

Sex-drenched as they are, they are especially prone to going the wrong direction, dragging themselves toward what they think is a deep and peaceful water valley in which to recover (until night) but instead ending up stranded on land, or tumbled onto their backs by the breakers, or both.  If you walk early you will see up to a dozen upside-down, soon-to-be-carcasses, too exhausted by their efforts on all fronts to right themselves to continue, about to die by the sun, the seagulls and curious toddlers with sticks.

So as a mini-mission in life I would go in the mornings and flip as many as I could find.

After a year or two I wondered if I was somehow weakening the species--there were more and more of them!--but maybe they were just actually breeding rather than beaching themselves.  Regardless, I asked inside the Audubon center if it was the right thing to do and found out there's a program, called Just Flip 'Em (accurately enough) to encourage people to save the ancient species.  They are, apparently, largely helpless and hapless during mating and spawning.  And there are dozens of beachwalkers to try at various points in the day to help them out.

I wondered if I was overstating my individual importance, and indeed I am sure I was, but on days I didn't come there would be more dead crabs on the beach the next day, as it's a pretty deserted beach at dawn and the seagulls start early.   Whether it's high or low tide the stranded crabs were there, like puppies left in a road.  And here's where the stress came in--I worried about getting there on time, and what would happen if I walked another route, or took a day or two off.  The fun wore off, and it became work.

Mark and my discussions, when he reluctantly came with me for the hour there and back for my determined task, were around the question:  if you obsess over something good and worthy, is it any more useful than over something banal and inane?  And then the core problem:  you can't save every one who's suffering and at risk.  Then its corollary:  what is the use in trying? 

And here we go with the foster care (or adoption, or caring for the homeless, or the mentally ill).  What if you knew there were kids out there that were vulnerable, scared, suffering, trying to survive, and possibly failing?  And you just needed to help them right themselves, and move off back into their possibly turbulent but familiar waters of their lives?

Even if you could save just one, wouldn't it be worth it?

So now we're back to horseshoes.  Even if I could save just some of them, each was thankful in their own, brainless way, able to go on and procreate and crawl another day.  And, possibly, flip themselves the next night, and await me the next morning.  

I wish, the next time someone asked me why I ever got involved in any of those other things, I could say it's as natural as flipping a horseshoe because when they are right in front of you, what other choice is there?

Sunday, July 1, 2012

Sunshine Gives Me Headaches

I get asked how I am a lot.  It's nice, and it's difficult.  There are few one-sentence responses when your life is largely on hold as you recover from a head injury.  So, for those for whom I've given totally unsatisfying answers, here's my better attempt.

The acute physical symptoms of my third concussion (introduced in a May blog titled Head Hurricanes) continue to improve.  That is the nausea, dizziness, disorientation, lack of balance  and the acute anxiety and reactivity of not understanding everything going on around me are all lessening.  For this I am deeply grateful, though I always knew they would go eventually so I'm also not surprised.

image here
The chronic physical symptoms though, the ones that started with the first or second head hit--oh, they're a bear--much worse than before, and receding so imperceptibly (I'll take the optimistic route here) as to be pretty much the same every time I am asked.  These are the insomnia, the headaches, the fatigue, the irritability (or emotional flatness) and the sensory overload.  Sometimes they make each other worse, like a loud room full of people making me cranky or tired even if I'm not talking, or bright sunshine giving me headaches.  I really don't know what to say when asked about them, even by the doctor.  "Same" I guess fits but it's not very satisfying to hear, I know.  I'm trying some new meds but if I mention this it sets up the expectation that  now they will get better, and I'm not sure they will.  They've been with me for two years now; my best hope is they will get back close to where they were before May.

And these pale in comparison to the chronic, at least semi-permanent cognitive impairments.

We don't have casual language for cognitive problems that's not derogatory.  We have "slow" and "dumb" and "stupid" and "idiotic," "foolish," "whack" and "clueless."  For obvious reasons I'd rather not go with those, if for no other reason that they're very non-specific.  If you and I spoke you wouldn't think I was any of those things, necessarily, at least not on a good day, my fifteen-year-old daughter aside.

So I'll have to revert to psychology-speak, and for that I apologize--I'll try to liven it up where I can.

I had a pretty strong cognitive profile across the board going into all this.  I had some back injuries and chronic pain can wear away some of your focus but when I was pain-free I was good to go mentally.  Since my first concussion, and especially my second, my general cognitive state has ranged from clear to foggy, mostly settling in the middle.  Since May I've been on the foggy end, with some days feeling like my head if full of wool.  It affects my attention, my ability to process what's being said and done, organize a response and get it out there in the few seconds we're typically given to do so in life (less if we're driving).  If the situation or topic is expected (i.e. we're at my daughter's softball game and someone makes a game-related comment), I'm pretty normal in my responses because even if I'm slow for me, I'm still average.

If it's complex, unexpected, or requires creative thinking or novel problem-solving, though, you'll be waiting a long time.  More likely, you'll get the Blank Look.  Long, uncomfortable, stuttering moments later you'll get something approximating a response, and it won't be an especially profound one.  For that, you'll have to wait until I'm sitting in my quiet, dark room, thinking at my own pace about what you said, and able to sort through all the levels of complexity separately.  Then, if I can respond in writing with no time limits, you'll get something like The OM (Old Me).

In this state I've sorted it through further, largely for myself but also for those who care for me, and those who might be struggling through the same thing.  Here's what I think I've lost (on a good day) from my hypothesized intelligence (it was never assessed before the concussion so I'm just guessing here):

10 points:  verbal skills (comprehension, reasoning, expression)--it's still my strength but words often fail me.   I speak much less than half as much as I did before my first concussion, which not everyone minds.  I have word finding problems, difficulty putting emotions and thoughts into words, and often get stuck on the first thing a person has said, missing the rest.  So I smile and ask them to repeat, or fill in the blanks myself, sometimes incorrectly.  I am constantly debating with family members about what I or they said.  Since I can't fix the root problem, I'm just trying to argue less about it, in no small part because I am no longer daunting in terms of verbal sparring;  there are many chinks in my memory and logic armor and they're taking full advantage, as they should.  I was a fierce defender of my being right all these years;  payback's a bitch.

20 points:  visual and perceptual skills (including those needed for driving, watching body language and nonverbal communication, ball games, TV and the more complex coordination needed for biking or cooking).  I'm okay, but often not on my game.  I have never in my life not been able to ascertain what someone was trying to tell me with their face;  now I can't about half the time.  My driving is sketchy, though again I think probably average.  I read books during ball games, even ones I'm at, though this is complicated by my shortened attention span (below) and sensory overload (above).  I can't watch TV, ever, unless it's sports and I am very aware of what is supposed to be happening;  when something confusing happens I use my remote to watch it repeatedly until I understand it.  Commercials are so aversive to me that I have a visceral jump to them, leaping for the remote to hit mute (for the TV) or changing the radio station, every time.  I'm not sure why this is, but I think the jolt of the changes are too much for me to process on the several-second delay I have in my brain now, so they are extra-annoying.

30 points:  executive functioning skills (focus and concentration, problem-solving, ingenuity and creativity, cognitive flexibility, finding patterns and organization) and working memory (keeping things in mind so I can do something with the information, like writing onto a list what someone just told me we were out of, or taking notes in a meeting).  I forgot two out of two medical appointments this week despite many systems of reminders (remembering both exactly 24 hours later).  I went grocery shopping this week for the first time by myself and got through it, but couldn't find seven items that I thought Costco sold but couldn't seem to find even with employee help.  I can only deal with my kids' requests like lunch money or rides to practice rides with advance notice (so I can think it through) but no more than one day (or I'll forget). And this is the easy stuff.  I can see these areas are where I'm beginning to truly suck and this is largely why I'm not at work.  I would say that three-quarters of my job as a manager for psychiatric units involved all of these skills, weaving in and out of each other.  After the second concussion I noticed that the most I could do when faced with a problem was remember the last time I'd had that problem and what I did then, and I couldn't even do that all the time.  The OM wasn't happy unless I had tinkered a new response that fit the situation better, or come up with an entirely new way to view and approach it.  This is what made me really good as a therapist, as an evaluator, and a hospital administrator.  I'm not as good now, and I might not be good-enough, even when I finish my long recovery from this injury.  This is the be-all-end-all problem for me to figure out, but of course its solution may evade me for exactly these reasons.  Even before May I had to take breaks several times a day to rest my brain, limit supervisions to thirty minutes because I could only focus for twenty, and edit reports for students rather than write them.myself.  I'm quite a few levels below this now, and not sure I'm going to climb back to what was already marginally subpar work performance.  But I still know identifying a problem is worlds easier than solving it, even if it is the first step.  This is the area I am most averse to discussing, fyi.  It's too damn hard, at least right now.  

40 points:  mental processing speed.  A much less sensitive an area for me to discuss, even though it's more impaired.  I think slowly, like I'm slightly drunk (which means yes, add more than one drink I'm completely stupid, and I'll accept that derogatory word here because heavier drinking while recovering from a head injury deserves it).  I'm working on the Blank Look becoming a bemused look, just as a stalling strategy, or even a knowing response (sparing me from actually having to come up with a real one).  It amuses as well as frustrates me that when I spoke with my son Billy's camp counselors last Sunday and they asked me what they needed to know in order to care for him I couldn't generate any response beyond "keep him busy" until the ride home alone, when I thought of a dozen nice tips and essentials, which I tried to impart the next day when they called on an unrelated matter, but couldn't because I hadn't expected the call and the novelty threw me, a situation repeated the next day until I gave up.  They probably know him fine by now.  I am incapable of witty repartee, and talk less in part because I'm a few seconds behind on the conversation and trying to limit my embarrassment.   When I'm writing I have to stop, over and over again, to find and continue my train of thought or structure.  It's exhausting, and I would sleep twelve hours, if I didn't wake up after two or three, which doesn't help the processing speed (tired sigh here).

So that's it.  Give me a week to take notes and a few hours to write and edit and I can respond to "How are you?"  I know that some of these problems can come from other sources--chemo brain, depression, meds, dementia or just regular-old age-related decline--but for me, because I had the three concussion in three years and the subsequent problems are so clearly linked to them, and dementia has for the moment been ruled out, I'm sure these are the sequelae.  What I don't know, because we never do, is what's next.