Adverse Childhood Experiences 7 : Revisiting Erikson

Welcome back, to Adverse Childhood Experiences, and I have been thinking about Erikson’s Eight Stages of Psychosocial Development.

These were mentioned in medical school and in residency. I was in medical school from 1989 to 1993 and in Family Practice Residency from 1993 to 1996. Family Practice is at least half psychiatry, if you have time. We are losing the time with patients in order to achieve “production”. I complained about the 20 minutes I was allotted per patient and was told that I should spend 8 minutes with the patient and 12 minutes doing paperwork and labs and calling specialists. This is why I now have my own practice. A new patient under 65 gets 45 minutes and over 65 gets an hour and my “short” visits are 25 minutes. I am a happy doctor. And on the Boards last year I scored highest in psychiatry….

So, back to Erikson. The first stage, at birth to one year is Basic Trust vs Mistrust. “From warm, responsive care infants gain trust or confidence that the world is good.”

I was taught that people would have to “redo” the stage if they “failed”. Let’s look at that a little more closely.

Take an infant in a meth house. No, really, there are babies and small toddlers that have addict parents, alcohol, opiates, methamphetamines. We do not like to think about this.

A social worker told me that the toddlers from a meth house were really difficult to deal with. They do not trust adults. The first thing they do in foster care is hide food.

Hide food? Well, adults on meth are not hungry, sometimes for 24 hours or more, and they are high. So they may not feed the child.

Now, should this child trust the adult? No. No, no, no. This child is adaptable and would like to survive. So even under three they will learn to hide food. In more than one place. This is upsetting to foster care parents, but perfectly understandable from the perspective of the child.

So has the child “failed” the first stage? Well, I would say absolutely not. The child looked at the situation, decided not to starve and learned not to trust adults and hid food. Very sensible. Adaptive.

Is the child “damaged”? That is a very interesting question. After 25 years of family practice medicine I would say that no, the child is not damaged. However, the child has started out with a “crisis” brain. The brain is plastic, all our life, and so this child did what was needed to survive.

Is the child “sick”? Again, I would argue no, though our society often treats the child as sick. We think everyone should be “nice” and “warm” and “why isn’t he/she friendly?” Well, if you started in an addiction household or a crazy household or a war zone, it would not be a good adaptation to be warm and fuzzy to everyone.

How do we treat the adult? In a warm fuzzy nice world the child would have a foster parent who adored them, was patient with them, healed them and they would be a nice adult. I have a friend who said that foster care was so bad that he chose to live in an abandoned car his senior year rather than stay in foster care. He couldn’t play football because he had to get back to the car and under the layer of newspapers before it got too cold. I am sure that most foster parents are total wonders and angels. But some aren’t.

I have a person who says that he lived on the streets from age 8. He did get picked up and put into foster care. He kept running away. “The miliary loved me because I could go from zero to 60 in 60 seconds.” That is, he has crisis wiring. He is great in a crisis. The military is a sort of a safe place, because it has rules and a hierarchy and stands in for the failed parenting. Expect that then you get blown up by an AED in Afganistan and hello, that makes the crisis wiring worse.

How DO we treat the adult? We treat them horribly. We say why can’t this person be nice. We diagnose them we drug them we shun them we isolate them we as a society discriminate against them deny them and we are a horror.

I get so angry when I see the Facebook posts where people say “surround yourself with only nice people”. Ok, how dare you judge someone? You don’t know that person’s history. You don’t know what they grew up with. How dare they say that everyone should be NICE.

I am a Veteran’s Choice provider. I have 6 new veterans in the last 3 months. I suspect I will get more. They are not “NICE”. They come in suspicious, hurt, wary, cadgy. And I don’t care, because I am not “NICE” either. We get along just fine.

When I run into someone who isn’t “NICE”, I think, oh, what has happened to this person? What happened to them when they were little? What happened to them as an adult? How have they been hurt?

Pema Chodron writes about sending love: to your loved ones, to a friend, to an acquaintance, to a stranger, to a difficult person and to an “enemy”.

Send love. And do something about it. Help at your local school, help families on the edge, help single parents, sponsor a child to a sport if their parents can’t afford it, pay for musical instrument lessons, do Big Brother/Big Sister, become a “grandparent” to a child at risk, be a good foster parent, donate to addiction care….

The photo is from 2007, when my children and I visited their father in Colorado. A stranger in the parking lot took it at our request…..

Songs to raise girls: Billy Barlow

I knew the song “Billy Barlow” as “Let’s go hunting”. It was one of the silly songs that we recorded. I adored this song when I was little for two reasons. One was that it was funny. The other was that I interpreted it as a song that could be changed and sung about more than one animal. I can remember when I realized that no, the adults sang it the same way each time and they would not change the animal. I was disappointed but I still loved the song. And I could change the animal on my own.

It’s a good song to raise girls: an illustration of a group of guys….

Let’s go hunting, says Risky Rob
Let’s go hunting, says Robin to Bob
Let’s go hunting, says Dan’l and Joe
Let’s go hunting, says Billy Barlow

When my son was a teen, another parent commented that the IQ dropped in half for each teen added to a group. Two boys cut the IQ in half, three had it to one quarter and four was trouble.

What’ll we hunt for, says Risky Rob
What’ll we hunt for,
What’ll we hunt for,
Let’s hunt rats, says Billy Barlow

How’ll we catch them,
How’ll we catch them,
How’ll we catch them,
Let’s borrow a shotgun, says Billy Barlow

How’ll we divide them,
How’ll we divide them,
How’ll we divide them,
How’ll we divide them, says Billy Barlow

I also loved this song because the last line changed. Sometimes Billy Barlow said the same thing and sometimes he said something different. When I was very small and still learning the song, that was part of the joy of it, to see what Billy Barlow would do. And clearly he was wicked, like Coyote or Pan or Loki and going to lead the group to trouble if he could….

I’ll take shoulders,
I’ll take sides,
I’ll take hams
Tailbone mine, says Billy Barlow

How’ll we cook them,
How’ll we cook them,
How’ll we cook them,
How’ll we cook them,

I’ll fry shoulders,
I’ll boil sides
I’ll bake hams,
Tailbone raw, says Billy Barlow

Oh, delicious ickiness, raw rat tailbone… It would give my sister and me shivers….

Let’s go hunting, says Risky Rob
Let’s go hunting, says Robin to Bob
Let’s go hunting, says Dan’l and Joe
Let’s stay home, says Billy Barlow

And relief. Billy was messing with them all the time and he doesn’t want to go and he never did, which is why he suggested a shotgun to hunt rats…. I like this Billy.

When I search on Billy Barlow, here is an entirely different song, a civil war marching song for Company B from New York City that marched into Maryland in 1863 and had a 63% loss. My sister had a civil war marching band play at her rehearsal dinner and we ended up marching in pea gravel for a couple hours. It turns out that my oldest cousin had ambitions to be a marching band drum leader. The band thought we were so funny that they offered to return. But the civil war fighters on both sides had marching bands with them.

And here is Pete Seeger with our song, in a slightly different style:

And here is another site that says the song is a version of “The Cutty Wren” or “The Hunting of the Wren”.

The picture is my daughter. She was playing alone and was having a wonderful time with her imagination. I am not sure who took this picture…..

Songs to raise girls: Dark as a Dungeon

We sang Dark as a Dungeon as a family song and at singing parties from when my sister and I were very little. We learned many of the songs before we knew what the words meant. At some age I considered this a cautionary song and was glad that my father was not mining coal. I also decided that I didn’t want to mine coal.

It was written by Merle Travis, whose father was a miner in an Appalachian shaft mine: Johnny Cash sang it: and Willie Nelson: and Willie Nelson It became a protest song, to fight for safer conditions. We learned this and Drill ye Terriers, Drill and Sixteen Tons, so we were raised on protest songs.

The song words have morphed a little, since we sang from memory. Here is our version:

Come all ye young fellows so young and so fine
And seek not your fortune in the dark, dreary mines
It will form as a habit and seep in your soul
‘Til the stream of your blood runs as black as the coal

Where it’s dark as a dungeon and damp as the dew
Where the danger is double and the pleasures are few
Where the rain never falls and the sun never shines
It’s dark as a dungeon way down in the mines

I wrote an essay in college about a song that I learned from my mother. I researched versions of Green Grow the Rushes Oh. I had always wondered about some of the verses, because it’s a counting song, from one to 12. Twelve for the twelve apostles and eleven for the eleven that went up to heaven. In an atheist household it takes a while to figure out the meaning of apostle. But other verses are mysterious to this day: nine for the nine Bright Shiners and eight for the April Rainers. In oral traditions if you forget a verse you make up a new one.

There’s many a man that I have seen in my day
Who lived just to labor his whole life away
Like a fiend with his dope and a drunkard his wine
A man will have lust for the lure of the mine

The comparison of  mining to addiction impressed me: “it will creep in your soul, til the stream of your blood runs as dark as the coal”. “Like a fiend with his dope” — opiate addicts were called fiends. And people were called drunkards. So this song also made me cautious about both drugs and alcohol.

We didn’t learn the third verse:

The midnight, the morning, or the middle of the day
It’s the same to the miner who labors away
Where the demons of the death often come by surprise
One fall of the slate and you are buried alive

The last verse interested me. I liked the idea of bones turning to coal over time. My parents were atheists and did not go to church, but there were lots of songs that talked about God or heaven or the devil: including sacred music. We went to big chorus rehearsals when my parents couldn’t find a sitter and we were expected to behave politely during concerts: The Messiah. And we got to go to operettas. I saw Ruddigore in Ithaca at Cornell when I was 5 and the ancestral ghosts stepping out of their portraits and singing was terrible and wonderful.

I hope when I’m gone and the ages shall roll
My body will blacken and turn into coal
Then I’ll look out the door of my heavenly home
And I’ll pity the miners A-diggin’ my bones

The photo is my father’s family and he is in the back, first trumpet. This is the Bayers Family Orchestra. My great grandfather is conducting, my grandmother on violin and my grandfather on saxophone. They became a band when my grandparents moved away, because my grandmother was the only string player.


For RonovanWrites weekly haiku challenge #67.

The words are cheer and call.

Calling brings up my sister, calling her and waiting for her to call back. She died in 2012 of cancer. Grief, not cheer.

Cheer and call

cheer and call. I re
member dismember memo
ry no cheer or call

The photo is the Mount Saint Helen’s crater in 2012, with the recovering area below starting to be green again.

Songs to raise girls: Down by the Salley Gardens

In 2009 my sister came to visit for spring break and our birthdays. We were born in March, five days and three years apart. I said that her birthday present was arranged: a recording session with me, her and my father, to record some of the family songs that we had been singing since birth.

My family had music parties in the 1960s on the east coast and when they were in college at the University of Tennessee. My mother had quit Cornell and my father had quit Princeton and they got married and went to the U of TN and I was born 9 months later. They were very poor. My mother said that she wanted to buy me a three dollar teddy bear but that they just couldn’t afford it.

They did not have a television. They were beatniks and admired On the Road. My father’s family all played instruments and sang. My mother had a much less trained voice but she had a prodigious memory and knew the fourth, fifth, sixth and all the verses of the folk songs. My father also sang classical music and had already sung at Carnegie Hall in his prep school chorus, Williston Prep School. He hated prep school. He had a full scholarship there and to Princeton because he scored perfectly on the early SAT test.

My parents refused to get a television until I was nine and my sister was six. So we sang.

My sister’s response to the birthday present: “Best Birthday Gift Ever.”

She had cancer and my father had emphysema. My mother had died in 2000. I was trying to capture their voices.

We recorded for two two hour sessions in a local in home studio. We made a list of songs and lost it on the way there. So we just took turns naming songs. Both my sister and my father play guitar. I brought kazoos, which we used on a round. We recorded each song once and in two days we recorded 36 songs.

I bought two more recording sessions at silent auctions, but we did not get to record again. And now they are both gone.


My mother and father would sing “Down by the Salley Gardens” as a duet. He was a baritone and low bass. She was an alto. My sister and I sang her part in the recording.

Down by the salley gardens my love and I did meet;
She passed the salley gardens with little snow-white feet.
She bid me take love easy, as the leaves grow on the tree;
But I, being young and foolish, with her would not agree.

In a field by the river my love and I did stand,
And on my leaning shoulder she laid her snow-white hand.
She bid me take life easy, as the grass grows on the weirs;
But I was young and foolish, and now am full of tears

by William Butler Yeats in 1889

Listening to it, I miss my mother, my father, my sister. I miss singing with them. It was a love duet for my parents, and full of longing.

The photo is my parents, in about 1960.

Headache without words

When I was in residency, a staff member brought a young man to see me.

The young man couldn’t talk. He could make some sounds. His head was a funny shape, asymmetric. His mother had rubella during her pregnancy: German measles.

“His head hurts.” said the group home staff member.

“How do you know?” I asked.

“He isn’t acting right. There is something wrong. He’s different.”

“How long?”

“About a week or ten days.”

“Did he fall?”

“We’ve talked about that but we don’t think so.”

I tell the young man what I am going to do before each part of the exam. I look in his ears carefully. His ear canals are odd too and I can’t see well. His exam is basically pretty normal for him. He is not running a fever. He doesn’t have a stiff neck. He doesn’t seem to have nasal congestion.

“If he hit his head, he could have a subdural, a bleed pressing on his brain.”

The staff member shakes their head.

“Ok. I can treat him for an ear infection, though I can’t see that well. If that doesn’t work, we will have to image his head. Would he stay still in a CT scanner?”

“No.” says the staff member.

“Then I would have to set it up with anesthesia. Which is difficult.”

So we treated him for an ear infection. No improvement. He returned. Exam unchanged. The staff was still sure his head hurt. I had never seen him before the initial visit, so I couldn’t tell.

I set up the CT scan with anesthesia. Twice, because they mucked it up the first time and it wasn’t coordinated right. I had to explain to multiple people on both anesthesia and radiology what and why I was doing it. “His head hurts and he can’t talk?” I argued until they gave in.

The ENT chief resident called me with the results. Not radiology. “What?” I said.

“It’s the biggest pseudocyst we’ve ever seen!” said the ENT chief. Surgeon. “He needs surgery!” His voice said “Cool!”

In residency I’d noticed a striking difference between family practice and other residency folks: internal medicine, surgery, neurology, all the subspecialties. They got excited when there was something rare or weird. I always thought, oh, shit, my poor patient.

“What is a pseudocyst?” I actually didn’t ask, because they knew I was just a lowly family practice resident and would probably not have heard of a pseudocyst. A cyst like structure can form of snot in the sinuses and can cause headaches. It can erode through the bone into the brain. His hadn’t, thank goodness, because that can be bad. Bad as in lethal.

Because of the measles, he had some of the largest sinuses ENT had seen ever, and the largest pseudocyst. ENT happily took him off to surgery. Great case.

I got to see him in follow up. He was his normal self. His group home staff member was delighted. “He’s back to normal! Thank you so much!”

But it’s the group home staff that noticed and cared and brought him in. “Thank you for bringing him in,” I said, “I would not have noticed. And some people wouldn’t have cared.”

Differentiating pseudocysts and other things:

More on pseudocysts:

Pseudocyst images:

Rubella in pregnancy:

Rubella, aka German measles:

Full lunar eclipse

Long long ago, when the universe was forming, the Moon fell in love with the Sun.

The Moon was afraid that the Sun wouldn’t see her, because the Sun was so bright. Slowly she pulled herself together. After careful thought, she chose to orbit the Earth.

Now it is another full lunar eclipse. Her face reflects the Sun’s glory back to him. She slides behind the Earth in a three hour version of her usual cycle, from full to only her own light back to full.

“Where are you, Moon?” bellows the Sun. He hates these quick disappearances. He yells and bellows and tantrums. But the Moon knows that he will forget quickly and that he has not bothered to learn and predict her cycles. He doesn’t like to be reminded of loss and endings and death.

The Sun likes it best when he has her full glory, face reflected back to him. He doesn’t see her light. Each month she moves from reflecting his light towards her quiet time when it is only her light that is visible from Earth. She needs this time to remember that she has her own light, even if it is a shadow compared with the sun.

“You should orbit me!” says the Sun, but the Moon knows that if she orbited him she would be burned and barren and dead, no rest and no light of her own. One night a month the Moon remembers who she is and is alone. She lets her quiet darkness shine. The Earth whispers, “Why do you love the Sun so? Don’t cry, Sister.” The Earth’s salt water tides move like tears.

Sometimes the Moon longs for ending, but she remembers: all love, returned or not, is longing and praise for the Beloved. Maybe she will not be loved or seen as she longs to be in this life, but she too will return to the Beloved and be One. And after her time in the dark she slowly returns to reflecting the Sun.

And the Sun loves her in his way. He loves to watch his reflection grow on her face each month, preens in it, until she is full. He is more irritable in the second half, as she turns her face away again. She wishes that he would look past his own light and see her.

Now the little eclipse is ending and she is rapidly becoming full again. The Sun is cheering up.

“It’s silly of you to hide your face.” says the Sun, fondly.

The moon does not smile. The Sun sees his own smile reflected in her face.


I took the photo in 2009 at Joshua Tree.