Category Archives: adverse childhood experiences

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guns in the house

During wellness visits I used to ask, “Do you have guns in the house?” in the safety/accident prevention part of the visit. Along with helmets, seat belts, smoke alarms and not driving under the influence.

As a Family Practice Board Certified Physician, I counsel patients. Family Practice is a specialty, just as internal medicine and general surgeon are specialties. A three year residency training after medical school and I retake the Boards every 10 years. I counsel patients in “annual exams” or “medicare wellness” visits.

A patient reported me to the state board because of that question. I then got a letter from the state board saying that I was being investigated but not why. Later I got a letter saying that the patient had complained that I had asked about guns. The state replied that in fact, I am supposed to counsel patients about gun safety.

I changed my counseling. Now I say: “If you have guns in the house, I am to counsel you to keep them locked up with the ammunition locked up separately.”

I get three responses:

1. “My guns are in a gun safe, locked at all times, with the ammunition locked.”

2. “I don’t have any guns!”

3. Silence.

It is the silent ones that worry me.

I did not change my counseling because I was reported to the state and the state did not tell me to change it. I changed it in hope that someone who keeps their guns unlocked and loaded, in the bedside table, under their pillow, up in a closet, or where ever, will think about it. The question “Do you have guns in the house?” is too loaded for those people.

I met a woman with an impressive star shaped radiating scar on her chest. Her boyfriend kept a loaded gun under his pillow. One night she was returning from the bathroom. He shot her in the chest.

They are not together any more.

When my son went to preschool, over 20 years ago, I counseled him. “If another child says they can show you a gun or they have a gun, say that you have to go to the bathroom. Go and tell an adult right away. People can get killed.”

He reported an overheard conversation in preschool between two other boys. One said that he knew where his parents kept a gun. The two boys were planning to leave the school to go look at the gun. I called the preschool. They already knew about it and had talked to both boys’ parents. I don’t know if the parents locked the guns up.

In Portland one of my neighbors chased his upstairs neighbor into the street one day during rush hour, stark naked, trying to hit the upstairs neighber with a 5 iron. Yes, a golf club. I am very glad the downstairs neighbor did not have a gun right then, because he would have used it. Any of us could have been killed. And later the SWAT team was called to deal with him: he did have a gun that time. He threatened to shoot himself in the head. Then he did: well, except he only creased himself. He went to involuntary psychiatry, supposedly for six months. He was back in three months. The neighborhood was very very nervous. The house next door was sold and he disappeared and we were all relieved. He was strong, completely illogical and terrifying. We discussed how to deal with him but mostly we hid.

When he chased the neighbor into the street, I had already called 911 because I heard screaming next door. My voice shook. The dispatcher said, “Yes, we know the address, we’ve had three calls and they are on their way.” The traffic stopped dead at the sight of a nude man chasing another man with a 5 iron. I unbolted my door and stuck my head out. “(C—-)! Up here!” The upstairs neighbor ran up my steps and into my house. I slammed the door and bolted it and crouched by the front window with a baseball bat, ready to hit the downstairs neighbor as hard as I could if he came through my front window.

He didn’t. The police arrived. The whole thing was over the upstairs neighbor “playing music too loud” and “not turning it down enough”. The downstairs neighbor had broken down the upstairs neighbor’s door with the five iron. The upstairs neighbor had tried to defend himself with a butter knife and then ran. The police explained to the downstairs neighbor as he was arrested that if someone breaks your door down, it is not assault to defend yourself with a butter knife.

We discussed which illegal drugs we thought he was on. This was in the 1990s, so we thought it was crack. There was a big article soon after that about a crack house. We said, whew, glad we aren’t those neighbors and then realized that it was within two blocks of our house. Great.

Drugs and alcohol and guns and anger and grief….. it is a toxic mix.

Please, lock your guns.

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Unconditional 2

I think the hardest thing in the world is to love unconditionally. And we can’t love unconditionally unless we love ourselves in that too. Including our faults, our mistakes, our dark corners, our anger and grief, pettiness, unkindness, stupidity, jealousy, greed lust… if we only love our “good” side then we will attack others when they show the same weakness and faults that we know, deep inside, that we are capable of or have acted on. If we cannot love someone who is a sinner, we cannot love anyone, because we are all guilty. Love people anyhow and wholly and yourself too.

I went through a period after my mother died, where I felt I’d entirely failed. My marriage was disintegrating, and I was looking at myself very carefully. How had I gotten here? What mistakes had I made? I felt unlovable and stupid.

I found a letter from my mother written to herself when my father asked me to clean out her clothes. It was two or three years after she died. Here is the letter, with a few things left out for the privacy of the living:

____________________

Sept 18, Friday
1987
Seattle

I don’t want to go home. I want to stay here in Seattle. With the mountains that lift my heart. And clear air and only good memories. What is there to go home to? Struggling with X and his alcohol. I don’t want to try to do something about it. I don’t think it will work if I do. I think will only go on as it is and trying to get help will only lead to fight. I don’t think I have the strength, the courage or the wisdom to help myself or him.

What else am I going to? A house that needs a great deal of work that I only moderately like. A climate I loath. A landscape I find boring. I’m tired of living in a crowded suburb. And that house needs so much work.

People. What people do I go home to? Nearly all have problems. Y, wounded bird, so foolishly enamored of Z or thinks he is. And I have little sympathy or patience with it. And his propensity to failure which I’m tired of also.

A who I dearly love but her household is such chaos with those ill-behaved children and one crisis after another.

B who I like very much but really have so little in common with. I fear all that spiritual stuff may eventually bore me. Maybe not.

C. Another wounded bird, really. And not dependable.

D, barely around, anymore.

Mother, older and frailer. Who needs my care and patience.

E. There is one person to go home to. Thank God she’s there. Not wounded anymore. But so busy and it isn’t fair or wise to dump my troubles on her.

Who else? Why don’t I know any successful (in the best sense) sane people. People who are intellectuals, interested in ideas. F is. But not a fully successful human being and not when G is with him. Ugh. Besides he lives far away and he and X don’t like each other.

I don’t really want to have that show at H’s Church. I don’t like H very well. Oh dear.

I maybe have a job which if I get will be very hard work and if I don’t will be a great disappointment.

Winter’s coming and things cost more and we don’t have quite enough to live on. So that means digging into my inheritance.

I am sick of D.C. I am sick of being a struggling, unsuccessful artist. I am sick of worrying about X, about his moods, his acting the fool when half drunk and acting cruel and crazy when fully drunk. I’m sick of being afraid, of his depression, of his refusal to talk to me about anything of importance.

Of doing dishing. Of all the mess in our house. The mess on my desk, the mud room, the kitchen, the study, the basement. The dirty paint. The back yard. Oh God! How can I change things? Well there are a lot of bad things.

Oh, & I’m sick of being anxious, 10 lbs overweight, biting my nails, having bad teeth/gums. Life get tedjous, don’t it?

Any good stuff?

____________________________

For me, this letter was the key to finding myself lovable. My mother wrote to herself because she felt that she could not share these feelings with anyone. Terrible feelings. And I thought about it for a long time: I thought: my mother was charming, loved and an entertainer. But a child knows the parents’ hidden feelings. So I knew about my mother’s darkness and the letter confirmed it. And I thought, my mother didn’t need to hide that because I knew about it and I loved her anyhow. I love her more knowing that she was human too.

And if she is lovable whole, so am I. So are you. We all are. And we all make mistakes and are guilty of anger (sometimes appropriate but sometimes not!) jealousy, greed, lust, sloth and pride. Love people anyway and wholly and yourself too.

 

I have a view of Puget Sound if I stand in the road in front of my house. I took this with a zoom lens on solstice morning at sunrise.

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does chronic pain kill you?

Another writer sent me this story, saying that chronic pain killed Prince, not an overdose.

http://www.rawstory.com/2016/05/prince-did-not-die-from-pain-pills-he-died-from-chronic-pain/

My response is complex.

1. Is chronic pain an “illness” in it’s own right?

My answer is yes and no. It’s complicated and our understanding is evolving. Right now I think of chronic pain as a switch in the brain that gets thrown. It can be thrown by adverse childhood experiences, by infection, by trauma or war or abuse, by too much stress… or a combination of any of these.

2. Why a switch in the brain?

In fibromyalgia patients we can’t find much on physical exam, except that the pain seems out of proportion to the exam. Ditto with chronic fatigue, reflex sympathetic dystrophy, TMJ, etc. However, now we can image the brain with a functional MRI and watch which parts are lighting up and how much. A study of “normal” and fibromyalgia patients involved a standardized pain stimulus: a thumbscrew. (Kinky, right?) The normal patients said the pain stimulus was 3-4 out of 10 and their brains lit up a certain amount. The fibromyalgia patients said the same pain stimulus was 7-8 out of 10 and the pain parts of the brain lit up MORE corresponding to their pain level. So they are not lying… and it IS in their heads. Sort of. We aren’t sure whether the muscle is yelling more than normal or whether the brain is hypersensitive or both. My guess would be both.

And I think this is an adaptation. It is to get us to rest, heal, calm down, introspect, stop being type A, etc. Boy, do we suck at it. Though recently I had a person in clinic who said what their body wanted to do was nothing. They just wanted to lie around. I said, well, ok, so when can you do that? They did, for two weeks, at the holidays. And my patient said, “One day I had a cup of tea and a book and the cat on my lap and the dog at my feet. I realized that my adrenaline system was turning off and I felt calm and relaxed. Healed.” Back at work the person cannot always maintain it but is getting better at it.

3. What does this have to do with Prince?

The problem is that for 20 years we treated chronic pain with opiates. Unfortunately on continuous opiates, the brain cells change in many people and “down-regulate” the opiate receptors. Less receptors, the pain rises. The person needs more opiate. The brain removes more receptors. So two myths: one that if you have chronic pain and take medicine as directed, you can’t get addicted. Only dependent. Since that is a myth, the DSM-V has combined addiction and dependence into one diagnosis: opioid overuse syndrome. It is a spectrum, not two separate responses.

The second myth is that if you give enough opioid, it will help the pain. Well, no. UW Pain and Addiction Clinic says that on average pain is reduced about 30% by opiods, whatever the dose. And high doses start causing some weird  hyperalgesias. I’ve weaned two people from over 100mg methadone daily down to 20-30mg. It took two years. They felt better on the lower dose after they got through withdrawal symptoms and a short term increase in the pain receptors complaining at them. And they are much less likely to overdose and die.

Page two here http://www.supportprop.org/wp-content/uploads/2014/01/PROP_OpioidPrescribing.pdf discusses current knowledge about opioids.

4. So like, Prince?

He may have died from a combination of fatigue and sedating drugs. If you get enough sedating drugs, then you stop breathing. Opioids are the biggest offenders combined with alcohol or sleep medicine like ambien or benzodiazepines like valium or ativan or alprazolam or muscle relaxants like methacarbomal or a combination of all of the above. I am a strict physician about urine drugs screens and I do the dip in clinic in front of the person. Way too often, the person does not tell me about the alprazolam or whatever until I am holding the dip over the cup…. and that’s when they tell me. They got it from the ER or a friend or two years ago or … took their dog’s. Really.

He may have died from influenza, if he had it, with sedating drugs. Bad influenza causes lung tissue swelling and can mess up your oxygenation. Your heart has to take up the slack and go faster. If you are trying to work and your heart rate is well above normal, it’s exhausting. It can kill you.

He may have died from overwork, another infection, sedating medicines…. but not directly from chronic pain. Chronic pain slows us but I do not think it kills us*. What kills us is trying to treat it with a pill instead of resting and doing gentle exercise and saying: What does my body want?

 

5. Overdose?

Also, are we talking about an accidental overdose? Are we talking about drug abuse? Are we talking about accidental death or suicide or do we as a society think that addiction deserves overdose death but a person taking medicine for chronic pain is a tragedy? Aren’t we a bit judgemental?

Prince may have taken a pain pill as directed but taken it with too many other controlled substances or with alcohol or while sick and exhausted. Overdose means too high a dose. If it was two percocets, alcohol, flu and xanax…. it could be an accidental poisoning.

6. Are you sure?

No. Medicine changes. Our understanding of the brain changes. Science is about change and deepening understanding. We are barely getting started on the brain and I would say that we are in preschool there.

 

http://www.doh.wa.gov/LicensesPermitsandCertificates/MedicalCommission/MedicalResources/PainManagement

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPatients

*And on the other hand: http://www.practicalpainmanagement.com/sudden-unexpected-death-chronic-pain-patients

 

*Stress alone can cause heart attacks and sudden death:    http://www.health.harvard.edu/blog/stress-cardiomyopathy-a-different-kind-of-heart-attack-201509038239

The photograph is from a week ago, part of my Maxfield Parish cloud series, zoomed way in to the mountains across the water.

 

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Advice to young people

My biggest piece of advice to young singles and young couples is: put half of each take home salary away. Married or not married, and I don’t care how committed you are.

I know people who lose their house when one half of a couple is sick, and the other can’t pay all the bills on one salary. We don’t want to think about illness or cancer, but it happens. Young parents, with one very ill and the other with a job, children and a sick spouse. Having a reserve is way more important than keeping up with the Joneses, unless you happen to inherit like Mr. Trump.

If you each put half of your take home salary away, then when life throws surprises at you, you will have a reserve. A big reserve if the surprises hold off for a while. Divide that half into retirement and half into money that you have access to in emergencies.

I listed the top ten causes of death in the US in 2012 here, but lets look by age: http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2012-a.pdf.

From age 1 to 44 the top cause of death is accidents, unintentional injuries.

Suicide is second from age 15 to 44.

Cancer takes over as number one, malignant neoplasms, at age 45 to 65.

After 65, the number one cause of death is the heart, and that is where the biggest numbers are. But if a younger cause of death affects your family, it feels unfair, wrong, as if we all expect to like to age 78 or beyond.

Untintentional injury, that is, accidents, are broken down here: http://www.cdc.gov/injury. When I do physicals on teens, I ask them what the number one cause of death is for teens. They all know the answer, even if they have to think for a moment: motor vehicle accidents.

But lets look at accidents in the age 25-65 age group: poisonings. What? Poisoning? And NOT intentional…. what is going on there? It is drugs, legal and illegal, but more legal. Sedating drugs in combination are effective at sedating people enough to stop breathing and die. Alcohol with benzodiazepines (valium, ativan, etc.), opiates and opioids, sleep medicines such as ambien and sonata, withdrawal from methamphetamines, cocaine, crack….people die. And supplements may be contributing as well.

75 years of US mortality data: http://www.cdc.gov/nchs/data/databriefs/db88.pdf#x2013;2010%20

At birth now in the US the life expectancy averages 78, but not everyone reaches that….some people still die younger and some live longer.

The age of death is rising, world wide. In the US, many of us have a world envied standard of living and yet we have a significant number of people who are anxious and depressed and way too high a rate of substance abuse, alcohol, opiates and opioids, benzodiazepines and yes, marijuana is addictive. How do I reconcile this? How do you reconcile this?

Keep your reserve, young singles and young couples…..

http://www.worldlifeexpectancy.com/usa-cause-of-death-by-age-and-gender
As of the day I am writing this on 5/2/16:

POPULATION
318,857,056

Numbers to be corrected, first set was wrong, wrong, wrong.

I took the photograph yesterday evening: there were the most amazing Maxfield Parish clouds…. life and death are a mystery.

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W is for wrath

W is for wrath, the seventh sin.

From Webster 1913:

Wrath

1. Violent anger; vehement exasperation; indignation; rage; fury; ire.
Wrath is a fire, and jealousy a weed. Spenser.
When the wrath of king Ahasuerus was appeased. Esther ii. 1.
Now smoking and frothing Its tumult and wrath in. Southey.

2. The effects of anger or indignation; the just punishment of an offense or a crime.
“A revenger to execute wrath upon him that doeth evil.” Rom. xiii. 4.
Syn. — Anger; fury; rage; ire; vengeance; indignation; resentment; passion. See Anger.

 

Wrath is a sin, yet is it ever justified?

I am wrathful about this: http://www.npr.org/sections/health-shots/2016/03/23/471595323/drug-company-jacks-up-cost-of-aid-in-dying-medication

In my state a terminally ill patient may choose Death with Dignity: http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct

The person must be terminally ill, must not be suicidal and must go through a process. But one of the tablets prescribed, which only the person may administer to themselves, has had a price increase from $200.00 to over $3000.00.

I heard this from another physician, who has a patient who is going through the process.

I feel wrath and anger and hurt and rage that a corporation is choosing to make an enormous profit from terminally ill patients.

And so wrath may be a sin, but it is also an appropriate feeling at times.

In a sermon about forgiveness, hate is also discussed:

“Let me also say a word here about hatred, since I am speaking of forgiveness as being the release of hatred. Many  of us,  I suppose, like myself, have been taught not to hate.  We have been taught that hatred is always a bad thing and there is no place for it.  Thus, we feel uncomfortable in the face of this intense emotion and attitude.  Many times I have stumbled on the line from the biblical book of Ecclesiastes which reads, “There’s a time to love and a time to hate.”

Can there be  a time to hate?  Ironically, when  reflecting on the subject of forgiveness, I see that there is a place for hatred.
 
First,  your  hatred  lets  you  know  that  you  are  feeling  diminished  and  perhaps  being stepped on and treated as no human being ought to be treated.

Secondly,  your  hatred  lets  you  know  that  you’re  fighting  back  and  that  you  have something  to  fight  back  with.    It  lets  you  know  that  the  situation  is  intolerable  and  you will not put up with it.

And  so  hatred  can  be  a  natural  and  even  necessary  response  to  situations  that  threaten human dignity.  Says one author, “Not to feel resentment when resentment is called for is a sign of servility,… a lack of self-respect.”  (Forgiveness, Haber)”

From: November 15, 2009, here: http://www.quuf.org/index.php?page=2009—2010-sermons

p7
http://www.quuf.org/uploads/Sermons/Is%20Forgiveness%20Always%20Called%20For%20Part%20II%20Nov%2015%2009%20print.pdf

I took the picture in 2007. No wrath here, but three different expressions, and all complex….

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sing for the girls

Sing for the girls who grow up in war zones.
Sing for the girls who grow up scared.
Sing for the girls who grow up abused.
Sing for the girls unprepared.

Sing for the girls who grow up with alcohol.
Sing for the girls who grow in broken homes.
Sing for the girls who don’t tell anyone.
Sing for the girls alone.

Sing for the girls who grow up beaten.
Sing for the girls who grow up raped.
Sing for the girls who care for siblings.
Sing for the girls who learn to hate.

Sing for the women who now look frozen.
Sing for the women who now look old.
Sing for the women who survived it anyway.
Sing for the women who told.

Sing for the girls who grow up broken.
Sing for the girls who break everything.
Sing for the girls who break the silence.
We are broken and breaking: sing.

I took the photograph at the US Synchronized Swimming Nationals in 2012.

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Adverse Childhood Experiences 8: Social cues

I am thinking about social cues for people with high Adverse Childhood Experience scores. With crisis brain wiring the response to social cues may be very different than what is considered the acceptable “norm”.

I always miss the cue when someone says “see you later”. I think “When?” Then I realize it’s a social comment and they do not in fact plan to see me later. I have a moment of disappointment. I do the same thing when someone says, “Let’s get together for dinner.” or “Let’s have coffee some time!” or “I will call you back!” or “Why don’t you come to our cabin some day?” Yes, I think, when?

And then I think “Liar.”

So I fail social cues….. or do I? Maybe I am not responding to the “correct” or “conventional” or “nice” social cues.

My father drank too much and especially while I was in high school and college. And my mother would enable and cover up and pretend nothing was happening. Children in this situation, which is way too common, develop special skills.

My sister was three years younger. As adults we discussed the stages of drinking and which one we hated most. We would both walk in the house from school with trepidation. In the door and almost feeling the air: what is happening? Am I safe? Do I need to hide? How dangerous is it? How much will it hurt?

I walked in once during high school and missed the cue. I was thinking about something. I thought my father was asleep in the kitchen. I went in to get something. I was very quiet so as not to wake him. I made a cup of tea.

He was not asleep, or else he woke up. And it was the worst stage, or the one I hated most.
Not physical violence. But he started talking. One of things he said was “You can tell me anything.” Now, he meant it. But he was crying by then and I knew I did not want to tell him anything and all I wanted was desperately to leave the room. And neither my sister or my mother was home. Finally I was crying too, because I said “I just want to go read my book.” and he was more crushed and maudlin and emotional and crying. And I tore out of the room and up to my room, as my mother walked in.

I did not cry much. Ever.

I refused to talk to my mother about it.

The next day she said to me, “Your father told me that you were talking about Lamont.” Lamont Cranston was a very beloved cat, The Shadow, who was missing now. Dead, we thought.

I said nothing. Because we had not talked about Lamont. So either my father was lying or else he’d had a blackout, didn’t remember and was making shit up. And if I told my mother the truth, she would back him and deny what I said or make it into a joke.

The stages my sister and I identified were:
1. sober
2. a little bit
3. goofy/silly/makes no sense
4. crying
5. asleep

We were ok with 2 and 5. I don’t think we saw 1 for years. We disliked 3 intensely, especially in public and especially when our mother was doing a cover up dance. And 4 we hated.
And yet I loved my parents and mostly miss them now that they are gone. Except when I remember things like this.

So, what is the point?

I miss “social cues” because that is NOT what the crisis brain, the ACE score brain, pays attention to. I am paying attention to far more intuitive things: body language. Whether what the person is saying matches what I know about them and what they have done in the past. I am looking for whether this person is telling me the truth.

I don’t trust instantly. Why would I?

I said to a counselor once that reading the “cloud” around the person was terribly useful in medicine but made me a social misfit. “I don’t know how to turn it off.” I said. She grimaced and said, “Why do you think I went into counseling?” She said, “I can’t turn it off either but I have learned to ignore it during social situations.” I was in my forties before I realized that there are people who don’t sense this cloud, who trust people until the person is dishonest, who understand that it is just fine to say “Let’s get together.” and not mean it.

Because actually, when someone says “I’ll see you later.” and they don’t mean it, they are saying an untruth. They are not planning to see me later. They don’t mean it. And my brain automatically files that under evidence that this person is not trustworthy. To them it is a social cue that is polite. To some of us, it is clearly something that is not actually true. I pick up on a cloud of social cues, but not the ones that are acceptable or conventional. And I am not the only one.

my sister on the left and me on the right, in the 1960s

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Why care for addicts?

Why care for addicts?

Children. If we do addiction medicine and help and treat addicts, we are helping children and their parents and our elderly patients’ children. We are helping families, and that is why I chose Family Practice as my specialty.

Stop thinking of addiction as the evil person who chooses to buy drugs instead of paying their bills. Instead, think of it as a disease where the drug takes over. Essentially, we have trouble with addicts because they lie about using drugs. But I think of it as the drug takes over: when the addict is out of control, the drug has control. The drug is not just lying to the doctor, the spouse, the parents, the family, the police: the drug is lying to the patient too.

The drug says: just a little. You feel so sick. You will feel so much better. Just a tiny bit and you can stop then. No one will know. You are smart. You can do it. You have control. You can just use a tiny bit, just today and then you can stop. They say they are helping you, but they aren’t. Look how horrible you feel! And you need to get the shopping done and you can’t because you are so sick…. just a little. I won’t hurt you. I am your best friend.

I think of drug and alcohol addiction as a loss of boundaries and a loss of control. I treat opiate overuse patients and I explain: you are here to be treated because you have lost your boundaries with this drug. Therefore it is my job to help you rebuild those boundaries. We both know that if the drug takes control, it will lie. So I have to do urine drug tests and hold you to your appointments and refuse to alter MY boundaries to help keep you safe. If the drug is taking over, I will have you come for more frequent visits. You have to keep your part of the contract: going to AA, to NA, to your treatment group, giving urine specimens. These things rebuild your internal boundaries. Meanwhile you and I and drug treatment are the external boundaries. If that fails, I will offer to help you go to inpatient treatment. Some people refuse and go back to the drug. I feel sad but I hope that they will have another chance. Some people die from the drug and are lost.

Addiction is a family illness. The loved one is controlled by the drug and lies. The family WANTS to believe their loved one and often the family “enables” by helping the loved one cover up the illness. Telling the boss that the loved one is sick, procuring them alcohol or giving them their pills, telling the children and the grandparents that everything is ok. Everything is NOT ok and the children are frightened. One parent behaves horribly when they are high or drunk and the other parent is anxious, distracted, stressed and denies the problem. Or BOTH are using and imagine if you are a child in that. Terror and confusion.

Children from addiction homes are more likely to be addicts themselves or marry addicts. They have grown up in confusing lonely dysfunction and exactly how are they supposed to learn to act “normally” or to heal themselves? The parents may have covered well enough that the community tells them how wonderful their father was or how charming their mother was at the funeral. What does the adult child say to that, if they have memories of terror and horror? The children learn to numb the feelings in order to survive the household and they learn to keep their mouths shut: it’s safer. It is very hard to unlearn as an adult.

I have people with opiate overuse syndrome who come to see me with their children. I have drawings by children that have a doctor and a nurse and the words “heroes” underneath and “thank you”. I  have had a young pregnant patient thank me for doing a urine drug screen as routine early in pregnancy. “My friend used meth the whole pregnancy and they never checked,” she said, “Now her baby is messed up.”

Addiction medicine is complicated because we think people should tell the truth. But it is a disease precisely because it’s the loss of control and loss of boundaries that cause the lying. We should be angry at the drug, not the person: love the person and help them change their behavior. We need to stop stigmatizing and demeaning addiction and help people. For them, for their families, for their children and for ourselves.

I took the photo of my daughter on Easter years ago.

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Where oh where is love?

How could we have love without grief?

The US culture seems to suppress grief, take grief away, heal grief, get over grief, but think about love without grief.

Could we love someone if we didn’t grieve when they died?

No. We couldn’t. That wouldn’t be love. Or that would be the pale shadow of love, love without loss, love that turned from the grave and forgot.

We cannot love without grief, so we need to make room for grief. We need to stand by each other during grief. We need to help each other, be present, be there, say the wrong thing, say the right thing, say nothing and just give love.

Love builds the Taj Mahal. Love writes Rumi’s poems. Love is the memories of the person we loved, we tell our children about them, we hold them in our hearts.

Love loves without logic, without sense. Love in spite of alcohol, addiction, lies, how can a person love an abuser? They love the person, not the abuse. They love the person, not the actions, not when the alcohol takes over, when the meth takes over, when the oxycontin takes over. Love loves the whole person and grieves the damage.

Love and grief are intertwined, a rosebush with thorns, there is no one without the other. No joy without despair, no light without dark, no you without me, no joining without separation.

I enter grief as I enter love, whole heartedly, oh, I may be afraid of the dark but I go there anyhow, I know as the waves close over my head and I sink into the depths:

There is no love without grief.

 

The picture is my mother, Helen Burling Ottaway, in high school. She died of cancer in 2000 and I still miss her terribly.

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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…..