Category Archives: adverse childhood experiences

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Dark sky with stars

Yesterday I had my “Armour suit”  massage at 4:00.

Sometimes during the massage I space out and go elsewhere. I don’t know if it is falling asleep. My practitioner knows when I am gone, because he is telling me to roll my leg to the left against resistance and I will just stop in the middle. I usually see pictures and tell him what I saw.

Yesterday I saw a dream that I had years ago.

I dreamed that I was looking through a window and the sky was black, with stars.  The stars started to fall. The stars were all angels, all falling, slowly, down. I wanted to ask the angels, “Why do you have to fall?” but I was frightened. I was terrified. Because all of the angels were falling: every one. Slipping slowly down the sky.

Then I saw their faces. They were not afraid or angry or resisting. They all had expressions of acceptance and peace.

In the dream then there was no window between me and the angels. I was in the dark too and falling slowly. I did not resist. I knew I needed to let myself fall, like the angels. We all must let go and fall. I was crying even as I accepted it.

I wonder why the angels were made to fall. I think they fall for us, to show us acceptance and love.

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Demon Chainers

And you thought the hard work was over
Finding your demons
Facing them
Adopting them
Comforting them
Learning to love the parts that no one loved
That you hid as a child
Mothering your own unloved self
Fathering the parts he couldn’t love
And to surface knowing that you are a child of God
And lovable
Only to be attacked
With a concerted effort
To return you to what you were before

Don’t be frightened enough to give up
You are right
You are still a child of God
Lovable
In your wholeness
Talents and faults

Those who attack
Feel their demons
Clamoring at them
Clawing
When you learned to love your demons
Theirs want to be loved too
So badly
But their keepers are frightened
They are pressing their demons back into the depths
Desperate
Attack you for you have made them feel their sorrows
All unaware

Seek those who have also
Dealt with their demons
And they will welcome you
You are not crazy
To feel the euphoria
Of surfacing
But do not get carried away
And be kind to the demon chainers
Remember where you were before.

8/16/05

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Angel Witness

Sometimes
Even as you make
The same mistake
Cross the threshold
Open the door
Lift the glass

You feel the presence
Of angels
Drawn by the seriousness
Of your decision

Present
Not to pull you away
From the cup
The drug
The wrong man
The dire pattern
You feel their intensity
The presence
As if outer space
Has clung to their wings
Or motes from heaven
Alien
The weight of their gaze
And their interest

Sometimes
Even as you make
The same mistake
It’s not the same
To sense an angel
Witness

previously published on an obscure writing site

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Weekly Angel/Devil Fight: Love everyone

This is my weekly (biweekly, snarls my devil) blog about the arguments between the devil on one shoulder and the angel on the other.

Do I really see an angel and a devil? Well, no. But we all use archetypes and we all have all of the archetypes within us. So when I have a dilemma or something comes up, I call the angel and the devil to the internal conference table of my mind and ask for their advice. They are going to give it to me whether I ask or not, so it’s more effective to be polite!

Ok, sometimes it isn’t a conference table. Sometimes it’s a hell scenario with bubbling lava or the fire forest from A Princess Bride… or it could be a field with daisies and a blue sky….

Today I am thinking about what we are supposed to do: Love everyone.

How good are we at that? Not very! Or are we?

My angel: You can love everyone. (The angel is kind and completely confident.)

My devil: Yeah, til they knife you in the back. Right. Go ahead, love them and they’ll treat you like dirt!

My angel: You can love them anyway.

My devil: Paula Pell said, “Be nice to all assholes because it disables them!”

My angel: Yes. You should be nice to those people too. (She doesn’t approve of swearing.)

Devil: sulking.

In my job, I get to love everyone. That is, as a doctor I want to be able to treat everyone and anyone who walks in my office. They can be talking about aliens or refuse to do what I suggest or they can say, “I hate doctors especially YOU.” and I am still supposed and do try to help them. Sometimes it doesn’t work very well. Sometimes we don’t connect or they are going to do the opposite of whatever I say or they return to using heroin. But I still get to try.

In my personal life, I would like to be the same. I am not there yet.

Devil: yeah, and don’t want to be….

Angel: keep trying….

But I can bring something from my job to my personal life. I don’t have to love what people DO and they can be MEAN and I don’t have to LIKE IT. But that is separate from the person themselves: I can still love the person even if they seem to be acting like an idiot and my devil wants to strangle them…..

Devil: oooo, strangle, I like it

Angel: separate the person from the action. Love them anyway.

Keep on trying…..

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Bill Cosby and the Real Men

I do not want to decide if Bill Cosby is guilty. I am not on a jury nor am I his judge. But I do have a question: Where are the men?

Women have come forward. Woman after woman. They were younger than him and he was already famous and on his way. But there were men there too, who worked with him. Why haven’t we heard from them? We have heard from only one man.

Various people say how dare these women come forward after all this time. But back then, I think that if a woman had gone to the police, the attitude may well have been, “You were out with a married man. You can’t prove anything, you slut whore.”

Why do I say this? In my second year of medical school, in 1990, we had a lecture about domestic violence and rape. A day or two later, I was with four people from my class: we were two men and three women.

One of the men said, “If I were a woman who was raped, I would never tell anyone.”

I said, “Oh, I’d be in the emergency room getting a rape kit done for evidence and I’d have his ass in jail immediately.”

Silence. Then he said, “Um. Wow. Can I ask why?”

I explained that I had been sexually abused by a neighbor at seven. Being a bit clueless, I asked my mother about what it meant when a guy rubbed his penis on a girl. She explained sex. I got worried that I was pregnant, I was sure that I was no longer a virgin and I thought it was my fault. And I told my four year old sister never ever to go near him. I think my mother had no idea what was in my head. I had a doctor appointment a few months later and decided that I probably was not pregnant, because surely the doctor would have noticed. I felt guilty and at fault for letting it happen. I was seven. On the school bus to second grade I thought sadly that I was the only girl who was not a virgin.

I was lucky in the I could and did stop it. It was not a family member. I stood up for myself at seven.

I revisited it in college. I heard a program about how rape victims feel and how guilty and at fault they feel. And how they are often treated with suspicion, what were they doing to inflame the man? I was so stunned as they described the feelings that I had at age 7 that I burned the bacon I was cooking.

“So,” I said, “If I walk naked down the street, I am fine with being arrested for indecency. But no one can rape me. That is violence and it is illegal.”

The medical school men continued to look at me. “See?” I said, “I am ok. I think the perception is still that women are “ruined” and destroyed by rape. The numbers of women experiencing rape or domestic violence is one in four.”

“Yes,” said one of the guys, “But I didn’t believe that.”

“Well, we have three women here.” We all looked at the other two. One nodded yes and the other shook her head no.

After the child abuse lecture, the male student came to me. “I thought of you during the lecture. What you said will make me treat women who have been abused differently. Thank you.”

So: where are the men who worked with Cosby? Was this an open secret?

If the women are telling the truth, then the men who worked with Cosby know. I am afraid that the silence means:

They didn’t want to know.
They turned a blind eye.
They tell themselves they can’t prove it.
He was the goose laying the golden egg.
Those girls deserved what they got, he was a married man.

So: Where are the REAL MEN who worked with Bill Cosby? If it is true and they stay silent, they are accomplices. Every single one of them should call their lawyer and say, “I saw evidence that supports what the women are saying. Please contact their lawyers so that I can make a statement.” Or: “I am willing to make a statement that I worked with Bill Cosby for x years and never saw anything suspicious.” Not a statement for the press. A statement that they will stand by in court: that it’s the truth, the whole truth and nothing but the truth.

And think if it had been men being preyed on. Take that as a scenario. Men would have screamed the house down and what’s more they would have been believed. And they would not be accused of leading him on or being whores or being sluts or asked what they were wearing.

Will the Real Men who worked with Bill Cosby please stand up.

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Adverse Childhood Experiences 3: Attachment Disorder

I ought to have an attachment disorder, which now is called “separation anxiety disorder” in the DSM IV, now redefined in the DSM IV-TR and then the DSM V. That is, they keep changing the definition of psychiatric disorders. It’s a bit unnerving, isn’t it? Not only the brain is “plastic” and can be rewired throughout our lives, but the psychiatric diagnosis manual is being updated.

When I went into allopathic medicine, I was under the impression that I needed to learn everything I could and apply it. Spectacularly wrong. I needed to learn everything and then track everything because at least one fourth of what I learned was wrong or was going to change. I just didn’t know WHICH 25% was wrong.

This is why older doctors have a healthy skepticism towards new medicines, new equipment, new ideas. Older doctors are more likely to use old cheap medicines and eschew the new-fangled samples. It’s not just that the pharmaceutical companies only give us samples of the new expensive stuff. It’s also that some of the new expensive stuff is not as good as advertised and has a chance of hurting people. I still would advise my patients to use coumadin (warfarin) if they have a clotting disorder. Yes, you can take the new drugs without doing a monthly blood test — BUT if you bleed, I can’t reverse the new medicines. So I wouldn’t take them: if I need a medicine to keep me from clotting, I want coumadin. I will decide about the new medicines in 5-10 years. Old and cynical, that’s me….

As previously written, I had five “experiences” under age three that left me not trusting adults. However, the adults seemed to love me, even though they kept abandoning me to other adults. At under three, this did not make sense. I could have decided never to trust anyone and presumably would have really gone off into some sociopathic bad place, but I didn’t do that.

The clue to what I did is in my mother’s stories. My sister was born five days before my 3rd birthday. She came home right by my birthday, at Easter.

My mother said, “You asked if you could dress Chris. She was two days old. She was nearly ten pounds and had a triple chin. You wanted to put a lacy dress on her. I decided that you could try and told you to be very gentle.

You put Chris into the newborn baby dress. She was so big that it barely fit and in fact, that was the only time she ever wore it. You had to stuff her arms through the sleeves. She cracked her eyes and looked at you, but she did not object at all. You were gentle.”

That doesn’t seem like much. Next story:

My mother said, “You would meet visitors who came to see Chris at the door. You would say “Come see my baby.” I let you open presents for Chris because she didn’t care. You would show the visitors your sister.”

My baby. That is the key.

I think what happened is this:
1. The adults who took care of me did seem to love me.
2. Even though they loved me, they kept abandoning me, or giving me to other adults. I really really disliked this.
3. I thought that adults were misguided and wrong to give me away. I thought there must be some explanation. I would try to figure it out. Meanwhile, I was going to take care of my sister: she was MY BABY. I was going to show those stupid, loving, confused adults how to take care of a baby and NO ONE was going to give HER away. I could love adults but no way was I going to trust them.

That was my crisis brain wiring by age 3. Adults are loving and untrustworthy. You can love them back but they may abandon you to someone else at any moment. You can’t predict what they will do. They may be even LESS trustworthy if they are loving and you know them, than if it is a stranger.

My mother again, “When I got you back at nine months, you didn’t know me. You wanted to be as independent as possible. You missed your (maternal) grandmother. In the grocery store, you would cry if you saw a white haired woman. We couldn’t comfort you.

I thought that you didn’t like us at all until you ate a cigarette butt and got really sick. You let us take care of you. Then we left you with friends for a night. You were absolutely furious when we got back and I thought that you really did like us….”

Poor young mom, 23 and recovering from tuberculosis and still not strong, with an angry and grieving nine month old who really didn’t want much to do with her and didn’t trust her at all…..

Changes from the DSM IV-TR to the DSM V: http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf

The DSM IV criteria for separation anxiety: http://behavenet.com/node/21498

Theme song: The Devil Makes Three “All Hail”

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Adverse Childhood Experiences 2: Out on a Limb

We are approaching a seismic shift in psychiatry. I am now going out of a limb to predict the direction we will go in.

The allopathic medical community will resist, including many psychiatrists. But it is the neurobiologists and brain imaging and psychiatrists who will prevail. If the creek don’t rise and we aren’t hit by a giant asteroid, nuclear winter, devolve into fighting over the remaining arable land as the world heats up….

I have been thinking about this all through my career, but especially since the lecture on adverse childhood experiences, which I heard in Washington, DC about ten years ago. I wrote about that lecture on January 6, 2015. The lecturer was a woman. She said that it appeared that the brain formed differently in response to childhood adverse experiences. She said that we don’t yet know what to do with this information.

Staggering understatement. I went from that lecture to one about ADHD. The lecturer was male. He said, “Children diagnosed with ADHD have brains that are different from normal children on PET scans and functional MRIs. We don’t understand this.” He sounded puzzled. I thought, he didn’t go to the previous lecture….

Childhood adverse experiences are scored zero to seven. I score a five. I am at high risk for addiction. I assumed this when I realized at age 19 that my father was an alcoholic and my mother was enabling. I was very very careful about alcohol. I tried pot twice and didn’t like it. I refused to try anything else, and refused benzodiazepines when I was depressed: they are addictive. With an ACE score of five, I am also at higher risk than a person with a score of zero for ALL mental health diagnosis: ADHD, depression, bipolar disorder, obsessive compulsive disorder, etc. People with a score of five had a 60% chance of being diagnosed with depression compared with a 10% chance in people with a score of zero over the life of the study. In the last fourteen years I’ve only been diagnosed with a “grief reaction” which is a temporary reaction to grief. It is also called an adjustment disorder. High adverse childhood experience scores are also at higher risk for morbidity and mortality from heart disease, emphysema, arthritis, basically everything and tend to die younger.

What this means, I think, is that our brains are plastic in utero and in childhood: the wiring is put down in response to the environment. This is adaptation. I have crisis wiring: my mother had tuberculosis when I was conceived and born. Really, from an evolutionary standpoint I AM weird: babies whose mothers had tuberculosis died. Quickly. I was saved because my mother coughed blood one month before I was due. A lot of blood. She thought she had lung cancer and would die. The fetus is bathed in those stress hormones, grief, fear….

I was removed from my mother at birth to save my life. I then was removed from people at 4 months and at 9 months. I grew up trying to be independent and highly suspicious of adults.

I predict that we are going to revamp all of our ideas about mental health. The brain wiring is set up depending on the environment, physical and emotional, that the child grows up in. My friend Johanna was outraged in college when we learned that the fetus and placenta basically take over the hormones of the woman for 9 months. “I’m not letting some baby grow in me and do that!” Johanna said. “I am going to figure out how to implant the pregnancy in a cow. You take good care of the cow and you can drink beer through the whole pregnancy! The cow won’t even notice when the baby falls out!” She has three children, an MD and a PhD in genetics. She did not use a cow.

The brain wiring is an adaptation to the environment. If there is war or domestic violence or addiction or mental health problems, the child’s brain kicks in emergency wiring. This is to help the child survive this childhood. As an adult they are then more at risk for mental health disorders, addiction and physical health disorders.

In the end, the sins of the parents, or the terrible circumstances of the parents, are visited upon the children. We have to take care of the children from the start in order to be healthy.

And people who have low adverse childhood experience scores don’t understand. They grew up with nice people and in a nice environment. They wonder why people can’t just be nice. The fear and grief and suspicion and emotional responses that appear maladaptive in adults, that is what helped people survive their childhoods. That is what I remember each time I see an addict in clinic, or someone who is on multiple psychiatric medicines, or someone who is acting out.

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Adverse Childhood Experiences

I went to a sparsely attended lecture about the Adverse Childhood Experiences Study, or ACE Study, in 2005 and it blew my mind. I think that it has the most far reaching implications of any medical study that I’ve read. It makes me feel hopeful, helpless and angry at God.

The lecture was at the American Academy of Family Practice Scientific Assembly. That year, it was in Washington, DC. There are 94,000 plus Family Practice doctors and residents and students in the US, the conference hall had 10,000 seats and the exhibition hall was massive. At the most recent assembly, there were more than 2600 exhibitors.

I try to attend the lectures numbered one through ten, because they are the chosen as the information that will change our practices, studies that change what we understand about medicine.

The ACE Study talk was among the top ten. Yet when I walked in, the attendees numbered in the hundreds, looking tiny in three joined conference rooms that could seat 10,000. The speaker was nervous, her image projected onto a giant screen behind her. My experience has been that doctors don’t like to ask about child abuse and domestic violence: I thought, they don’t want to go to lectures about it either.

The initial part of the study was done at Kaiser Permanante, from 1995-1997, with physicals of 17,000 adults. The adults were given a confidential survey about childhood maltreatment and family dysfunction. A simpler questionnaire is at http://www.acestudy.org/files/ACE_Score_Calculator.pdf, but it is not the one used in the study. Over 9000 adults completed the survey and were given a score of 0-7, their ACE score. This was a score for childhood psychological, physical or sexual abuse, domestic violence, or living in a household with an adult who was a substance abuser, mentally ill or suicidal, or ever imprisoned.

Half of the adults reported a score over 2 and one fourth over 4. The scores were compared with the risk factors for “the leading causes of death in adult life”. They found a graded relationship between the scores and each of the adult risk factors studied. That is, an increase in addiction: tobacco, alcohol and drugs. An increase in the likelihood of depression and suicide attempt. And an increase in heart disease, cancer, chronic lung disease, fractures and liver disease. The risk of alcoholism, drug addiction and depression was increased four to twelve times for a score of four or more.

The speaker said that the implications were that the brain was much more malleable in childhood than anyone realized. She said that much of the addictive behaviors and poor health behaviors of adults could be self-medication and self-care attempts as a result of the way the brain tried to learn to cope with this childhood damage.

I left the lecture stunned. How do I help heal an adult who is smoking if part of it is related to childhood events? From there I went to a lecture about ADHD, where the speaker said that MRIs and PET scans were showing that children with ADHD had brains that looked different from children without ADHD. I thought that speaker should have come to the other lecture. And I did not much like my ACE score, though it does explain some things.

I feel hopeful because we can’t address a problem until we recognize it.

I feel helpless because I still do not know what to do. The World Health Organization has used the ACE Study in their Preventing Child Maltreatment monograph from 2006. But it is not very cheerful either: “There is thus an increased awareness of the problem of child maltreatment and growing pressure on governments to take preventive action. At the same time, the paucity of evidence for the effectiveness of interventions raises concerns that scarce resources may be wasted through investment in well-intentioned but unsystematic prevention efforts whose effectiveness is unproven and which may never be proven.”

Do I do ACE scores on my patients? With the new Washington State opiate law, we do a survey called the Opiate Risk Tool. It includes parental addiction in scoring the person’s risk of opiate addiction. But not the rest of the ACE test. At this time, I don’t do ACE scores on my adult patients. I don’t like to do tests where I don’t know what to do with the results. “Wow, you have a high score, you will probably die early,” does not seem very helpful. But I remain hopeful that knowledge can lead to change. And it makes me more gentle with my smoking patients, my addicted patients, the depressed, the heart patient who will not exercise.

I am angry at God, because it seems as if the sins of the fathers ARE visited upon the children. It is the most vulnerable suffering children who are most damaged. That does not seem fair. It makes me cry. I would rather go to hell then to the heaven of a God who organized this. I stand with the Bodhisattva, who will not leave until every sufferer is healed.

1. ACE study   http://www.cdc.gov/ace/about.htm

2. American Academy of Family Practice   http://www.aafp.org/events/assembly.html

3. ACE questionaire   http://www.cdc.gov/ace/questionnaires.htm

4. Score correlation with health in adults   http://www.ajpmonline.org/article/PIIS0749379798000178/abstract

5. WHO preventing child mistreatment   http://whqlibdoc.who.int/publications/2006/9241594365_eng.pdf

6. Washington State Opiate Law   http://www.agencymeddirectors.wa.gov/

7. Opiate Risk Tool   http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf

First published on everything2 November 2011.

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mermaid

This poem is related to yesterday’s post about learning to keep my temper. I wrote it in April 2012.

mermaid

when I was born, they took my skin

i had no skin
i was frightened
i wept

a witch came
she studied me
i turned my head from the spoon

“Good,” she said, “You may refuse it if you want.”

She gave me the gift of anger

it was the only defense I had

but over the years
I studied and thought
and I found my tears
and I found my fears

i made my skin of tears
this took me many years
one tear for each hair

at last it is done
my skin
is complete

i smile at the sky
as i don it

i slip into the water
and i am gone