Oppositionality

Forget the diagnosis ‘Oppositional Defiant Disorder’, commonly abbreviated to O.D.D.  Dare I say, I find this diagnosis to be 'odd'.  Something’s not quite right, taking childhood rebellious and defiant behavior and turning it into a mental disorder. My office was once filled with very oppositional children . . .  oppositional but otherwise healthy children.

Not all oppositionality is the same. Some oppositionality is found in children who have difficult and irritable temperaments.  About 10% of all children are born with such a difficult temperament.  This is not considered to be abnormal or pathologic, just difficult.  These kids are often edgy, rigid, and inflexible. They adapt poorly to change and inconsistency.

When children have difficult temperaments, parents and teachers should provide a calm, reassuring, and consistent environment.  Occasionally interjecting some fun and humor goes a long way helping these children to interact more positively with the grown-ups.

Some oppositionality occurs in children who are asked to do what they cannot.  Sometimes teachers and parents have expectations that exceed the child’s physical or mental capacity. In response to the miserable, poorly tolerated, and passive state of “I can’t”, these children change their interactions to the in-control and active state of, “I won’t.”

It is unfair, even cruel, to expect children to do what they cannot.  Sometimes expectations have to be revised.  These children should be evaluated and provided supportive services when needed. Parents and teachers need to identify these children’s strengths and assets. Give them opportunities for success, not for additional frustration.

A great deal of oppositionality arises when children interact with authoritarian, obedience-obsessed adults, grown-ups whose over-arching expectation is, “Do as I say.” When obedience is demanded, a child has only two choices, to obey or to disobey. Many choose the latter.

When obedience is demanded, it can lead to a test of wills. “Do as I say.” “You can’t make me.”  “Oh yes I can.”  Oh no you can’t.”  This is a win/lose battle.  The problem is, in the long run, the child will always lose.  If the child wins the battle, then defiance is rewarded, and the behavior escalates.  If the child loses the battle, they do so with accumulating resentment. No one likes to lose and, in the future, they will learn to fight the battles longer and harder.

It’s not always easy, but authoritarian adults need to learn alternatives to win/lose interactions.  The absolutes should be few in number:  no hitting, no stealing, no running into the street, etc.  But battles need not be fought over the small things.  If a child wants to wear plaid and stripes together, so what? Let ‘em.

Some degree of oppositionality is developmentally normal.  Children challenge rules and boundaries, especially with their parents.  A child who is oppositional around the house but goes out into the world and interacts appropriately with teachers and other adults, is of far less concern than a child who acts defiantly outside of the home.

Some degree of oppositionality is even normal in adults.  Matter of fact, I’ve been called oppositional, but I’m not.

Modernism

 “In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a swampy lowland where situations are confusing “messes” incapable of technical solution.  The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are problems of greatest human concern.”  (Donald Schon, 1930--1997)

Modernism, the prominent philosophic movement of the late 19^th and early 20^th century, embraced the promise of science and technology.  Science was believed to be the path to all meaningful knowledge.  Technology was believed to be the means to a better world for all.

In the day-to-day ethos of Western European culture, Modernism largely displaced religion, leading the German philosopher Nietzsche to pronounce that, “God is dead.”  The existentialist Nietzsche, though an avowed atheist, did not declare God’s death with joy, but with trepidation.  With the collapse of traditional religious values, he anticipated a great void, a void that science and technology could not fill.

Then came the horrors of a modernized 20^th century: two world wars, genocide, nuclear weapons, and environmental devastation on a global scale.  The world felt the void that Nietzsche had feared and prophesized.

For most of my career I worked in an academic, science-oriented milieu. Where I worked was committed to the values of Modernism, devoted to the belief that a better world, including better mental health, would come from science, research, and applied technology.

During my career as a child psychiatrist, I witnessed an exponential increase in scientific knowledge about the brain, about genetics, and about mental illness.  Some of what we learned was of great importance. We learned that autism is not caused by cold and rejecting parents.  We learned that schizophrenia is not caused by double-bind communication and schizophrenogenic parents.

However, along with the increased knowledge came an increased number of possible diagnoses and an increased number of children being diagnosed.  Unfortunately, a diagnosis doesn't necessarily translate to a better life.  It used to be rare to have 1 or 2 children in a school on Ritalin.  Now it is common to have 1 or 2 children in a classroom on stimulants or other psychotropic medications.

ADHD, autism, gender confusion, depression and suicide, drugs and alcohol, trauma and abuse; despite increased scientific knowledge the mental health challenges for children have only gotten worse. But why?

Modernism has fallen short of its promise. Science alone is not enough.  There is a piece missing. There is a game in academia called, "publish or perish." But much that gets published in the professional journals, though sounding quite erudite, is in reality quite trivial. Too much science and research pursues technical minutiae, all the while failing to wade into the "swampy lowland where situations are confusing." However, before we can discover better solutions, we must first learn to ask better questions, questions that address the "problems of greatest human concern."

The Clinician

“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”  (Abraham Maslow, psychologist, 1908—1970)

In the arena of mental health care, there are three types of providers: the theoretician, the technician, and the clinician.

Sigmund Freud was theoretician.  His theory was psychoanalysis. Psychoanalysis was the tool he used to understand and treat patients.  Freud described his patients according to their ids, their defenses, and their superegos.  He placed patients on his couch and asked them to free associate. He would then make interpretations, trying to make the unconscious conscious. Psychoanalysis was Freud’s hammer.

B.F. Skinner was a theoretician.  His theory was behavior modification (specifically, operant conditioning). Behavior mod was the tool he used to understand his subjects, both human and animal.  Skinner described his subjects according to stimuli, rewards, and responses.  Skinner tried to modify the behavior of his subjects by reinforcing desired behavior and extinguishing undesired behavior.  Behavior mod was Skinner’s hammer.

In the mid-20^th century, psychoanalysis and behavior modification were the prevailing theories informing mental health care.  Each theory had its adherents, some of whom became theoreticians in their own right, expanding and rewriting the works of Freud and Skinner.  Some went on to develop novel theories, viewing mental health through new lenses, creating new and improved hammers.

There are only a few practicing theoreticians. There are far more technicians. A technician works with neither the depth of the theoretician, nor the breadth of the clinician (which I shall get to shortly). The technician works from one model, trying to implement and imitate the work of the theoretician. An informed technician reads journals and attends conferences. A skilled technician may be a warm, genuine, and imminently relatable individual.  Often aided by manuals and algorithms, many technicians are effective therapists.  However, the technician ultimately relies upon the theoretician’s hammer.

 In contrast to the theoretician and the technician, the clinician uses a broad array of lenses in order to explain, understand, and ultimately treat the client.  A clinician first listens, unbiased by any one theory, and then customizes a therapy suited to the unique needs, strengths, and challenges of the presenting client.  The clinician is a pluralist.  The clinician knows that no single theory is sufficient to understand human complexity.  The more theories that are understood, integrated, and utilized, the clearer the understanding of the client.  The clearer the understanding of the client, the better the chances for a successful outcome.  For any one theory, the clinician may not have the theoretician’s depth of understanding.  However, the clinician has a breadth of understanding and a range of tools that the theoretician often lacks.

Whenever I taught psychotherapy, I wanted to inspire future clinicians.  I taught multiple psychological and behavioral theories, believing that each model taught was another tool added to the student clinician’s toolbox. With multiple tools in the box, the student was less apt to enter into practice seeing only nails and using only hammers. By providing them with multiple tools, I tried to prepare students for the craftsmanship of clinical care.

Psychotherapy 101

“The harvest of psychotherapy is not cure—surely, in our field that is an illusion—but instead change or growth.” (Irving Yalom, 1931--)

While on faculty at Washington University School of Medicine, I developed and taught a two-year introductory course on Child and Family Psychotherapy. My students were residents and fellows, M.D.’s and D.O.’s in their 4^th and 5^th years of post-graduate psychiatry training.  Coming into this course, these students were well trained in biological psychiatry, psychiatry as a medical specialty. Now, it was their time to be introduced to a wide range of behavioral and psychological theories and techniques.  This blog is about day-one of that course, the basics. On that first day five questions were asked and explored.

1) What is psychotherapy?  Perhaps it would be more accurate to ask, “What are psychotherapies?”, for there are many models and theories of psychotherapy.  However, with the input of my students, we arrived at the following definition that captures the common and quintessential nature of most, if not all, of the psychological and behavioral therapies.  “Psychotherapy is a process of guiding change in a patient or client, undertaken within a theoretic framework, by a therapist trained in the application and implementation of that theory.”

2) What are the goals of psychotherapy?  There are as many goals as there are theories of psychotherapy:  making the unconscious conscious, strengthening the ego, working through problems, expressing feelings, clarifying goals and beliefs, reducing symptoms, resolving conflicts, improving self-esteem, empowering, growing, finding meaning, improving relationships, self-actualizing, extinguishing negative behaviors, reinforcing positive behaviors, correcting distorted cognitive schema, etc., etc., etc.  Yet, however otherwise stated, the common purpose and goal of psychotherapy is constructive change; behavioral, psychological, cognitive, and/or emotional change.

3) How does change occur?  In medicine, change occurs either by altering structure (anatomy) through surgery, or by altering function (physiology) through the use of medication.  In psychotherapy, change occurs when someone’s way of thinking, or someone’s way of behaving, are modified through use of one or more techniques associated with psychological and behavioral therapies.

4) What skills and characteristics are found in a good therapist?  A good therapist is well-trained and well-informed. A good therapist is genuine and warm.  A good therapist is a good communicator.  A good therapist is cognitively flexible, able to tolerate uncertainty, ambiguity, and subjectivity.  A good therapist is ethical, adhering strictly to professional boundaries and standards.  A good therapist possesses a sense of humility, understanding the limits of psychotherapy or what has been called by some ‘the impossible profession’.

5) What determines good outcome in therapy?  Outcome in therapy may be less determined by the specific type of therapy and more determined by the experience, quality, and personality of the therapist.  Theory is important, but relationship is even more so.  Outcome also depends upon the attitude of the patient coming into therapy. Good things happen when a patient comes to therapy ready to learn and to change.

It reminds me of an old joke.  How many therapists does it take to change a lightbulb?  Just one, but the lightbulb has to really want to change.

Amor Fati

 “. . . amor fati—that one wants nothing to be different—not forward, not backward, not in all eternity.  Not merely bear what is necessary . . . but love it.”   (Friedrich Nietzsche, 1844-1900)

I have type II diabetes, have had it for the past twenty years. My initial reaction to the diagnosis was, “Why me?” I have no family history for diabetes. Sure, I was overweight, but not that overweight.  Sure, I sat at my desk sedentary for much of the day, but I was not that out of shape.  I was indignant and angry, wrestling with the unfairness of it all.  I felt sorry for myself. I felt scared about my future.  However, none of that lasted long. I had to accept the reality of my diagnosis. I had to change my diet.  I had to lose weight. I had to exercise.

For several years, I was able to manage my diabetes through diet alone.  After a few years, oral medication became part of my management regimen.  For the past few years, I have had to take shots of insulin with each meal.  Nevertheless, with diligent management I remain relatively free from the sequelae of diabetes. I still have good kidneys, good eyes, and no neuropathy.

Loss comes in many forms. Receiving the diagnosis of a chronic illness was experienced by me as a loss, and with every loss there is a process of grieving. At some point in time, I probably experienced each of Elisabeth Kubler-Ross’ five stages of grief:  denial, anger, bargaining, depression, and acceptance.

Recently I learned that contemporary French philosopher Andre Comte-Sponville suggested that there is a sixth stage of grief:  gratitude.  “Gratitude does not abolish grief, it completes it. . . the grateful recollection of what has been. . .”  In other words, the work of grief is complete when one can recall a loss and be able to say, “But for having had that experience my life is richer.”  Gratitude does not negate the loss and grief. It gives meaning and value to some of life’s hardest experiences.

I am not happy to have diabetes.  But without my diabetes, there is every chance that I would be in poorer health today.  Because I have diabetes, I eat a healthier diet. I keep the pounds off.  I exercise regularly. Despite the demands and inconvenience of diabetes, I am grateful that I have made lifestyle changes and can say that I feel well.

Grief is an on-going process.  There are still days I slip back into the anger and sadness of ‘why me?’  I get tired of shots and checking my glucose. There are days when I resent having to count carbs, while watching others casually eating their bread, pasta, and dessert.  However, it was my fate to get diabetes, and but for a few momentary lapses I can usually embrace that fate.  From the hard experience of diabetes, my life is better, and for that I am grateful.

Sued

During an otherwise normal workday, I was served a subpoena.  I was being sued for malpractice.  The trial itself took place eight years later and lasted for two weeks. The ordeal ended with the jury deliberating for 20-minutes, finding me and my two co-defendants free of any liability.  All allegations of neglect and malpractice were dismissed.

When it was done, my lawyers and the plaintiff’s lawyers shook hands, smiled, laughed, and joked as-if this had all been a grand sports event.  No hard feelings.  For me, it had been no game.  To this day I detest the plaintiff’s attorneys who knew they had a weak case, who hoped for a quick out-of-court settlement, and who, in court, had twisted and distorted facts in an attempt to win the game, at any cost.

My initial reaction in the aftermath of the trial was to deny any significant psychological sequela.  I was prepared to return to work and carry on as-if nothing had changed.  But work did change, subtly.  I became a little more obsessive with each of my written notes.  I became a little more cautious with patients, second-guessing my decisions, wondering in the back of my head, who might be next to sue.  I began to enjoy work less and less.  And while the lawsuit was not the only factor in my retirement, it was a significant factor.

Malpractice and medical neglect occur.  Patients need protection and redress of grievances.  But sometimes bad outcomes occur despite good medical care.  Given the nature of the work, healthcare providers also need protection.  There must be a better way.  The lawsuit hung over my head for eight years.  I estimate that the total cost of the legal defense was in excess of one-million dollars.  Not added into the cost were the many hours of lost clinical productivity. In the meantime, until and unless there is a better system, we all bear the significant burden of cost in an already cost-burdened health care system.

I think about being on the witness stand.  Remembering my lawyer’s advice, I tried to not be provoked to anger.  Under the plaintiff attorney’s accusatory and seemingly mocking attack, I mostly recall feeling numb.  At one point, the plaintiff’s attorney stooped to a bit of courtroom theatrics yelling at me, “Dr. Boxer, are you prepared here and now to apologize to this family!”  The judge quickly interrupted the proceeding, instructed me not to answer, scolded the attorney and called for a brief recess.

Even to this day, I repeat the answer I wish I could have made.  “Yes, I am sorry that bad illnesses happen to children.  I am sorry that, due to a serious illness, your child had many years of hardship and suffering. I am sorry that good doctors and good nurses who devote their lives to the care of sick children must defend their competence and integrity in these adversarial arenas. That said, I am, in good conscience, unapologetic about the care I gave your child eight years ago.”

Debate

“Deliberation and debate are the way you stir the soul of our democracy.” (Jesse Jackson, 1941--)

I used to judge High School debates.  I did so when my son, and later my grandson, were debaters.  As a judge, I recognized some very particular characteristics and skills shared by all of the really accomplished debaters.

A good debater was a good researcher, prepared with the facts. In my son’s time, debaters carried large and sometimes multiple boxes filled with articles and information, sorted and filed, pertaining to all aspects of the debate question.  Good debaters understood the value of thorough documentation. By the time my grandson was in debate, file boxes were no longer needed. Instead, files were downloaded onto much easier to carry personal computers.

A good debater was a good critical thinker able to use facts effectively, as building blocks to a logically constructed argument.  Reasoning, backed by solid information, sustained their case.  A good debater could distinguish logic from fallacy.  Perhaps the worst, and certainly the most offensive, of the fallacious arguments was the Ad hominem argument. Only an unskilled and unprepared debater resorted to personal attack and insult.

A good debater was a good communicator and an effective persuader.  A good debater spoke clearly, made good eye contact, used humor judiciously, and mixed raw data with illustrative stories and examples.  I would describe a good debater’s demeanor as calm and confident, assertive but not aggressive.

A good debater not only had to speak . . . a good debater had to listen.  An opponent’s argument had to be heard and understood.  A good debater then had to follow-up with an effective rebuttal.  A good rebuttal often required the debater to be a quick and flexible thinker, able to adjust to new and unexpected twists and turns.

A good debater, going into a meet, had to be prepared to argue either side of the debate question, both the affirmative and the negative.  Debate questions were typically complex, requiring the debater to examine the question from multiple perspectives.  I suppose that a good debater even learned to appreciate that, in life, the most difficult questions often lack definitive answers.

Those who learn debate learn invaluable skills. Personally, I believe that debate should be part of the required High School curriculum.  Debate teaches skills of critical thinking along with skills of good communication. All students could benefit.

I think that many students would be shocked to find out that debate, as taught in High School, is something vastly different than “debate” as practiced and modelled on T.V. by our public servants.  When Trump and Biden were running their campaigns, we did not see a debate.  We witnessed a spectacle.

I recently heard in the news that Rep. Marjorie Taylor Greene has challenged Rep. Alexandria Ocasio-Cortez to debate the Green New Deal.  I doubt this debate, or spectacle, will occur.  But should it happen, I would love to come out of retirement and judge once more. I know the characteristics and skills necessary for a good debate. But do they?