Restraint

Some years ago, I was running errands in Providence and North Providence. Much like today, it was an unusually hot, humid Fall day. Eventually, I got hungry and thirsty. I remembered an Italian bakery in the area. It was in a rundown neighborhood but had great calzones. I drove to it.
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Once inside, I took my place in line at the counter. There were around twenty people in the bakery. Some, like me were in line; others ate at small tables.

Out of the corner of my eye, I saw a neatly dressed, cute, young black girl walking toward me. She was maybe 8 or 9 years old. I didn’t recognize her and wondered why she was looking at me.

She walked right up to me. In a clear, matter-of-fact voice, she said “You’re the man who grabbed me and held me on the floor at the hospital!”

It felt like everything stopped in the bakery and all eyes turned on me.

The girl was right, of course. I remembered her as soon as she said that I had restrained her. Her statement was a fair representation of what had happened.

That didn’t help my situation much. A pretty, young girl, with no malice, had just introduced me to the patrons and staff of the bakery as the man who grabbed her and held her down on the floor.

My hair is long and runs 3/4 of the way down my back. That morning, I was in a rush. I hadn’t taken the time to put my hair into a ponytail. I was in the process of renovating my house and was dressed in torn sweat pants and a grungy t-shirt. I was unshaven and sweating in the heat of the day. In short, I looked pretty much like a mess. That day I was more interested in running errands and working on the house than in making good first impressions.

Given what the girl said to me and my appearance, I couldn’t really blame anybody in the bakery if they thought I was a dangerous creep.

I squatted down a bit to get more towards eye-level with the girl. I asked her how she was since the last time we met. She told me that she felt a little happier. I asked if the hospital had helped her and she said not really. I said that I was glad to see her and hoped that things got better for her. We spoke for a few more moments.

By then it was my turn to order. I got a coke and a calzone. I got it to go instead of eating at one of their tables.

Let me offer a little bit of history. I worked in a psychiatric hospital for about 15 years and much of that was spent in the emergency room, or patient assessment service as it is now called. This girl was brought in for an evaluation. I did the initial assessment of her. At the end, she asked me if I thought she needed to be there. I said that I thought the hospital could help her. She did not like that response and tried to elope from the evaluation room. The room that we were in had doors that opened to a hallway and to the ambulance entrance. To stop her, I restrained her until other staff came and helped.

The girl was quickly admitted to the hospital and I did not see her again until maybe a year later in the bakery.

As part of my duties at that hospital and in various other of my jobs, I have been in more restraints than I can now count. While not commonplace, restraints happened with regularity. Usually, I did not think much about them afterward. To my knowledge, none of people I restrained was ever physically injured. I got hurt only twice. Except for those two instances, I didn’t see much point in thinking about the restraints after they were over. Although I will admit that for years, I watched my rearview mirror on the drive home, sat facing the entrance in restaurants, and took similar precautions. A fair number of people that I restrained or was involved in involuntarily hospitalizing made threats about what they planned to do once they left the hospital.

Clearly, this girl had a different attitude about the restraint. She was frightened, in a strange place against her will. The hospital was filled with strangers and she only wanted to go home. I physically stopped her from that. I can’t say for sure, but I believe it was the first time any professional had ever restrained her. So, for her, the event was unique, novel and wholly unwanted.

And that’s how she remembered me. I was the guy who grabbed her and held her on the floor in the hospital. She wasn’t angry with me. I don’t think she held a grudge because we chatted fairly easily for a few moments in the bakery. Yet it seems fair to say that she didn’t think I was a nice person.

She did not remember me as the clinician who spent an hour gently talking with her about her life. For her, I was not the man who suggested that the hospital could keep her safe and help her to feel better. Her memory of me was not one of jointly finding her strengths and trying to build her sense of self-confidence and optimism. All that is, however, what I remember of the time we spent together in the hospital’s ER.

In the bakery, I was in a strange place filled with strangers. She seemed quite at ease there. Maybe she lived in the neighborhood. I guessed so at the time because she was not accompanied by an adult. When she said that I had grabbed her, I felt ashamed, embarrassed and afraid. I did not know how the other people in the bakery would react. I feared a scene or worse. In addition, I felt badly because she seemed not to understand my situation in the bakery or at the hospital. I greatly wanted to turn and run out of there.

All in all, this was a very neat reversal of positions, courtesy of fate.

A number of years ago, the hospital made a policy that all restraints are reviewed with the patients once they become safe. But that could be done by staff that were on a different shift and had only second hand information about the restraint. I never reviewed that restraint with the young girl. She was sent to the children’s unit and I assume staff went over the event with her some time later. However, only she and I knew firsthand what happened in the room. Just the two of us knew the emotional bond that formed during the hour-long evaluation and was ruptured by the restraint.

Her memory of me remained as the guy who grabbed her and put her on the floor.

As I say, I left the hospital several years ago. I have no knowledge of their current policies on helping patients process being restrained. Perhaps they have included at least one of the staff actually in the restraint into the review with the patient. That would be a good thing, I think.

Why does this memory surface again now? There is no chance that I am aware of that I’ll be in a restraint any time soon. I don’t think it’s because it’s a similarly hot and humid day in early Fall. I do know that I am about to use a different type of coercion with a current patient. That’s something that I don’t like to do at all. However, I can’t come up with another option to keep him safe. Perhaps this memory has come to try to help me see my plan from his perspective. Alternatively, maybe I’ve been in a position of power with somebody else recently and pushed it too quickly out of awareness. Whatever event that was, the memory could be prompting me to pay more attention to it.

I’m not sure at the moment.

Object Relations Theory and Anaclitic Depression: 1

Anaclitic Depression or Anxiety Defending Against Depression

Today, I will start to explain the difference between an anaclitic depression and anxiety guarding against a depressive episode. We will open with a beginner’s introduction to object relations theory.

For this post, it’s not necessary to have read the previous posts. If you’d like, you can read the fifth post for a bit of background. However, again, that is not a requirement for understanding this post.

To understand anaclitic depressions, it is quite helpful to know a bit about object relations theory.
Winnicott

Right from the start, let me acknowledge that I have difficulty writing about object relations theory in a simple, conversational style. For me, it is like conveying the experience of a warm sunny day while using the language of quantum field theory. Nevertheless, if we are to explore how anaclitic depression may relate to anxiety as a defense against depression, then we need some object relations theory.

Melanie KleinTo try to save us all some hardship with this topic, I will use a metaphor. Granted this metaphor is limited. For a more technical and historical explanation of object relations theory, you can start with a nice review by Sam Vaknin, Ph.D. Scroll down the page a bit and start at “XV. Narcissism and Schizoid Disorders – Melanie Klein.” For further information, you can also read Wikipedia’s entry for object relations theory and Victor Daniel’s website.

Imagine a large amphitheatre. On the stage is Robert. More accurately, Robert’s ego is on the stage. Behind him, instead of scenery and curtains, is the real world where he interacts with other real people. In front of him, the seats are occupied by all of the people with whom he has had significant experiences in the past. These are not the actual persons but are his representations of them. For example, his first grade teacher actually may have cared deeply for him and been a good teacher. However, in Robert’s experience, she was scary and hard to please. Therefore, his representation of her is frightening. This audience consists of the memories of his life.

To his left are the warm, loving people. It is from them that Robert gets self-soothing, guidance, support, etc. In the center are neutral figures. On the right is where the harsh, critical, angry and destructive persons sit.

To complicate things a bit more, the same person can have multiple representations. Robert’s mother can be seated on the left based on the time when she calmed him after a nightmare. But she can also occupy a seat on the right. This would be an unintegrated memory of the time that she wrongly accused him of a theft and punished him unjustly.

Depending on what is happening between Robert and the real world, the audience can shift. Some people will move their seat to the other side, some stay where they are, some may even leave the theater.

In a reciprocal fashion, and this is important, how the audience is arranged in the seats influences the way that Robert interacts with the real world and stores new memories of his experience.

Sometimes the audience is polite and accepting. They don’t interrupt Robert. They wait for him to address them or to recall them in memory. Consider this as a Zen moment. His object relations are in alignment with his experience of the world and criticism is suspended.

Other times, the audience can be intrusive. Out of the blue, a rotten tomato is thrown at Robert’s head. A torrent of unexpectedly harsh criticisms of his performance interrupts his dealings with the real world. Or, perhaps, a gentle, soothing sense of acceptance and love sweeps over him as he reads a novel late at night.

On still other occasions, the audience may start arguing among themselves.

Now the members of the audience may not all be exactly human. Granted, the most advanced of them look completely human. These patrons are well known to Robert and he sees them as reliable and fairly predictable. He has known them through good times and bad. Robert knows these patrons well. He sees them as reliable and fairly predictable.

Some in the audience look only mostly human. Their features are somehow not quite fully developed. Robert only knows one side of them. This part of the crowd can be confusing and unpredictable to Robert.

Then we have gooey, blob-like creatures. They are the least advanced persons in attendance. These are the raw, primitive introjects. Some are scarier than Frankenstein. Others are purely and exquisitely pleasurable and intoxicating. Even the gratifying blobs can be dangerous, though. There is a threat that they can consume you in their gooeyness. (Think of the allure of an urge to regress back to being a coddled, dependent child in times of high conflict.)

In our metaphor, the more psychologically advanced a person becomes, then the more that the audience will look fully human. It is likely that the psychologically mature person will not have multiple representations of significant persons. Instead, the mature person will have integrated the various experiences with, say, his mother into a coherent whole.

If Robert regresses or if a person is psychologically immature, then the audience begins to look more like the gooey blobs. There will be multiple representations of the same person, split off from each other. The blobs can unexpectedly shift positions depending on what is happening either in the real world or in the audience itself.

This should be adequate for our current purposes. There are many elements left out of this metaphor. For instance, I did not mention the drives interacting with the audience. Nor did I get into how object relations mesh with the various structures of the mind, e.g., the superego or the id. (Hints: gooey blobs are raw expressions of the drives in the id, but some might also be in the superego, and usually they are part object (as opposed to whole object) representations. Well-formed humans are in the superego or ego ideal. The left side is fueled by the libido and the right side is powered by the aggressive drive. Those in the middle either are decathected or are unrelated to the current experience with the world.) As I said, this stuff gets complicated fast. For now, we’ll leave this metaphor as it stands.

For quick reference, I made a pictorial representation of this metaphor. You can view it here.

We will now briefly leave object relations theory. In the next post, I will move on to anaclitic depressions.

Anxiety as a Defense Against Depression: Part 8

Couples Therapy for Robert and Julia (Romeo and Juliet)

Julia and Robert have come to my office. We are discussing their desire to elope.

I’ve just asked Julia if there is any way that her parents would agree to delay her return to their home island in Portugal.
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Julia: I tried to get my father to delay my trip. He went crazy on me. This is exactly what he said: “You’re going to São Miguel. And if you don’t go on your own, I’ll drag you there. You disgust me, you little bug! You worthless girl!”

I cried and cried. I said, “Father, I’m begging you on my knees, be patient and listen to me say just one thing.”

He just wouldn’t listen. He went on and on. “Forget about you, you worthless girl! You disobedient wretch! I’ll tell you what. Go to the airport on Thursday or never look me in the face again. Don’t say anything. Don’t reply. Don’t talk back to me.

“I feel like slapping you. Wife, we were cursed when we had her. She disgusts me!”

My mother and my assistant tried to help me. It was useless. The longer he yelled, the angrier he got. His last words to me were:

“If you don’t act like my daughter, you can beg, starve, and die in the streets. I swear on my soul, I will never take you back or do anything for you. Believe me. Think about it. I won’t break this promise.”

Then my father stormed out of the room.

Me: What did you do then?

Julia: I begged my mother and my assistant for help. I said, “Mother, don’t throw me out! Delay this trip for a month. Or, if you don’t delay, make my travel plans to my grave.”

Me: Did you mean that? Do you want to die instead of returning to São Miguel?

Julia: Yes, of course I mean it! How can I marry Robert if that happens? I’d rather die than live without him! If everything else fails, at least I have the power to take my own life.

Me: But what if they insist that you leave on Thursday or get thrown out of the house?

Julia: I have a plan for that.

Me: Can you share your plan with me?

Julia: Well, it’s not really my plan. I went to the parish priest after the fight with my parents. He’s from the islands and I thought he might have a solution for me.

Me: What did you say to him?

Julia: I said, if you who are so wise can’t help, please be kind enough to call my solution wise. Then, I showed him my knife. I told him, I’ll solve the problem now with this knife. Love joined my heart to Robert’s. Before I go to São Miguel and am married to another man, I’ll kill myself. You are wise and you have so much experience. Give me some advice. I want to die if what you say isn’t the solution to how I can be with Robert.

Me: What was his plan?

Julia: This is what he told me to do. He said:

“Tomorrow night make sure that you are alone. When you’re in bed, take this vial, mix its contents with liquor, and drink. Then a cold, sleep-inducing drug will run through your veins, and your pulse will stop. Your flesh will be cold, and you’ll stop breathing. The red in your lips and your cheeks will turn pale, and your eyes will shut. It will seem like you’re dead. You won’t be able to move, and your body will be stiff like a corpse. You’ll remain in this deathlike state for forty-two hours, and then you’ll wake up as if from a pleasant sleep.

“Now, when your father comes to get you out of bed on Thursday morning, you’ll seem dead. Then, as tradition demands, you’ll be dressed up in your best clothes, put in an open coffin, and carried to the church. Meanwhile, Robert will come here, and we’ll keep a watch for when you wake up. Then we’ll seal the coffin and nobody will be know that you’re not in it. That night, Robert will take you away to New York City. This plan will free you from your shameful situation as long as you don’t change your mind, or become scared like a silly woman and ruin your brave effort.”

Me: (I look at Robert) You know about this plan? What do you think?

Robert: I trust the priest. We’ve both known him forever. If this is what he thinks is best, then I’m willing to try.

Me: But suppose the medicine is too strong? Suppose Julia doesn’t wake up from the coma or suppose that she dies instead?

Robert and Julia together: It will work.

Me: But the priest is not a doctor. Suppose something goes wrong. Robert, how would you feel if something bad happened to Julia?

Robert: Well, I’d be the one to find her. So I’d just drink the same poison, and kiss Julia good-bye. That way I’d die with a kiss.

There’s no other way. Either we do what the priest suggests or she leaves the country next Thursday.

Me: (to Julia) You know about his plan to suicide if you die? Do you approve of it?

Julia: I wouldn’t say that I “approve” but I can understand it. I’m not worried, I’m not going to die so he won’t have to either.
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Me: Suppose we try to come up with a different plan. If we could find one, would you agree not to take the priest’s advice?

Robert: For me, I’m in favor of our plan. We’ve already discussed it. We both think it’s our only option and that it will work. No offense, but I trust my priest more than I trust you.

Me: Julia, what do you think?

Julia: I agree with Robert.

Me: Julia, you mentioned your assistant. She seems to know about your situation. What does she say?

Julia: Well, she was helpful in the beginning. But then she agreed with my parents. She said, “Since things are the way they are, I think the best thing to do is leave for São Miguel.”

Me: So you don’t think that she could help us come up with an alternative to your plan?

Julia: No.

Me: There’s nothing, then, that can replace your current plan?

Julia: No.

Robert: Can’t think of anything.

Me: Well, to be honest, this plan makes me nervous. It sounds too close to a suicide pact. Or that’s what could happen, anyway, if even the smallest thing goes wrong.

Robert: (talking over me) Well, it’s our only way to be together and we’re both willing to take the risk.

Me: Oh, gee, I forgot to tell my receptionist something. I’m really sorry but I need to step out for a second. I’ll be right back.

I go to the receptionist and ask her to call 911 for me. I tell her that the couple has a suicide pact and needs to go to the hospital for evaluation.

When I go back into the room, I going to explain what I’ve just done. Both of them are very angry. They threaten to bolt from the office. I explain that the police will be here before they get to the street. I also explain my rationale for calling the police and rescue. Their pact was too dangerous. My duty is to preserve their health and well-being. Therefore, I had to call the police. I offer to continue treatment after they are safe and stabilized.

Julia breaks into uncontrollable sobs. They make all sorts of objections and threaten to sue me for violating their confidentiality.

After a few more minutes, there is a knock on my door and the rescue team comes into my office.

It will surprise no one that I am not as bright as Shakespeare. Try as I would, I could not resolve the dilemma that Shakespeare created for Romeo and Juliet with a smooth therapeutic move. Just as in the play, the resolution could only come from drastic measures.

The Chorus tells us this in the opening Prologue: “For the next two hours, we will watch the story of their doomed love and their parents’ anger, which nothing but the children’s deaths could stop.”

This was not my intended treatment outcome. However, I have no alternative. I tried several versions of this post. I used every way that I could think of to solve their dilemma without involuntary hospitalization. None of it, though, rang true to the situation or the dialogue from Romeo and Juliet.

Their circumstances are too acute and progressed. Neither of them, in my opinion, can be trusted not to act on their plan. They might even devise a more risky, impulsive course.

As Robert says, they trust the priest more than me. Our therapeutic alliance is in its nascent stage and still weak. Their thinking is concrete and action-oriented. Interpretations of their situation and plan do no good in this case. For instance, I might try to point out to Julia that her plan has at least as much to do with parental rejection as it does with love for Robert. She plans to do to herself what her father threatened. Instead of his threat that she “beg, starve, and die in the streets,” she was planning a death in her own bed. Julia would laugh at me for that interpretation. The therapy has not progressed to the point where she could use such an explanation.

Furthermore, even on a more concrete plane, they reject my offer to help problem-solve and find other options.

Neither of them can identify a trustworthy external support. That is, of course, except for their parish priest. And he designed the plan to enter a drug-induced coma.

I have found few internal resources that either of them has to self-sooth or to improve their judgement and insight. They are both overwhelmed.

Their anxiety is fueled by a fear of losing one another. Additionally, for Robert, the fear of a return to deep depression is intense. The anxiety is propelling them toward ever more dangerous and hastily conceived actions.

Even though their plan stems from anxiety and is in itself intensely anxiety provoking, it keeps their hope alive. Seeing their plan as foolhardy would leave them without hope. And that would place them on the threshold of depression. So, rather than see the reality of their situation and cope with it accordingly, they lunge into anxiety and near irrationality.

I do not want to give the impression that all cases of anxiety guarding against depression lead to such an outcome. Recall Donovan Campbell; he certainly did not meet the criteria for psychiatric hospitalization.

Hospitalization could go either way for Robert and Julia. It might make them more emotionally and cognitively available for treatment. Or, they may lose their trust in therapists and shun any further therapy. At the least, the families will find out about their plans to wed. Any immediate repercussions of that can be handled in the safety of the hospital.

If any readers can suggest a viable alternative to involuntary hospitalization, I’d be appreciative.

I want again to acknowledge that the overwhelming majority of the dialogue for Robert and Julia comes verbatim from No Fear Shakespeare’s modern translation of Romeo and Juliet.