DID YOU SEE…?: Bruce Perry on how stress works

Starting from my own personal experience and extending into my professional practice as a psychotherapist, I’ve long been aware that managing stress is a crucial part of health and well-being, every bit as important as diet, exercise, sleep, and touch. But I’ve never known the scientific particulars of how stress works on the body, especially the brain, for better and for worse, until reading an article published in the latest issue of The Sun, an excellent literary magazine published in North Carolina that doesn’t accept advertising and is completely supported by its readers — the magazine equivalent of National Public Radio, without the big federal grants. Each issue contains a lengthy Q-and-A interview with someone who’s an authority on some important political, social, spiritual, or medical concern. The November 2016 issue presents an interview conducted by Jeanne Supin with Bruce Perry, a North Dakota-born Houston-based psychiatrist and researcher who has co-authored two books, The Boy Who Was Raised as a Dog and Born for Love: Why Empathy Is Essential — and Endangered. In this conversation, titled “The Long Shadow: Bruce Perry on the Lingering Effects of Childhood Trauma,” Perry gives the simplest, most thorough explanation I’ve ever read of how stress interacts with the human body.

The interview is long and interesting and worth seeking out in full. I’d like to share here a significant chunk specifically talking about stress. Here’s the gist of what he has to say.

On the harmful impact of chronic stress: “When you are overstressed, you no longer have efficient access to your higher brain functions. By the time you’re in a state of alarm, significant parts of your cortex – the highest-functioning part of your brain – have shut down entirely. This is adaptive if you’re confronted by a predator, because you don’t want to waste time thinking about how to respond: you want to fight or run away. But to do your best reasoning, you need access to that sophisticated part of your brain. To learn and plan, you need to be in a relatively calm state.”

On the healthy aspect of stress: “Resilience comes from stress. It’s important that parents, teachers, and coaches not be afraid of it. Exploring, getting dirty, and falling down help you build resilience and tolerate novelty and discomfort.”

To put those passages in context, read on, and let me know what you think.

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Supin: Can you explain how our stress-response systems work?

Perry: All input – feelings of hunger or thirst, loud noises, the sound of someone’s voice, some information we learn – first enters the lower, more primitive part of our brains, which determines if this input is familiar or unfamiliar. If the input is familiar, it then travels to a higher, more evolved part of our brain, where we decide based on memory whether it’s good, bad, or neutral. If the input is unfamiliar, the brain’s default conclusion is This can’t be good. Any novelty – even desirable novelty, like learning something new – activates our stress-response system.

Some stress is actually good for us – for example, the stress related to meeting a new person or traveling to a new place. Predictable, controllable, and moderate activation of the stress-response system has been shown to build our capacity to manage challenges. When a child has the opportunity to challenge herself in the presence of supportive adults, it builds resilience. It’s the dose, the pattern, and the controllability that determine whether the stress is adaptive or harmful.

Let’s say you’re a six-year-old boy, and up until now your life has been OK. Mom and Dad split up, and there was some conflict around the divorce, but nothing too horrible. Then all of a sudden Mom has a new boyfriend in the house. That’s novel, so it generates moderate stress. At dinner he raises his voice at you; that’s unpredictable. He soon starts barking orders at you more frequently. He yells at your mom. He hits you, or he hits your mom. Your stress-response system doesn’t have time to return to baseline before another source of stress arrives. You start having anticipatory anxiety about what will happen next. Your baseline level of stress increases; things that would not have bothered you much before now bother you a lot. A harsh tone of voice that may have been mildly upsetting is now overwhelming. If the boyfriend’s behavior continues, your stress-response system may start to register any angry tone of voice as threatening. You’ve become what we call “sensitized.”

Conventional wisdom might suggest that the boy would get used to the angry, violent behavior and be less affected by it over time, but you’re saying the opposite is true.

Exactly. The more our stress-response system is activated in uncontrollable ways, the less able we are to handle even small amounts of stress.

When you are overstressed, you no longer have efficient access to your higher brain functions. By the time you’re in a state of alarm, significant parts of your cortex – the highest-functioning part of your brain – have shut down entirely. This is adaptive if you’re confronted by a predator, because you don’t want to waste time thinking about how to respond: you want to fight or run away. But to do your best reasoning, you need access to that sophisticated part of your brain. To learn and plan, you need to be in a relatively calm state.

Let’s go back to the six-year-old boy in your example. What happens to him at school?

The brain is good at generalizing from one kind of experience to another. Most of the time this ability is a gift, but this boy may generalize that all male authority figures who raise their voices are terrifying. This starts a vicious cycle: The boy arrives at school already on heightened alert due to his home situation, and he can’t pay attention. The teacher gets frustrated and raises his voice. The child is now even more on red alert. It’s impossible for him to concentrate. The rational parts of his brain shut down. Instead he has access only to the parts that process information valuable in threatening situations. He’s attuned to the teacher’s tone of voice, to whom the teacher is smiling at. He’s learning to read nonverbal cues. The calm child will learn the state capitals; the sensitized child will learn who is the teacher’s pet.

Can he recover from that?

Yes, opportunities for controlled, moderate doses of stress can shift these systems back toward well-regulated functioning. The key is that a moderate challenge for a typical child may be a huge challenge for a sensitized child.

The achievement gap in schools has a lot to do with the child’s home and community life if the family is concerned about not having money for food or rent or a doctor’s visit, that creates a pervasive sense of anxiety and unpredictability. The longer the child is in that environment, the worse the vicious cycle at school becomes. Eventually the kid says to himself, “There’s something wrong with me. I’m stupid.” And he drops out as soon as he can.

What about the character-building benefits of facing down adversity, of “rising to the challenge”? Is that ever applicable in these situations?

If you start from a healthy place, adversity can be character building. But if you grow up amid constant adversity, you are less likely to have the flexible and capable stress-response systems you need to face down adversity. Certainly many children do grow up with remarkable gifts and strengths despite their challenges, but when this happens, it’s often because there were people in the child’s environment who helped create a safe, predictable space for the child at least part of the time.

Are there instances in which well-intentioned parents protect their children from stress too much?

Yes, I’ve seen upper-middle-class children develop anxiety disorders because they had never been given the opportunity to explore the world. They’d been told only, “Don’t do this, don’t do that, don’t get dirty.” By the time these children went to preschool, they hadn’t learned to tolerate even slight discomforts. They became overwhelmed by the novelty of preschool and had meltdowns.

Resilience comes from stress. It’s important that parents, teachers, and coaches not be afraid of it. Exploring, getting dirty, and falling down help you build resilience and tolerate novelty and discomfort.

How might we apply this to whole communities?

First we have to understand that feeling connected to other people is one of our most fundamental needs. We feel safer when we are with kind and familiar people. Tension can arise from being part of a marginalized minority, whether you define that minority status by economics, race, ethnicity, religion, gender identity, sexual preference, or whatever. The marginalized group has a much higher level of baseline stress. It’s not a specific traumatic event; it’s a continuous sense of disconnection.

Our brain is constantly monitoring our environment to gauge whether or not we belong someplace. If we frequently get feedback that we don’t belong – or, worse, overt threats – then our body’s systems stay in a constant state of arousal. This increases the risk for diabetes and hypertension and makes learning, reflection, planning, and creative problem-solving harder. Over time it will actually change the physiology of your brain.

For example, for someone who already feels marginalized and is hypervigilant, even a relatively benign interaction, such as a police officer asking for your license, can trigger a volatile reaction. This is true for both the person being stopped and for the cop who’s doing the stopping. They both can be sensitized. People in law enforcement should know the principles of stress and trauma. It’s the key to understanding why some of their policies and behaviors have a destructive effect.

 

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DID YOU SEE: Esther Perel interviewed in The Sun

Belgian-born sex therapist Esther Perel is an expert on the subject of sex, intimacy, love, and desire in long-term relationships. The author of Mating in Captivity and the subject of a very smart and widely-circulated TED talk on desire, she was recently interviewed by Mark Leviton in The Sun, an excellent literary magazine renowned for its in-depth Q-and-As with remarkable thinkers.

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I’m a tough customer when it comes to speaking and writing in this field, I suppose because these subjects are near and dear to my heart, and I hate the amount of misinformation, bad advice, and stale thinking that goes out under the rubric of relationship counseling. But Perel passes my bullshit-detector with flying colors.  I found myself completely engrossed in this article (“A More Perfect Union”) and in agreement with her almost every step of the way. I particularly like the way she talks about fantasies and also how she addresses the subject of parenting in contemporary life. Since I’ve quoted those passages online already, I’ll offer an excerpt here in which she talks about the subject of infidelity:

I don’t abide by the perpetrator-victim model of infidelity, in which the cheater is criminalized and the victim is given all the empathy. I also don’t believe an affair automatically means the relationship is bad. Here’s the usual view: If we, as a couple, have everything we want from each other, there’s no reason for either of us to go elsewhere. Hence, if one of us goes elsewhere, there’s something missing between us; infidelity is a symptom of a problem in the relationship.

That’s sometimes the case, but affairs often have more to do with the unfaithful individual than with the couple. People go elsewhere for sex not so much because they want to leave their partners but because they want to escape who they themselves have become. They are looking for parts of themselves that they’ve lost because of the relationship. But many adulterers are reasonably content in their marriage and monogamous in their beliefs. In my experience most have been faithful for ten or fifteen years before they’ve cheated.

If you see adultery only as a symptom, you sometimes take good relationships that have worked well for decades and make them look like failures. I don’t think that’s right…

I’ve seen couples in which I’m convinced there’s an affair going on but no one wants to talk about it. I’ve seen couples in which one person keeps asking the question and the other keeps denying it, or one keeps dropping hints and the other doesn’t want to pick up on them. I’ve had clients who are resisting having an affair, and others who can’t talk clearly about their marriage because they are intoxicated by an ongoing affair and everything else pales in comparison. Or they are irritable and don’t want to go home because of their guilt or because they don’t like their partner at the moment. Other clients might want to be in the relationship, but their partner has Alzheimer’s and can’t recognize them, and they need a way to rejuvenate themselves so they can spend an hour every day with their partner at the nursing home. I hear about kinds of infidelities that never existed before now, but infidelity itself is timeless. At all four corners of the world, at any moment, someone is either betraying a beloved or being betrayed. Infidelity: historically condemned, universally practiced.

You can read the entire interview online here. Check it out and let me know what you think.

DID YOU SEE: mating habits and medicating the human condition

It’s undeniable that antidepressant medications have improved many people’s lives, allowing them to enjoy social functioning and a range of emotional experience that would otherwise be out of reach. I think it’s also indisputable that some people are over-medicated. There’s a multi-billion-dollar pharmaceutical industry that depends upon — we could say exploits — the human tendency to look for a magic pill for everything and doctors who are willing to write a prescription rather than take the time to step back and look at the root cause of physical and mental distress. As the publication date approaches for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the field has been engaging in serious debate about proposed changes in how mental health is categorized and treated. The DSM was created in the interest of establishing industry standards for diagnosing and treating patients, and insurance companies rely heavily on DSM terminology when deciding coverage of claims for treatment. The number of ailments classified as disorders requiring pharmaceutical treatment continues to increase. Although I’m willing to believe that the people making these decisions have good intentions, I’m often distrustful of what seems like a misguided if not sinister impulse to pathologize the human condition — that is, to treat ordinary human emotions such as grief, melancholy, fear, and defiance as if they were illnesses to be eradicated at all costs.

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Christopher Lane (above) is one of the major critics of modern psychiatric theory and practice. I recently got around to reading an extensive interview with him that appeared last year in The Sun, one of my favorite literary magazines. Doing research about how the editors of the DSM arrive at their conclusions, Arnie Cooper writes in his introduction to the interview, “Lane was troubled by what he found: evidence of drug-company influence, especially in the promotion of ‘panic disorder’ by Pharmacia & Upjohn, maker of the anti-anxiety drug Xanax. He also uncovered extensive evidence of questionable research (sometimes involving just one patient), sloppy thinking, dismissal of nonmedical approaches to psychiatric problems, and a degree of inventiveness with terms and symptoms that struck him as playing fast and loose with the facts.

“All of this served as the basis for Lane’s 2007 book, Shyness: How Normal Behavior Became a Sickness, in which he observes that behaviors once understood as reactions to one’s environment and upbringing are increasingly seen as innate conditions of brain chemistry, resulting from problematic levels of neurotransmitters, especially serotonin. He suggests that because of the open-ended language in the DSM and the wide range of behaviors it pathologizes, anyone who is shy, as he was as a teenager, now risks being diagnosed as mentally ill. The new disorders were ‘obviously music to the ears of drug companies,’ he says, ‘insofar as they massively increased the market for their products, which the media greeted with incredible enthusiasm.’ ”

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The interview is well worth seeking out and reading, considering, critiquing, and discussing. A lengthy excerpt is available online here. As a sex therapist, I took particular interest in this passage (not available online) about the dubious prospects of applying medical criteria to standardize human sexual behavior:

Cooper: Let’s talk about some disorders that have been proposed for the DSM-5. After golfer Tiger Woods’s adultery scandal, we began to hear about “hypersexual disorder.” It’s being considered for inclusion.

Lane: A number of articles have been written that tried to attribute promiscuity or adultery in men to a brain disorder. I find this questionable for a number of reasons.

First, it’s worrying to me that a group of psychiatrists is trying to determine how much sexual activity and how many encounters we can want or fantasize about before we’re considered “mentally ill.” Given the embarrassing history of the DSM revisions and all the shoddy science informing them, why should we trust the APA to dictate yet another norm to us, much less accept its judgment about something so personal and intimate? People have markedly different appetites for sexual experiences. I’m uncomfortable with the idea that the APA would determine implicit guidelines, even quotas, for sexual activity, with a view to pathologizing behavior that is, in its estimation, “excessive.”

Even if you were in favor of creating such a disorder should the parameters for young adults be the same as for retirees with, most likely, much lower sex drives? Would the standard for “excessive” sexual activity be identical for a newly formed relationship and one that’s lasted decades? Why should we see a man’s cheating on his wife with multiple women as a result of brain chemistry rather than, say, marital unhappiness or personal recklessness? Personally I think expecting lifelong fidelity to one partner may be asking too much of certain people who are ill-suited to it, or who simply don’t believe monogamy is the best way to achieve emotional and sexual happiness. That’s surely up to them, isn’t it? Yet there’s an expectation, even a kind of demand, in our culture that one person will meet all of our needs – emotional and sexual. That can happen, and it’s great when it satisfies both parties, but those choices don’t work for everyone, and an organization seeking to pathologize “excessive” sexual activity needs to recognize that. We need broader public discussion of this complex issue rather than the kind of psychiatric judgment and ritualized shaming that goes on right now for those who prefer to remain non-monogamous. Good for them if that’s what they want.

What do you think?