Deficits in working memory – but not ADHD

The go-to diagnosis for kids who have trouble learning, focusing and following directions in school is ADHD. Even leaving aside official diagnoses, when we look at the way parents and teachers talk about these children, it doesn’t take long for ADHD to pop up as the label of choice regardless of the actual problem.

In The Learning Brain by Torkel Klingberg, the author points out that kids who have deficits in working memory may be misdiagnosed with ADHD. People with ADHD often have problems with working memory, but not everyone with working memory issues has ADHD.

What’s working memory? There’s a colorful description of it here: “your brain’s Post-it note.”

Working memory helps you retain and process incoming information, such as a set of directions with multiple steps, the thread of a conversation, unfolding stories, math problems and other academic exercises. Even if most of this information never makes it to your long-term memory, you need to hold onto it for the present time to carry out different tasks successfully.

You can see why kids with working memory deficits struggle at school. And given that working memory and attention are closely intertwined, the label of ADHD hovers over these kids. It doesn’t help that when kids are struggling with schoolwork and falling behind their classmates, they often get restless, act out, or let their attention wander – which further reinforces the notion in people’s minds that they have ADHD.

And in kids with both ADHD and working memory deficits, the concern is that people will focus on controlling (medicating) any hyperactivity, at the expense of addressing the working memory problems.

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On Becoming a Person, Chapter 2 – How do therapists foster personal growth?

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What’s the best way to help someone develop intellectually and emotionally?

In Chapter 2 of On Becoming a Person, Carl Rogers writes that it’s a mistake for a psychotherapist to relate to a client as a “case” or a set of problems to fix. Instead therapists should see each client as a whole person, and beyond that form a relationship with them in which they can free themselves of lies and psychological defense mechanisms and grow as people.

What kind of relationship is this?

Rogers characterizes it as one in which: 1) he’s genuine about his own thoughts and feelings; 2) develops an “acceptance and liking” towards the other person; 3) tries to understand the other person.

But he also writes:

I am by no means always able to achieve this kind of relationship with another, and sometimes, even when I feel I have achieved it in myself, he may be too frightened to perceive what is being offered to him.

What happens if a therapist genuinely dislikes a client? Cultivating an attitude of acceptance (discussed more in this earlier post and comment thread) can help override your initial impulse to try to fix the other person or shut him/her out for not being exactly like you. But beyond that? Under what circumstances – even with an attitude of openness, understanding, and genuineness – does a relationship just not work out between therapist and client?

And what about those clients who are “too frightened to perceive what is being offered”? Is the fear something they can work past in time with the therapist, or something that’s a precondition for therapy that they need to work through on their own? Also, fear isn’t the only obstacle standing in the way of a good therapeutic relationship; for instance I’m picturing someone malicious and manipulative, ordered to undergo therapy by a court. (Maybe fear of some kind can also lie at the root of malice and conscious dishonesty.)

Rogers also compares the kind of ‘helping relationship’ between a therapist and client to similar relationships that facilitate growth in people: parent-child, teacher-student, etc. Any relationship in which there’s growth needs to have genuineness, acceptance, and understanding. I’m inclined to agree with him, though each kind of relationship also has qualities that set it apart from others. Returning to the therapist-client relationship more specifically, how does a therapist become a “companion” to the client (as Rogers puts it) without over-stepping certain bounds? The therapist isn’t exactly a friend, or a parent, or a teacher really – or is the therapist something of each of these?

On Becoming a Person, Chapter 1 – What does acceptance mean?

Skeletons embracing

When hearing people argue for ‘acceptance’ and ‘accepting others’ I’ve usually gotten the sense that they’re supporting a lazy relativism – all viewpoints are equally valid, all opinions have merit, all practices and beliefs are beyond reproach. I’ve rejected this idea of acceptance because it falls flat in the face of reality. In some situations you can disagree with people while seeing the merits in their argument, or accept that they have their own tastes and way of life. Other times this kind of ‘acceptance’ stems from laziness, dishonesty and indifference, and can lead to terrible problems if people use it to excuse or ignore destructive practices.

I’ve started reading On Becoming a Person by Carl Rogers, an influential psychotherapist who broke away from both Freudian psychoanalysis and behaviorist approaches to psychotherapy. In Chapter 1 of this book, which was published in the early 1960s, he brings up acceptance:

I believe that it is an increasingly common pattern in our culture for each one of us to believe, “Every other person must feel and think and believe the same as I do.”

And a few sentences later he writes…

Each person is an island unto himself, in a very real sense; and he can only build bridges to other islands if he is first of all willing to be himself and permitted to be himself. So I find that when I can accept another person, which means specifically accepting the feelings and attitudes and beliefs that he has as a real and vital part of him, then I am assisting him to become a person: and there seems to me great value in this.

Shifting away from the lazy relativism discussed earlier, the acceptance described here seems to focus on acknowledging that people’s beliefs/feelings/etc. are a real and valid part of them. It matters to them in some way. Maybe we completely disagree with what it is they’re expressing or we find it abhorrent, but we accept that it’s real to them.

We have a strong tendency to invalidate other people by pretending that what they think or feel isn’t real (“You can’t be serious,” we say, or “no one thinks that way” or “you’re lying”); we can even make up explanations to override them (“you don’t really feel like that, you’re just tired” or “you’re hysterical/emotional/unstable…”). Rogers writes that when he’s more “open to the realities in me and in the other person” he’s much more likely to listen and try to understand, instead of immediately leaping in to “fix things” or bend people to his own way of viewing the world.

I think this kind of acceptance is generally a good approach; it reduces the chances that we’ll steamroll someone with our own thoughts, manipulate them and tell them exactly what it is they’re thinking/feeling. It also resonates with some of my readings on mindfulness training and accepting the present moment as it is, with all of its positive and negative qualities (instead of avoiding reality or warping it with our own thoughts of what it should be like).

Then again, what do we do when we want to change ourselves or when other people’s thoughts, feelings and behaviors are destructive to themselves and to others? We can accept that what they’re doing is real and serves some important psychological need… but if they want to change and ask for help, how can we help them? Does the kind of acceptance described by Rogers in this chapter easily slide into the lazy relativism mentioned earlier in the post? I’ll keep reading more of this book (and more about mindfulness) to better understand (hopefully) how these ideas of acceptance interact with personal development and change. At least for now, Rogers writes that it’s a paradox:

Yet the paradoxical aspect of my experience is that the more I am simply willing to be myself, in all this complexity of life and the more I am willing to understand and accept the realities in myself and in the other person, the more change seems to be stirred up.

Fearing the mind – some thoughts on “The Politics of Experience”

My background in psychology hasn’t included readings on psychotherapy so I’ve started checking out books on the topic and just finished R.D. Laing’s The Politics of Experience.

A few points that jumped out at me from Laing’s book:

1) We (by which he mostly means European/North American people) live in a society that doesn’t truly admit to the existence of a complex “inner world” of dreams/imagination/fantasies/etc. that have any meaning (he wrote this book in the 1960s but there’s relevance to that position today).

(I put “inner world” in quotations, because the boundaries between what goes on in our heads and what’s out in the world is blurry – even our basic perceptions of the external world are filtered through our brains, and our thoughts and mental processes alter the way we perceive the world, what we attend to, what we remember, etc. Laing makes a similar point about there not being a sharp divide between internal and external.)

2) We view people who have been diagnosed with mental illness as lesser and as Others; mental health professionals do their best to subdue and drug them instead of explore and understand their perspective.

3) We can’t help people thrive if we don’t see them as human individuals enmeshed in relationships with others and interacting with society, its institutions and culture.

The terrifying mind

Our mental landscape can be a scary place. Beautiful too, sublime, but also unpredictable, intense, and terrifying.

Laing quotes people who went through – and ultimately emerged from – psychotic episodes where they felt they were traveling back in time, touching other dimensions and planes of existence, encountering core truths about life that were transcendent and overwhelming. Along with confronting visions and wonders, people can easily lose themselves in this mental realm, which seems limitless and is shot through with darkness and terrors as well.

Even mental activity that’s more mundane is awe-inspiring – for instance, everyday acts of creativity: filling a blank page with words or images. From where did they come? What’s inspiration and creativity really? Furthermore (and this is something Laing doesn’t really go into) so many of our basic mental processes occur beneath our awareness, guiding our decisions and actions. Laing speaks in general about people in modern society being alienated from who they are, but how do we come to know who we are and why we choose to act as we do when so much of our brain’s activity is by necessity unfolding beneath our notice? (I say “by necessity” because there’s only a little we can attend to and notice at any given time – meanwhile our brains are gathering, sorting, processing tons of information about the world and matching up current happenings with memories of prior events.) I’m not advocating for a position where we dismiss ourselves as unknowable and leave it at that; but what does it mean to “know yourself”?

Somehow, our brain’s activities give rise to “the mind” – consciousness, imagination, intuition, reveries, rationality, rationalizations, recollections, etc. It’s wondrous and mysterious, and mysteries can be terrifying.

Stamping out the mind

Laing rejected explanations of mental activity and ‘mental illness’ (a term he doesn’t want to use) that are concerned only with external behaviors or that see people as isolated units. These days individuals get reduced to products of cell activity or to animals in the thrall of evolutionary drives. Everything else is treated as so much noise or explained away glibly. I’m reading E.M. Forster’s A Room with a View now and there’s a passage that reminds me of this tendency to iron out the complexities of the mind and pretend its chaos is meaningless (a jangle of nerves):

Lucy faced the situation bravely, though, like most of us, she only faced the situation that encompassed her. She never gazed inwards. If at times strange images rose from the depths, she put them down to nerves… Once she had suffered from ‘things that came out of nothing and meant she didn’t know what’. Now Cecil had explained psychology to her one wet afternoon, and all the troubles of youth in an unknown world could be dismissed.

Psychology (and psychiatry) can be used, and have often been used, as a way to obscure self-knowledge and diminish people. Those classified as mentally ill are especially vulnerable to being treated in inhuman ways: drugged to the gills, incarcerated, subjected to abuse in the guise of treatment, and told they’re incapable of any valid perceptions of reality and meaningful experience. This approach to mental health is yet another way of dismissing the frightening complexity of the mind, rather than trying to understand and work with each individual as a person, which would take effort and a willingness to confront our vulnerability and our painful, puzzling, and beautiful experiences of life – or at the very least accept that they exist and aren’t meaningless.

If Laing sometimes writes as if he’s romanticizing psychotic episodes and their potential for exploring the mind, he’s balancing out other approaches that wipe away the mind’s messiness entirely, kill self-awareness, and diminish intimacy between people. One point he returns to over and again – and it’s worth making – is that when people do experience the world in ways classified as “mentally ill” (depending on the individual, he/she may not be actually ill, just labeled that way), they aren’t experiencing their mental illness in a vacuum. Their interpersonal relationships and the society they live in have an impact on the course of their illness, its manifestation, the potential for recovery and adapting to daily life, and whether or not they’re accepted as a person instead of an embarrassment and an upsetting reminder of how the mind dances beyond the reach of neat little labels and human control.

Social impact

An article I came across recently by Tanya Marie Luhrmann – Beyond the Brain – is well-worth reading and centers on the effects of social environment on people with schizophrenia, including the influence of other people’s attitudes and behavior. The bottom line is that the brain doesn’t operate in isolation; the same goes for the body as a whole, down to the activity in the most remote cells. We’re constantly responding to and interacting with our environments. While drugs can play a role in treatment of psychiatric illness, particularly of severe cases, drugs aren’t everything and don’t solve all problems. Same goes for looking at brain scans and pointing to patterns of brain activation. What do they tell me about what it’s like to be you? To think and dream and experience the world the way you do?

Luhrmann writes:

We are deeply social creatures. Our bodies constrain us, but our social interactions make us who we are.

We can’t fully know each other, but why pretend there’s nothing to know at all aside from relatively superficial qualities? What Laing seems to put forward in his book is a vision of psychotherapy where you aren’t trying to aggressively make people “normal” (whatever normal happens to be in a given society) but to be a guide to them, and to actually hear what they say about their experience of the world instead of dismissing it all as a mass of symptoms.

More unanswered questions

Laing’s book doesn’t really go into how these changes in treatment will be achieved practically (but he does suggest at one point that people who have gone through similar psychotic breaks or psychological experiences can help serve as guides and counselors).

As for his general view of a society in which people are alienated from themselves and from each other, it wasn’t clear what alternative he proposes: what’s an example of a society, in his view, that would promote better mental health and acceptance of different individual experiences? All societies are founded on compromises between individuals and agreements to abide by certain principles. What about personal relationships – what’s an example of a healthy parent-child relationship, for example? He doesn’t get into that; he says only that parents ‘murder’ various potentialities in their children and mold them to societal specifications. If he’s right, what’s to be done?

He points to instances in the past or in other cultures where individuals could explore alternate mental states (through drugs, fasting, etc.), but weren’t these people few in number? Sometimes their activities were sanctioned, sometimes they were revered, but many times they were considered dangerous or aberrant as well.

One person Laing writes about in this book who went through a psychotic episode and emerged from it intact said that the world became illuminated in new ways, even as he continued his day-to-day life with its dissembling and false faces. To what extent can a more transcendent experience of the world co-exist with the smaller, pettier interactions of daily life?

Laing asks at one point: If our society is so dysfunctional, why would we want to adapt to its ideas of normal mental functioning?