"TRAINING FOR AWARENESS, RESILIENCE AND ACTION": A Handbook for Depressed Kids

(This is a bit of a side-bar for the five Domain discussion I've been pursuing.)

TARA is the acronym for addressing problems of adolescence based on the RDoC approach of brain pathways rather than labeling and sorting using the Diagnostic labels.  That is, reconciling assumptions about clinical issues with what is known about the brain from neurology research. These thoughts (TARA's are the ones in italics) are meant for all kids, but esp. for troubled kids.  Is there such a thing as an untroubled kid?  Anyway, the goal is a handbook which should be published soon.

Training for Awareness, Resilience and Action

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137278/

“Major depressive disorder (MDD) is one of the current leading causes of disability worldwide. Adolescence is a vulnerable period for the onset of depression, with MDD affecting 8–20% of all youth. Traditional treatment methods have not been sufficiently effective to slow the increasing prevalence of adolescent depression. We therefore propose a new model for the treatment of adolescent depression – Training for Awareness, Resilience, and Action (TARA) – that is based on current understanding of developmental and depression neurobiology. The TARA model is aligned with the Research Domain Criteria (RDoC) of the National Institute of Mental Health. . .

“Approximately 13–20% of the children living in the United States experience a psychiatric disorder often including depressive disorders, with suicide being the second leading cause of death among US children aged 12–17 years in 2010 (Perou et al., 2013)”

Studying brain systems is complicated by development, which is the main characteristic of adolescents, and offers many chances for something to not-get-done/do-too-much/go-entirely-missing.  Three special considerations are understanding the causes, predicting what will happen, and figuring out what to do about it.

Brain systems often evolve from the pre-existing substrate “animal” or limbic impulses by imposing new restraints rather adding something novel.  Maturation can mean "wait now!"  The internal restraints that are not yet in place for adolescents may include those on impulsivity, risk-taking, novelty-seeking, increased emotional intensity and reactivity.  These impulses are naturally present in most mammals and are vital to the exploration of behavior that expands cultures.  A young animal that will not risk doesn't learn to hunt or find a new range.  It stays in place, dependent on adults for food.  In other words, it's "domesticated," an aberration good for the people who "own" them.  It's close to depression IMHO.

The benefit of risk goes to the survival of the culture rather than that of the individual, since a percentage of individuals (8–20% ?) can be sacrificed without destroying  the larger group.  The reality is that in every population, human or not, some individuals are going to be lost.  The culture wants it to be the children of the Other, not them.  

These are the principles of the Minotaur in the Labyrinth.  Thus, high school students work hard to be excellent football players so they will earn scholarships to good schools where they will destroy each other's brains by bashing into each other.  But many of the players will be ghetto kids who will flunk out anyway, after making a lot of money for the institution of higher learning.  Pencil-necked mild kids will make it all the way to post-grad and earn the big salaries the ghetto kids only imagined.  They are domesticated and will donate generously to their Alma Maters. They are likely to struggle with depression IMHO.

Since human mental restraints are located in the prefrontal cortex, damage to the forehead and other frontal areas may delay or eliminate some of the regulatory capacity.  This is the age of reconciliation between the need to belong to a peer-group, and also the need for autonomy.  Many little neurological structures that control emotion, ruminating (going obsessively over and over one’s experience), and other processes that can become depression vortexes, are just maturing and settling their internal interaction with each other.  Raw cognition is not so much a problem as figuring out how to put it together.  The specifics of this stuff is well or at least thoroughly described in the document linked at the beginning.

Survivor.

The other side of the equation is that developing youngsters are still plastic enough to compensate in major ways, if they have enough of what they need and some shelter.

The concept of anhedonia comes up often and seems to be less about inability to accept pleasure -- the origin of the term -- than about emptiness which doesn’t come from boredom so much as from feeling hopeless, pathologically lonely, and isolated.  “There’s nothing to do, this place hates me, I can’t wait to escape.”  They may refuse all awards, honors and praise as attempts to control or as just lies.  I see this around here, both on the rez and off, and it is also clear in the “Bridgend” movie.  This is where S-R breaks down for adolescents.

Here is a list of red flags for depression:

1. Sustained threat with symptoms of anxious arousal, increased conflict detection, attentional bias to threat and emotion-laden stimuli, helplessness behavior, punishment sensitivity and avoidance.

2. Arousal and wakefulness including limbic and autonomic hyperarousal with manifestations such as insomnia and secondary sleep dependent behavioral dysfunctions.

3. Loss, including feelings of sadness, guilt, shame, low self-esteem, worry, rumination, increased self-focus, and withdrawal.

4. Attention and cognitive control with concentration difficulties, distractibility, and low impulse control.

5. Approach motivation, mechanisms of reward learning and social processes such as social communication, perception and understanding self and others and self knowledge are valuable salutogenic life skills which should be addressed in treatment of adolescent depression.  [WTF is "salutogenic"?  Does it mean you're the Salutatorian?"]

These are the children of prostitutes in India who were taught by a female photographer to use cameras which made them all very happy and positive.  Not all of them were able to leave the brothel community.  A few won prizes and traveled.

This is a list of functions to address.  

They’re mostly “mindfulness” learning.  “Mindfulness” is a range of techniques for “being here now,” for increasing awareness of one’s own internal life in the normally unconscious part of the brain and responding body.  The team working on TARA likes yoga, but there are “disciplines” (the restrictive sound of the word is unfortunate) in every culture that respond to this approach from “walking meditation,” to retreats, but the Asian traditions (Buddhist, Hindu, Taoist) have honored them the most.

1. Improve autonomic regulation and decreased hyper-arousal and limbic hyper-reactivity (with hypothesized secondary effects on sleep disturbances).  Unconscious stuff, but habits can be built consciously.

2. Practice attention and interoceptive (internal signals) awareness to enhance dynamic switching away from self-evaluative processing and rumination.  Suffering, danger, hunger, forced labor, abuse and unwanted sex are all imposed experience that destroy this awareness as a way of protecting the self.  It will take assurance of safety to do this.  

When I've been in groups that were intense, the counselor would sometimes say to someone:  "What are you feeling right now?"  Sometimes they didn't know.  Sometimes they realized something surprising, not what they had thought.

3. Promote emotion recognition by training interoceptive awareness (emotion) and enhance prefrontal cortical regulation of affect by practicing labeling and communication of emotions.  It can be a shock and confusion to begin “feeling” without ways to think about feeling.

4. Train top-down cognitive control over affective responses such as negatively biased states of attention, processing, thinking, memory, rumination, and dysfunctional attitudes.  These are dashboard skills: seeing the speedometer needle go up and being able to take one’s foot off the gas.  (Simply braking may not be the answer.)

5. Identify intrinsic values to drive pro-social behavior and increase motivation for committed behavioral activation.  This moves the attention out of the person and into the culture, but in a supported way.

To repeat in slightly different language:

1.  Calm down and create a sense of safety.  Learn how to match detection of danger to reality.  To respond too little is to be vulnerable, but to respond too much is damaging.

2.  Attend to and care about inner experience.   Build your emotional dashboard.

3.  Recognize, regulate and communicate emotions.  Calm the limbic, clarify the pre-frontal thoughts.  

4.  Core values, goal setting and committed action -- connecting the cortico-limbic with the thoughtful pre-frontal processes.

COMMENTS:

I hardly qualify to reflect personally on this material myself since I’ve handled my unconscious mostly by stuffing it down and putting my effort into the rational, often by writing, which many kids do online now.  One risks others reading what was tentative and exploratory, and freaking out -- trying to take over and impose order or THEIR answers.  

Here is a metaphor.  The only way to learn how to drive on ice -- short of a skid-pad -- is to find a safely frozen pond or parking lot (shallow enough to keep from drowning if you break through) and cut cookies, slam brakes, etc.  In actual practice on real ice you are risking a roll-over.  Good to have someone standing by, even when exploring one’s own guts.  As the Brits say, “Take advice.”  

If early versions of humans had evolved as naturally rational beings, with onset of sexuality delayed until full maturity, we would not have an overpopulation problem.  They might be always waiting for just the right moment to fall in love, which means risking children without the skid-pad of marriage.  See how dangerous metaphors are?  

Anyway, it’s inaccurate to think that sexual feelings are only present in teens.  It’s like saying that eating is only important at one stage of life.  The survival basics are always present.  The problem is not eliminating them, but managing them in an authentic way.

IF YOU GIVE YOUR BODY AWAY . . .

If you give your body away, where do you live?  Lovers, the tortured, athletes, combatants, the grievously afflicted, and perhaps dancers or musicians surrender the control of their physical selves to something larger.  But, doing this, they can feel enormous intimacy, even spiritual.  Perhaps the parts of the identity that dwelt in the larger body come to concentrate in the mental life, brain-based.  There is often some kind of attachment that develops, very intimately and not necessarily caressing.  Then attachment can become obsession and finally addiction, which is a minutely physical neuronal change in the body, most intensely in the brain.  Usually it works against survival.   So now I’m including on this short list all kinds of PTSD and much drug use.  There may or may not be self-awareness of what has happened, no perceived ability to change back to a former self or a future addiction-free state, except through great suffering, like opiod withdrawal.  

I’m speaking from observation and testimony, not my own experience, in the way the first aboriginal people assigned an interpreter, who were often women living at crossroads.  The tribal lives were not lesser, but different; not better or worse, but different.  Those whose brain nodes-of-assumptions (I mean literal neuron sorting centers) have been deeply changed will try to avoid explaining and probably couldn’t if they tried.  The inside/outside boundary cannot be breached except by those very few who can go back and forth.  It is a shaman’s journey and humbling.

My copy of “Love in the Western World” by de Rougement is second-hand (Princeton, ’83).  Ch. 8, “The Love of Love,” has been previously underlined almost throughout.  None of the other chapters are marked except for one sentence in the next chapter: “The Love of Death.”  “. . .the lovers’ secret -- that they are seeking peril for its own sake.  But so long as the peril comes from without, Tristan’s prowess in overcoming it is an affirmation of life.”

The original tale is far more elaborate than we are used to knowing, with many partings and reunions, many struggles to give each other up, many ordeals.  De Rougement is worth quoting.  P. 39 in my paperback.  :  “They are thus in a thrillingly contradictory position.  They love, but not one another.  They have sinned, but cannot repent; for they are not to blame.  They make confession, but wish neither to reform nor even to beg forgiveness.  Actually, then, like all other great lovers, they imagine that they have been ravished ‘beyond good and evil’ into a kind of transcendental state outside ordinary human experience, into an ineffable absolute irreconcilable with the world, but that they feel to be more real than the world.” 

This is a condition of the instrument, not that which is measured.  The sensory interface with the world becomes engraved on the lens of the observer, so that nothing else matters or can be accurately perceived.  But in addition there is always an over-chord of transcendence, a feeling that there must be something mystical going on.  As I write, the radio is suddenly playing Wagner.

Still, we are bodies, embraceable and sometimes singing.  We age.  Unexpectedly I found this quote from a David Brooks conversation with Gail Collins entitled “How to be Old.” “Michelangelo, Titian, Rembrandt, Turner and Cézanne, peaked in their elderly years. These artists shared what he called:  A sense of isolation, a feeling of holy rage, developing into what I have called transcendental pessimism; a mistrust of reason, a belief in instinct.”  And yet a wish to help others. 

In fact, fascination/obsession/addiction to these issues comes through a felt intimacy (as ill-fated as that of Tristan and Iseult and not at all physical) that holds attention, which is the craved state, but equally strong is fear of entrapment and that’s true on the other end as well, a tie between two people.  It’s not dependent on writing except that print can be the body of the connection. 

De Rougemont gives much attention to the END of this relationship between Tristan and Iseult.  Contemporary derivations emphasize eternal love, endlessness. “love beyond death.”  This seems to come from Christianity and its roots, not as universally transcendent as those sources would claim.  Compared to Buddhism, it seems to me shallow.  Compared to awareness of simple embeddedness in the natural world, it seems to me unnecessary.

Chapter 11, “Unhappy Mutual Love” addresses suffering.  (The previous owner of the book has now begun dog-earing pages.  One could easily write a short story playing that reader against this reader against the text.)  De Rougement proposes (p. 51) these alternatives:  “According to the sturdiness of our spirit, this unhappiness may be the ‘delightful sadness’ and spleen of nineteenth-century decadence, a transfiguring torment, or a challenge which the mind flings down to the world.”  They are not mutually exclusive.  

In spite of the emphasis on transcendence evoked or even forced by the inescapable dilemma, religion is not the solution -- it is an example.  Particularly the ones that premise an anthro-theos can only harden the dilemma of unrequited love locking one into addiction to one’s own brain template.

De Rougement claims in the Freudian way that this is all rooted in a yearning for death.  I think this is pretty much a distraction since we all die anyway.  If you want death, all you have to do is to wait.  Maybe be a little careless.  Live in the wrong place.  Have passionate encounters with the wrong people -- or, worse, passionless transactions with the wrong people.  But since the whole assurance of Christian and Islamic traditions is that obedience will earn eternal life, maybe yearning for death is simply a Celtic assertion of belonging to oneself and one's own body -- not some system imported from the Middle East.

Once one realizes the inevitability of death, then the issue moves to how to be most alive in the time allotted.  One of the figures not often considered in the Tristan and Iseult tale is the “Morholt” which is a kind of Minotaur figure that demands the sacrifice of youths.  Youth is much admired by older persons (in spite of their willingness to sacrifice them) but despised by those still in that state.  The young are still death-deniers, still susceptible to the love-potions, still on the surface of their mind formation.  Therefore they are vulnerable to ill-use, addiction without wisdom, and resistance to the culture that could have supported them.  Tristan slays the Morholt -- then discovers that the creature is Iseult’s brother.  (Remember the giant albino in “The Girl with the Dragon Tattoo” trilogy?)

The whole point of King Mark’s marriage to Iseult the Fair is to produce heirs for his kingdom.  Genetic succession keeps order and might even assure quality.  Tristan and Iseult prevent the creation of children, a new generation.  This could destroy the whole nation.  Even Tristan’s legal marriage to Iseult of the Fair Hands is never consummated and therefore produces no rival children, which preserves the community.  The lovers have taken themselves out of the standing order without creating something new except for ideas, story.