June 25, 2021
Dear Interested Readers,
What Happened to You?
Most Monday mornings since the COVID lockdown began I meet on Zoom with a few local friends to discuss a book that we have all been reading. We take on one or two chapters a week and really bore into the author’s intent. I look forward to these sessions because invariably we touch on the concerns that need resolving to reach Erikson’s eighth stage, “integrity vs. despair.” If your memory of the stages has slipped a little since your last psychology class in high school or college, click on the link for an overview of Erikson’s concept and a complete definition of each stage. To keep us all on the same page I am going to jump to the last stage which is where most of the members of my reading group are clustered. There is one younger member of our group. She is a recently retired minister who is only sixty-three, but she is an “old soul.” The rest of us have all qualified for Medicare which means that we are working on Erikson’s eighth stage.
The article at the end of the link describes the eighth stage of Erikson’s development scheme as “Integrity vs. Despair.”
Stage 8: Integrity vs. Despair
The final psychosocial stage occurs during old age and is focused on reflecting back on life. At this point in development, people look back on the events of their lives and determine if they are happy with the life that they lived or if they regret the things they did or didn’t do.
Erikson’s theory differed from many others because it addressed development throughout the entire lifespan, including old age. Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.
At this stage, people reflect back on the events of their lives and take stock. Those who look back on a life they feel was well-lived will feel satisfied and ready to face the end of their lives with a sense of peace. Those who look back and only feel regret will instead feel fearful that their lives will end without accomplishing the things they feel they should have.
Outcomes
Those who are unsuccessful during this stage will feel that their life has been wasted and may experience many regrets. The person will be left with feelings of bitterness and despair.
Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death.
I have come to believe that most of us dance back and forth across the finish line of the eighth stage. Some days we are accepting of all that has happened and can’t be changed and even feel pretty good about our pasts. We love to tell each other stories about the events that confirm our success and even present our failures as examples of our ability to learn from our errors. On other days dark clouds form on the horizon and uncertainty and regret roll in like a “blue norther.” The book we have just completed is Falling Upward: A Spirituality for the Two Halves of Life confirms these recurrent “shadowland” visits as part of the process of spiritual growth. I think that we all remain vulnerable to setbacks when unexpected external events, losses of those we love, or illnesses occur. Those events cause us to lose the peace and wisdom we had been so sure was ours forever, but if we have done our work well and have the support of caring people in our environment the regression is countered by our resilience which is probably the most practical skill of the eighth stage. In the end, for me, Falling Upward was an analysis of the sources of resilience.
The book was written by Richard Rohr who is a Franciscan priest in New Mexico who founded the Center For Action and Contemplation in Albuquerque. I first learned of Father Rohr’s daily inspirational emails from Dr. Patty Gabow, the former CEO of Denver Health, while having breakfast with her at a conference we were both attending. Since Patty introduced me to Rohr’s work, I have been amazed to find that many of my friends are also readers of his daily letters and one has read many of his twenty books. My relationship with Patty was a perfect example of a source of resilience. CEOs and other medical leaders often feel isolated. It is difficult to express your worries and doubts to those that you are trying to lead. Part of your job as a leader is to be a source of resilience. Finding someone who understands and shares your doubts and confusion is a source that supports resilience. Patty frequently helped me find a fresh perspective when there were clouds on the horizon.
In the link attached to the title Falling Upward, Lauren Winter from the Divinity School at Duke writes:
The message of Falling Upward is straightforward and bracing: the spiritual life is not static. You will come to a crisis in your life, and after the crisis, if you are open to it, you will enter a space of spiritual refreshment, peace, and compassion that you could not have imagined before.
Each of the members of my group is able to describe disappointments or some sort of failure in life that has been ultimately liberating. In fact, it is impossible to imagine a life that does not contain failure as part of the way forward. David Brooks covered much of the same territory in his 2019 book The Second Mountain: The Quest for a Moral Life which I have discussed with you before. We live the first part of our lives “becoming.” The work of “becoming” consumes us and frequently crowds out more meaningful experiences. The inevitable losses in the first part of life put those efforts at “becoming” into a perspective that can be a springboard toward a more meaningful and richer existence that has much less of the anxiety that is common in the first part of life where the concern is: “What is to become of me?” Many of us are plagued by the fear that we will be “outed” as professionally incompetent or that we are some other type of “fraud.” Both Rohr and Brooks describe how what we fear limits our possibilities. When we survive the failures or setbacks that do occur it can be liberating and the outcome can open up much better possibilities. Both books lead us toward a positive resolution of Erikson’s eighth stage. You can imagine the rich discussions and the sharing that occurs when a group of people who can trust one another come together to explore a resource such as one of these books.
I am always a little anxious toward the end of one of our books. It feels like there is some vulnerability as we end one study and ask each other, “What’s next?” We always consider discontinuing the process, but inevitably we are reluctant to do so. Any moment of transition is a vulnerable moment. The mental image that I have for transitions is the trapeze performer who must let go of one trapeze and fly through the air to grab the next one. Perhaps I saw too many circus movies as a child.
I am always relieved when someone makes a good suggestion and we all agree to give the new selection a chance. This time the transition was very quick and easy with absolutely no chance for an interruption in our Monday sessions. One member of our group, Ron, a former psychiatric nurse practitioner, offered us What Happened To You? Conversations On Trauma, Resilience, And Healing by Bruce D. Perry, M.D., Ph.D., and Oprah Winfrey. I must admit that I have had little exposure to Oprah and was somewhat apprehensive about whether the book would be an exercise in “pop” psychology of the “Dr. Phil” variety. Ron assured us that the book had great value and endorsed it by saying that it would have been a valuable asset to him in practice. He offered us a link to a YouTube presentation about the book by Oprah and Dr. Perry. Even before watching the video based on his recommendation and with no hesitation or debate we elected to give the book a try.
I did look at the YouTube program and I would recommend it to you. Oprah is always a little annoying with her style of interrupting other speakers, but Dr. Perry is magnanimous and seems to understand how to work with her and around her. They have been working together for over thirty years. I bought the hard-backed book because I love reading the old fashion way, and then I bought the audiobook since it gave me instant access and I could listen to it on my bike rides. I highly recommend the audiobook. If you are not a regular subscriber to Audiobooks, it is available to you as a free download. I would also recommend the excellent website that the publisher has put together which gives a lot of insight into the process the authors used and offers a good introduction to Dr. Perry’s lifelong work. The audiobook offers the authors as the readers and their voices alternate in a way that compliments the stories from Oprah’s years of interviews and Dr. Perry’s years of clinical practice and neuroscience research.
I have often said that the book jacket or the forward of many books gives the reader much of what is to be gleaned from the book. With this book, much is achieved with the title. In both the book and the video Dr. Perry and Oprah come back to a critical clinical point again and again which is the title of the book. They point out that it is the common practice of most clinicians to address patients with the question “What is wrong with you?” Dr. Perry’s work and Oprah’s personal history and experience from more than 50,000 televised interviews lead them to assert that asking “What happened to you?” often yields more clinically useful information and a faster path to healing.
So far I have consumed about three-quarters of the audiobook on my bike rides. I have relistened to a few of the most interesting chapters. Dr. Perry stresses the importance of what happens in the first two months of life. He also gives the best description I have heard of the neuropathophysiology of PTSD and how different clinical pictures emerge based on what happened and where in life the patient was when the trauma occurred. He reveals the difficulty in assessing the impact of a particularly traumatic event since so many variables in age, personal resources, and associated circumstances make each trauma intensely personal. An event that might rock one patient for a few hours but then quickly becomes a non-issue may become the origin of a lifelong disability for a different person. Perry spends a lot of time addressing the subcortical memories that are stored in our autonomic nervous system from events that occur very early in childhood. These hidden memories can be triggered by many unexpected events such as unexpected smells, changes in temperature, loud noises, and other triggers that often go unnoticed by most people but lead to unexplained episodes of dysfunctional behavior and substance abuse in previously traumatized individuals. These events can impact others who are nearby at home or in the workplace and can create cycles of disease and disability that are perpetuated through multiple generations.
Perry convincingly correlates these often forgotten traumas with chronic disease, difficulties in school and at work, despair in mid-life, and demonstrates how the traumas can lead to other issues that perpetuate the inequities that produce poverty. and make poverty an inherited reality for so many. If the book has done anything for me it has further clarified that it is impossible to imagine achieving the Triple Aim or positively impacting substance abuse, poverty, or healthcare disparities without addressing the traumas experienced by the impoverished. Many children in poverty depend on parents who are also extremely stressed. These children have a good reason not to trust those around them. This is not really new information. Erikson described the importance of developing trust in the first year of life in his description of Stage 1: Trust vs. Mistrust. In the article referenced earlier we read:
Stage 1: Trust vs. Mistrust
The first stage of Erikson’s theory of psychosocial development occurs between birth and 1 year of age and is the most fundamental stage in life. Because an infant is utterly dependent, developing trust is based on the dependability and quality of the child’s caregivers.
At this point in development, the child is utterly dependent upon adult caregivers for everything they need to survive including food, love, warmth, safety, and nurturing. If a caregiver fails to provide adequate care and love, the child will come to feel that they cannot trust or depend upon the adults in their life.
Outcomes
If a child successfully develops trust, the child will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust in the children under their care. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable.
During the first stage of psychosocial development, children develop a sense of trust when caregivers provide reliability, care, and affection. A lack of this will lead to mistrust.
No child is going to develop a sense of 100% trust or 100% doubt. Erikson believed that successful development was all about striking a balance between the two opposing sides. When this happens, children acquire hope, which Erikson described as an openness to experience tempered by some wariness that danger may be present.
Subsequent work by researchers including John Bowlby and Mary Ainsworth demonstrated the importance of trust in forming healthy attachments during childhood and adulthood.
I think the importance of traumas in early childhood is magnified in this moment post-COVID when we are seeking to evolve a “new normal” that includes a greater awareness of the importance of addressing structural racism, the issues of all Americans living in poverty, and the importance of considering housing, early education, child care, paid family leaves, and all of the other issues that President Biden has addressed in the American Jobs Act and the American Families Act as critical infrastructure.
The devastating impact of early childhood trauma is emphasized through the evolution of attempts to measure the impact of childhood trauma in the research on “Adverse Childhood Experiences” (A.C.E.) The first ACE research was done by the C.D.C. and Kaiser in 1995-97. Perry notes that the study was a flawed beginning, but its findings are durable and we now must deal with the reality that if we don’t effectively address the upstream impact of poverty and trauma in the lives of young children we will always need to deal with the manifestation of those early injuries through the damaged lives of adults in successive generations. These are the issues that my friend Joe Knowles is attempting to address with his Family Health Project which I have recently discussed in a piece entitled “Moving From Contemplation To Action.”
I hope that if you have not given these issues some thought as you seek to work in healthcare or any other form of social service you will read the book or listen to the audiobook and begin to ask “What happened to you?’ when you try to help a patient or client. if you are not a caregiver, it is still an empowering question that will be beneficial to you as you try to establish rewarding relationships at home or at work. It is a good question to ask yourself. Even at my age, as I struggle with the challenges of Erikson’s Stage 8, the question is central to the work that is still left for me to do. This critical question and the answers that flow from its consideration are key to any success our nation may have at this critical juncture in the experiences, vulnerabilities, and hopes that we all share as we seek to live into the potential blessings of our founding aspirations. The question should lead to rich discussions. You can be certain that you will hear more about “What Happened To You?” from me.
There Is A Baby Loon on Little Lake Sunapee! Hope Lives On.
I attached a “postscript” to last Friday’s letter:
PS: The baby loon hatched on the 16th. I hope to have pictures for next week!
To our delight, we were able to see the loon family on Saturday by using binoculars. We have been disappointed with how rarely we have seen them on our end of the lake this week. In past years the loons seemed to “hang out” a few yards off our little beach and dock. When we did see them this week they were so far away that my wife could not get a picture even with her long lens.
My wife is the president of the Little Sunapee Protective Association (LSPA) which has a website and Facebook page. Fortunately, another member of the LSPA was able to take a clear picture of the loon family and posted the picture on Facebook. I was able to lift that picture from the FaceBook page of the group, and you can see it in today’s header.
You may have guessed that the loons have an outsized importance in my world. The loons provide the soundtrack for our summers. I enjoy seeing the eagles, the herons, the common mergansers, and even the mallards, but the loons are the ones that capture my heart and my imagination. There have been some summers when something went wrong and there was no baby. Unfortunately, one summer about five years ago the mother loon died of lead poisoning from swallowing fishing tackle. That was after lead tackle was made illegal by an act of the legislature! Another year the momma loon sat on her nest for at least two weeks longer than the usual time it takes to produce a chick. That was a painful experience for everyone. Life is fragile and just as our young are very vulnerable and survival is not a certainty, so is it also true for loons. Perhaps, the sense of shared vulnerability is the central issue until we see the chick. If the chick makes it, it is evidence that sometimes things do work out even when there are many threats. Is that too contrived or fanciful? All I know is the baby loon suggests hope for a better day. The loon population has been slowly increasing over the last several decades at a rate of 1 to 1.5% per year. The population growth is attributed to the elimination of lead fishing tackle and the utilization of artificial floating islands for nesting like the one on our lake. Even with the efforts to protect the loons and grow the loon population, there were still only 313 breeding pairs of loons in New Hampshire in 2019.
I have sometimes wondered what would happen if the State of New Hampshire took the plight of its citizens as seriously as it took the health of our loon population. We go out of our way to optimize the breeding success of every loon pair. We do everything we know to do to ensure the survival of every chick that is born. The social services safety net in New Hampshire has some gaping holes that need the same attention and repair that was given to the dwindling loon population several decades ago. I love our loons, and I would love to see every child in New Hampshire have an excellent opportunity in life. I have got to believe we could do both. I am also sure that even as New Hampshire has room for improvement there are many places in this wealthy nation where the plight of a child in poverty is even more precarious. I hope that you might see it the same way and perhaps together we can call for a better day. All things are possible. In time I am sure we will do better. Why not now?
Be well!
Gene
