Nature Red in Tooth and Claw - Lessons for Psychotherapy
Patapsco Valley State Park covers more than 16,000 acres along the Patapsco River a half-hour's drive from the hospital. Hiking, mountain biking, camping, horse-trails, fishing, and hunting are all available to the public. It's a great place to get outdoors and away from the heat and aromas of the city.
I've seen whitetail and belted kingfishers at Patapsco, rabbit, chipmunks, squirrels, groundhogs, and, once, a bald eagle cruising at about 25 feet right along the riverbed. One morning early I saw a fox kit in a meadow, playing with late summer leaves swirling about in the wind, oblivious to me sitting 20 feet away.
Walking my dog there a couple of weeks ago, sweating up and down the hillsides in true Sisyphean style, I was grateful to live near such a beautiful place, glad for the deep shade of the valleys and the cold of the river...
We crossed the river at the end of our loop and headed back toward the car. We had to wait at the train tracks (near its often-photographed tunnel) for a CSX freight to squeal its way slowly past us. As hot as it was, we quickly got off the gravel railbed and headed back under the trees along the river. The trail here was a narrow single track through low, thick ground cover, so I was in front of the dog.
Suddenly a grayish bird jumped out onto the trail, chirping piteously and flapping its wings ineffectually, moving away from me down the trail. I was fascinated, for though I couldn't tell what kind of bird it was, I thought this behavior was a distraction display, designed to lure me away from a nearby nest. According to this article on a Stanford website, distraction displays are learned. The behavior does not occur in birds raised in captivity and can be extinguished through exposure to "repeated nondamaging intrusions by predators." The behavior tends to increase when nestlings are near fledging. Here is a good example of a killdeer utilizing this behavior (killdeer are perhaps the most commonly described birds that utilize this behavior, perhaps because they nest on the ground, frequently near populated areas):
Unfortunately for this bird, I was wool-gathering over the behavior, and my dog shot around my legs and killed the bird nearly instantly. In case there were a nest or nestlings nearby, I moved us on down the path and so did not have a chance to see what kind of bird it was or look for the nest.
Distraction displays protect the longevity of the species by assuring that many young are protected from predators. To be clear, ideally the adult survives the display and continues to raise the young. In the present instance it's possible that the bird did not see the dog or simply did not move quickly enough.
Thinking about this natural encounter later, I was struck by the way individuals in treatment sometimes protect their vulnerabilities with displays of one kind or another. A patient of mine recently became infuriated with me that I repeatedly refused to discuss her mother's death and her complicated grief that came later. What I wanted to talk about was the patient's drinking, but the patient had little interest in that topic, and in fact wanted to keep drinking, to the detriment of her mental and physical well-being, her relationships, and so forth. Her anger distracted from the more pressing clinical issues, though thankfully not indefinitely.
Another patient had a hard time admitting when she was doing better and always wanted to focus on the things that were going wrong. Her language was dramatic, her frowns always stern, and her silences on the matter of her evident improvements were chilly. What was she protecting? Well, this is a matter of interpretation of course. Perhaps she was angling for disability. Perhaps she was looking to shirk responsibility within her family, or at work. A more benign interpretation is that recovery is fragile, and for patients who have been severely or chronically ill, a frightening part of the recovery process is acknowledge that change is actually happening, that the ill state to which patients have become accustomed is shifting. This may sound melodramatic, or patronizing, or simply unlikely - after all, who wouldn't want to get better?
At one level, of course, I don't know. Interpreting behavior in psychiatry is both necessary and inherently risky. The most straightforward layer of interpretation of my patient's behavior is that her difficult-to-treat symptoms were simply a reflection of the severity of her depression, and I'm making up stories because I have failed to adequately treat her disease. Any interpretation other than that may very well provoke a hostile reaction, since my interpretation says, "I think this is a distraction from what is really going on." Much like distraction displays in birds, these displays tend to arise in a threatening environment, so no matter how much your patient trusts you, if they've learned to do these kinds of things over a long period of time, it's going to take a while to extinguish the behavior.
Maybe my patient has a "personality disorder"? I put the quotation marks around the phrase because it's easy to label patients as personality disordered as a way of explaining their behavior, absolving clinicians of responsibility for trying to understand their patients' suffering (though of course there are effective treatments for many personality disorders). I am pretty sanguine about not being able to help everyone - there are a million reasons why what I'm doing might not be working. But there is a long, long way between "complicated" and "impossible", so let's take the freight train, not the express; perhaps we will see something along the way that helps. Working our way along the track, thoughtfully observing patients' behaviors, not allowing distraction displays to take us too far away from paying attention to what's important - pleasant thoughts from a lovely walk outdoors...