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Book review: New understanding offered of personality development
Rarely does someone come along who has new insight into behavior, someone who conceptualizes with such clarity that we wonder why we never saw it before.
Homer B. Martin, MD, was such a man. Over the course of 40 years’ psychodynamic psychotherapy work as a psychiatrist, he pieced together a concept of how we are emotionally conditioned in the first 3 years of life and how this conditioning affects us throughout our lives. Conditioning forces us to live on autopilot, creating inappropriate knee-jerk emotional responses to those closest to us.
Dr. Martin’s protégé, child and adolescent psychiatrist Christine B.L. Adams, MD, contributed her own 40 years of clinical practice as a psychodynamic psychotherapist to Dr. Martin’s new concept of emotional conditioning. Their findings are published in the award-winning book “Living on Automatic: How Emotional Conditioning Shapes our Lives and Relationships” (Praeger, 2018).
The authors aim to help both therapists and patients out of the quagmire of conflicted relationships and emotional illnesses that result from emotional conditioning. They propose a new understanding of personality development and subsequent relationship conflict, which incorporates work of Pavlov, Skinner, and Lorenz, along with techniques of Freud.
Dr. Martin and Dr. Adams discovered that we are conditioned into one of two roles – omnipotent and impotent. Those roles become the bedrock of our personalities. We display those roles in marriages, with our children, friends, and colleagues, without regard to gender.
Each role exists on a continuum, from mild to severe, determined by upbringing in the family. Once you acquire a role in childhood, the role is reinforced by both family and society at large – peers, teachers, and friends.
The authors unveil a new conceptualization of how the mind works for each role – thinking style, ways of elaborating emotions, attitudes, personal standards, value systems, reality testing mode, quality of thought, and mode of commitment.
The book has three sections. “Part One, Understanding Emotional Conditioning” describes the basic concepts, the effects of conditioning, and the two personality types. “Part Two, Relationship Struggles: Miscommunications and Marriages” examines marriage conflict, divorce, and living single. “Part Three, Solutions: Psychotherapy and Deconditioning” presents steps we can take to decondition ourselves, as well as the process of deconditioning psychotherapy.
To escape automatic living, Dr. Martin and Dr. Adams endorse the use of deconditioning psychotherapy, which helps people lessen their emotional conditioning. The cornerstone of deconditioning treatment is helping people turn off automatic responses through replacing emotional conditioning with thinking.
In undergoing deconditioning you discover how you were emotionally conditioned as a child and how you skew participation in your relationships. You learn to slow down and dissect the automatic responding that you and others do. You discover how to evaluate what the situation calls for with the involved people. Who needs what, how much, and from whom?
This book is written for both general readers and psychotherapists. Its novel approach for alleviating emotional illnesses in “ordinary” people is a welcome addition to the armamentarium of any therapist.
The book is extraordinarily well written. It offers valuable case vignettes, tables, and self-inquiry questions to assist in understanding the characteristics associated with each emotionally conditioned role.
Dr. Martin and Dr. Adams have made the book very digestible, intriguing and practical. And it is a marvelous tribute to the value of a 30-year mentorship.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. She has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Rarely does someone come along who has new insight into behavior, someone who conceptualizes with such clarity that we wonder why we never saw it before.
Homer B. Martin, MD, was such a man. Over the course of 40 years’ psychodynamic psychotherapy work as a psychiatrist, he pieced together a concept of how we are emotionally conditioned in the first 3 years of life and how this conditioning affects us throughout our lives. Conditioning forces us to live on autopilot, creating inappropriate knee-jerk emotional responses to those closest to us.
Dr. Martin’s protégé, child and adolescent psychiatrist Christine B.L. Adams, MD, contributed her own 40 years of clinical practice as a psychodynamic psychotherapist to Dr. Martin’s new concept of emotional conditioning. Their findings are published in the award-winning book “Living on Automatic: How Emotional Conditioning Shapes our Lives and Relationships” (Praeger, 2018).
The authors aim to help both therapists and patients out of the quagmire of conflicted relationships and emotional illnesses that result from emotional conditioning. They propose a new understanding of personality development and subsequent relationship conflict, which incorporates work of Pavlov, Skinner, and Lorenz, along with techniques of Freud.
Dr. Martin and Dr. Adams discovered that we are conditioned into one of two roles – omnipotent and impotent. Those roles become the bedrock of our personalities. We display those roles in marriages, with our children, friends, and colleagues, without regard to gender.
Each role exists on a continuum, from mild to severe, determined by upbringing in the family. Once you acquire a role in childhood, the role is reinforced by both family and society at large – peers, teachers, and friends.
The authors unveil a new conceptualization of how the mind works for each role – thinking style, ways of elaborating emotions, attitudes, personal standards, value systems, reality testing mode, quality of thought, and mode of commitment.
The book has three sections. “Part One, Understanding Emotional Conditioning” describes the basic concepts, the effects of conditioning, and the two personality types. “Part Two, Relationship Struggles: Miscommunications and Marriages” examines marriage conflict, divorce, and living single. “Part Three, Solutions: Psychotherapy and Deconditioning” presents steps we can take to decondition ourselves, as well as the process of deconditioning psychotherapy.
To escape automatic living, Dr. Martin and Dr. Adams endorse the use of deconditioning psychotherapy, which helps people lessen their emotional conditioning. The cornerstone of deconditioning treatment is helping people turn off automatic responses through replacing emotional conditioning with thinking.
In undergoing deconditioning you discover how you were emotionally conditioned as a child and how you skew participation in your relationships. You learn to slow down and dissect the automatic responding that you and others do. You discover how to evaluate what the situation calls for with the involved people. Who needs what, how much, and from whom?
This book is written for both general readers and psychotherapists. Its novel approach for alleviating emotional illnesses in “ordinary” people is a welcome addition to the armamentarium of any therapist.
The book is extraordinarily well written. It offers valuable case vignettes, tables, and self-inquiry questions to assist in understanding the characteristics associated with each emotionally conditioned role.
Dr. Martin and Dr. Adams have made the book very digestible, intriguing and practical. And it is a marvelous tribute to the value of a 30-year mentorship.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. She has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Rarely does someone come along who has new insight into behavior, someone who conceptualizes with such clarity that we wonder why we never saw it before.
Homer B. Martin, MD, was such a man. Over the course of 40 years’ psychodynamic psychotherapy work as a psychiatrist, he pieced together a concept of how we are emotionally conditioned in the first 3 years of life and how this conditioning affects us throughout our lives. Conditioning forces us to live on autopilot, creating inappropriate knee-jerk emotional responses to those closest to us.
Dr. Martin’s protégé, child and adolescent psychiatrist Christine B.L. Adams, MD, contributed her own 40 years of clinical practice as a psychodynamic psychotherapist to Dr. Martin’s new concept of emotional conditioning. Their findings are published in the award-winning book “Living on Automatic: How Emotional Conditioning Shapes our Lives and Relationships” (Praeger, 2018).
The authors aim to help both therapists and patients out of the quagmire of conflicted relationships and emotional illnesses that result from emotional conditioning. They propose a new understanding of personality development and subsequent relationship conflict, which incorporates work of Pavlov, Skinner, and Lorenz, along with techniques of Freud.
Dr. Martin and Dr. Adams discovered that we are conditioned into one of two roles – omnipotent and impotent. Those roles become the bedrock of our personalities. We display those roles in marriages, with our children, friends, and colleagues, without regard to gender.
Each role exists on a continuum, from mild to severe, determined by upbringing in the family. Once you acquire a role in childhood, the role is reinforced by both family and society at large – peers, teachers, and friends.
The authors unveil a new conceptualization of how the mind works for each role – thinking style, ways of elaborating emotions, attitudes, personal standards, value systems, reality testing mode, quality of thought, and mode of commitment.
The book has three sections. “Part One, Understanding Emotional Conditioning” describes the basic concepts, the effects of conditioning, and the two personality types. “Part Two, Relationship Struggles: Miscommunications and Marriages” examines marriage conflict, divorce, and living single. “Part Three, Solutions: Psychotherapy and Deconditioning” presents steps we can take to decondition ourselves, as well as the process of deconditioning psychotherapy.
To escape automatic living, Dr. Martin and Dr. Adams endorse the use of deconditioning psychotherapy, which helps people lessen their emotional conditioning. The cornerstone of deconditioning treatment is helping people turn off automatic responses through replacing emotional conditioning with thinking.
In undergoing deconditioning you discover how you were emotionally conditioned as a child and how you skew participation in your relationships. You learn to slow down and dissect the automatic responding that you and others do. You discover how to evaluate what the situation calls for with the involved people. Who needs what, how much, and from whom?
This book is written for both general readers and psychotherapists. Its novel approach for alleviating emotional illnesses in “ordinary” people is a welcome addition to the armamentarium of any therapist.
The book is extraordinarily well written. It offers valuable case vignettes, tables, and self-inquiry questions to assist in understanding the characteristics associated with each emotionally conditioned role.
Dr. Martin and Dr. Adams have made the book very digestible, intriguing and practical. And it is a marvelous tribute to the value of a 30-year mentorship.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. She has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Puerto Rico after Maria: Trauma team returns
Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.
Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
Week-long training gets underway
A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.
Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.
Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
Regressive behaviors cited
Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.
Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
Compassion fatigue
Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.
Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.
Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.
Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.
Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.
Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.
UMICPT curriculum
When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing.
Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
Future plans
UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.
Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
Week-long training gets underway
A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.
Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.
Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
Regressive behaviors cited
Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.
Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
Compassion fatigue
Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.
Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.
Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.
Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.
Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.
Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.
UMICPT curriculum
When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing.
Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
Future plans
UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.
Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
Week-long training gets underway
A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.
Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.
Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
Regressive behaviors cited
Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.
Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
Compassion fatigue
Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.
Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.
Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.
Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.
Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.
Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.
UMICPT curriculum
When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing.
Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
Future plans
UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Mental health stressors still loom for Puerto Ricans after Maria
The physical and mental health needs of the people of Puerto Rico cannot be underestimated. Just think of what they have been through over the last few months.
When Hurricane Maria barreled onto the island on Sept. 20, 2017 – just 2 weeks after Hurricane Irma reportedly left more than 1 million residents without power – it ripped off roofs and left behind massive flooding, roads washed out, and utility poles and transmission lines knocked down. Whole forests were defoliated, a massive loss of flora and fauna occurred, and 80% of the crop value was destroyed, along with massive loss of stray dogs and cats, dairy cows, industrial chicken coops, and tropical birds, including endangered species. Beloved pets were displaced.
The official death toll as a result of Maria was 64 in December, but according to reporting by The New York Times, that number could be as high as 1,052. Most of the people who died reportedly were men and women over age 50 in hospitals and nursing homes suffering from illnesses such as diabetes, Alzheimer’s, kidney disease, hypertension, pneumonia, and other respiratory diseases.
One grassroots organization that mobilized to provide supplies and medical assistance was Doctoras Boricuas, a group of all-female doctors in the United States and Puerto Rico that formed after the hurricanes to coordinate the delivery and distribution of supplies directly to Puerto Rico and the Virgin Islands. Two groups affiliated with the University of Missouri at Columbia joined forces to help: Global First Responder or GFR, a nonprofit, secular international medical relief organization founded in 2011 by Adam Beckett, MD, and the International Center for Psychosocial Trauma, or ICPT, a group established in 1995 by Syed Arshad Husain, MD, to help war-traumatized children in Bosnia. I joined Dr. Husain’s group of professionals – Kathryn Dewein, PhD; Andra Ferguson, PhD; and Cathy Grigg, PsyD, – all of whom have traveled broadly in the field of disaster psychiatry – to see how we could help the people of Puerto Rico in Maria’s aftermath.
What we did
ICPT and GFR were a combined team, but we served different functions. As part of ICPT, I focused on the mental health component and helped to train doctors, psychologists, social workers, and other mental health workers in both San Juan and Ponce. All told, we worked with about 50 people using the model of “Training the Trainers.” Many of our students were participants in the outreach teams. Our hope is that they will be able to train their peers to recognize and alleviate symptoms of acute and chronic stress disorders. Some of the techniques taught include patient education, relaxation training, breath work, visualization techniques, mindfulness training, narrative therapy, art therapy, and other expressive techniques.
What the PMSF did
Before Maria, the Ponce Medical School Foundation was in the process of facilitating the transfer of medical records into an electronic format. After the hurricane hit, however, PMSF’s program director, Antonio Fernandez, led a shift to disaster recovery work. PMSF got involved in airlifting dialysis patients off the island to safety, provided health care, and also collaborated with the Primary Care Psychology Program at Ponce Health Services University to assist in locating patients, identifying their health needs – including mental health – and providing for those needs to the extent possible.
At the time of our visit, Puerto Rico’s network of more than 90 largely rural federally funded primary care clinics mostly had reopened, but nearly half remained on back-up generators. Even with the medical centers open, patients were not coming in for one reason or another. People had medical problems, but the daily reality of survival, obtaining food and water, took precedence. Some patients were not showing up because they had left the country, or they were in shelters without transportation. Some people did not have fuel. Some could not keep track of their appointments without cell phones and electricity allowing them to access electronic planners. Some, having been without their medications since the storms, were too sick to travel. Outreach teams were necessary to locate patients, identify their needs, and provide medical and psychological care.
Community outreach
Nydia M. Cappas, PsyD, director of the Primary Care Psychology Program, told us that the outreach teams – consisting of doctors or other medical professionals, social workers, and psychologists, were being sent out to communities once a week. They visited homes for the elderly, orphans’ homes, and children in foster care, as well as individual patients. A similar service was provided by Vargas Medicine (VARMED) in the San Juan area.
Team members found that many people were suffering symptoms of posttraumatic stress disorder, even people who did not have prior psychiatric symptoms. They were having flashbacks and nightmares. Those flashbacks and nightmares were being triggered by clouds, by rain, by supplies beginning to run out.
Another trend we observed is that terrain changes prompted by Maria triggered PTSD symptoms among many veterans. The defoliated trees and brown earth were causing them to have flashbacks to the deserts of Afghanistan and Iraq. Children were showing regressive behaviors, loss of developmental milestones, and symptoms of separation anxiety such as wanting to sleep with their parents. In severe cases, they were having psychotic symptoms and auditory hallucinations. The children were grieving the loss of their homes, toys, pets, and family members, in some cases. , including medications, food, toiletries, and other household goods.
Puerto Rico’s future
Two and a half months after Maria, we learned from our students that things gradually had begun to improve. For example, the public schools had just reopened, and that change was expected to have a stabilizing effect on the children. We also learned that, of the 80 shelters that had been set up housing about 12,500 people, 40 shelters had closed. The five medical shelters that had been set up and funded by FEMA also were in the process of closing, and private donations were beginning to slow down. People were slowly returning to their tarped or otherwise repaired homes, albeit all too often without power.
During the storm, nearly 500,000* homes were destroyed. FEMA offered to airlift about 3,000 people who had no home 2 months past Maria to the U.S. mainland – either Florida or New York.
According to our students, people living in the mountains, mainly coffee growers and retired people and comprising about one-third of the population, remain in acute crisis. Part of the challenge is being able to reach this population: Some roads are still impassable, and supplies – such as drinking water – can be delivered only by helicopter. Despite current conditions, FEMA reportedly has announced that it would end emergency operations on the island.
Our team is currently involved in applying for grant funding that will enable us to return to provide additional training to physicians’ and teachers’ groups. Over the course of the next year, we would like to make six trips to Puerto Rico and focus each trip on a different region and different group of professionals so that the entire island has resources. In addition, we will offer follow-up consultations to professionals we trained previously. The regions to be trained would be San Juan, Ponce, Utuado, Mayagüez, Guayama, and a sixth to be determined upon need. We also would like to address the needs of any ongoing relief workers so that they will be more effective in their ongoing role. Meanwhile, financial assistance from the mainland remains uneven.
Many months after Maria (and Irma), the physical and mental health needs of the Puerto Rican people remain great. However, as mental health professionals, we have the tools to help them move forward.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee and Membership Committee for the American Academy of Child and Adolescent Psychiatry.
*Correction, 2/12/2018: An earlier version of this story misstated the number of homes reportedly destroyed by Hurricane Maria.
The physical and mental health needs of the people of Puerto Rico cannot be underestimated. Just think of what they have been through over the last few months.
When Hurricane Maria barreled onto the island on Sept. 20, 2017 – just 2 weeks after Hurricane Irma reportedly left more than 1 million residents without power – it ripped off roofs and left behind massive flooding, roads washed out, and utility poles and transmission lines knocked down. Whole forests were defoliated, a massive loss of flora and fauna occurred, and 80% of the crop value was destroyed, along with massive loss of stray dogs and cats, dairy cows, industrial chicken coops, and tropical birds, including endangered species. Beloved pets were displaced.
The official death toll as a result of Maria was 64 in December, but according to reporting by The New York Times, that number could be as high as 1,052. Most of the people who died reportedly were men and women over age 50 in hospitals and nursing homes suffering from illnesses such as diabetes, Alzheimer’s, kidney disease, hypertension, pneumonia, and other respiratory diseases.
One grassroots organization that mobilized to provide supplies and medical assistance was Doctoras Boricuas, a group of all-female doctors in the United States and Puerto Rico that formed after the hurricanes to coordinate the delivery and distribution of supplies directly to Puerto Rico and the Virgin Islands. Two groups affiliated with the University of Missouri at Columbia joined forces to help: Global First Responder or GFR, a nonprofit, secular international medical relief organization founded in 2011 by Adam Beckett, MD, and the International Center for Psychosocial Trauma, or ICPT, a group established in 1995 by Syed Arshad Husain, MD, to help war-traumatized children in Bosnia. I joined Dr. Husain’s group of professionals – Kathryn Dewein, PhD; Andra Ferguson, PhD; and Cathy Grigg, PsyD, – all of whom have traveled broadly in the field of disaster psychiatry – to see how we could help the people of Puerto Rico in Maria’s aftermath.
What we did
ICPT and GFR were a combined team, but we served different functions. As part of ICPT, I focused on the mental health component and helped to train doctors, psychologists, social workers, and other mental health workers in both San Juan and Ponce. All told, we worked with about 50 people using the model of “Training the Trainers.” Many of our students were participants in the outreach teams. Our hope is that they will be able to train their peers to recognize and alleviate symptoms of acute and chronic stress disorders. Some of the techniques taught include patient education, relaxation training, breath work, visualization techniques, mindfulness training, narrative therapy, art therapy, and other expressive techniques.
What the PMSF did
Before Maria, the Ponce Medical School Foundation was in the process of facilitating the transfer of medical records into an electronic format. After the hurricane hit, however, PMSF’s program director, Antonio Fernandez, led a shift to disaster recovery work. PMSF got involved in airlifting dialysis patients off the island to safety, provided health care, and also collaborated with the Primary Care Psychology Program at Ponce Health Services University to assist in locating patients, identifying their health needs – including mental health – and providing for those needs to the extent possible.
At the time of our visit, Puerto Rico’s network of more than 90 largely rural federally funded primary care clinics mostly had reopened, but nearly half remained on back-up generators. Even with the medical centers open, patients were not coming in for one reason or another. People had medical problems, but the daily reality of survival, obtaining food and water, took precedence. Some patients were not showing up because they had left the country, or they were in shelters without transportation. Some people did not have fuel. Some could not keep track of their appointments without cell phones and electricity allowing them to access electronic planners. Some, having been without their medications since the storms, were too sick to travel. Outreach teams were necessary to locate patients, identify their needs, and provide medical and psychological care.
Community outreach
Nydia M. Cappas, PsyD, director of the Primary Care Psychology Program, told us that the outreach teams – consisting of doctors or other medical professionals, social workers, and psychologists, were being sent out to communities once a week. They visited homes for the elderly, orphans’ homes, and children in foster care, as well as individual patients. A similar service was provided by Vargas Medicine (VARMED) in the San Juan area.
Team members found that many people were suffering symptoms of posttraumatic stress disorder, even people who did not have prior psychiatric symptoms. They were having flashbacks and nightmares. Those flashbacks and nightmares were being triggered by clouds, by rain, by supplies beginning to run out.
Another trend we observed is that terrain changes prompted by Maria triggered PTSD symptoms among many veterans. The defoliated trees and brown earth were causing them to have flashbacks to the deserts of Afghanistan and Iraq. Children were showing regressive behaviors, loss of developmental milestones, and symptoms of separation anxiety such as wanting to sleep with their parents. In severe cases, they were having psychotic symptoms and auditory hallucinations. The children were grieving the loss of their homes, toys, pets, and family members, in some cases. , including medications, food, toiletries, and other household goods.
Puerto Rico’s future
Two and a half months after Maria, we learned from our students that things gradually had begun to improve. For example, the public schools had just reopened, and that change was expected to have a stabilizing effect on the children. We also learned that, of the 80 shelters that had been set up housing about 12,500 people, 40 shelters had closed. The five medical shelters that had been set up and funded by FEMA also were in the process of closing, and private donations were beginning to slow down. People were slowly returning to their tarped or otherwise repaired homes, albeit all too often without power.
During the storm, nearly 500,000* homes were destroyed. FEMA offered to airlift about 3,000 people who had no home 2 months past Maria to the U.S. mainland – either Florida or New York.
According to our students, people living in the mountains, mainly coffee growers and retired people and comprising about one-third of the population, remain in acute crisis. Part of the challenge is being able to reach this population: Some roads are still impassable, and supplies – such as drinking water – can be delivered only by helicopter. Despite current conditions, FEMA reportedly has announced that it would end emergency operations on the island.
Our team is currently involved in applying for grant funding that will enable us to return to provide additional training to physicians’ and teachers’ groups. Over the course of the next year, we would like to make six trips to Puerto Rico and focus each trip on a different region and different group of professionals so that the entire island has resources. In addition, we will offer follow-up consultations to professionals we trained previously. The regions to be trained would be San Juan, Ponce, Utuado, Mayagüez, Guayama, and a sixth to be determined upon need. We also would like to address the needs of any ongoing relief workers so that they will be more effective in their ongoing role. Meanwhile, financial assistance from the mainland remains uneven.
Many months after Maria (and Irma), the physical and mental health needs of the Puerto Rican people remain great. However, as mental health professionals, we have the tools to help them move forward.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee and Membership Committee for the American Academy of Child and Adolescent Psychiatry.
*Correction, 2/12/2018: An earlier version of this story misstated the number of homes reportedly destroyed by Hurricane Maria.
The physical and mental health needs of the people of Puerto Rico cannot be underestimated. Just think of what they have been through over the last few months.
When Hurricane Maria barreled onto the island on Sept. 20, 2017 – just 2 weeks after Hurricane Irma reportedly left more than 1 million residents without power – it ripped off roofs and left behind massive flooding, roads washed out, and utility poles and transmission lines knocked down. Whole forests were defoliated, a massive loss of flora and fauna occurred, and 80% of the crop value was destroyed, along with massive loss of stray dogs and cats, dairy cows, industrial chicken coops, and tropical birds, including endangered species. Beloved pets were displaced.
The official death toll as a result of Maria was 64 in December, but according to reporting by The New York Times, that number could be as high as 1,052. Most of the people who died reportedly were men and women over age 50 in hospitals and nursing homes suffering from illnesses such as diabetes, Alzheimer’s, kidney disease, hypertension, pneumonia, and other respiratory diseases.
One grassroots organization that mobilized to provide supplies and medical assistance was Doctoras Boricuas, a group of all-female doctors in the United States and Puerto Rico that formed after the hurricanes to coordinate the delivery and distribution of supplies directly to Puerto Rico and the Virgin Islands. Two groups affiliated with the University of Missouri at Columbia joined forces to help: Global First Responder or GFR, a nonprofit, secular international medical relief organization founded in 2011 by Adam Beckett, MD, and the International Center for Psychosocial Trauma, or ICPT, a group established in 1995 by Syed Arshad Husain, MD, to help war-traumatized children in Bosnia. I joined Dr. Husain’s group of professionals – Kathryn Dewein, PhD; Andra Ferguson, PhD; and Cathy Grigg, PsyD, – all of whom have traveled broadly in the field of disaster psychiatry – to see how we could help the people of Puerto Rico in Maria’s aftermath.
What we did
ICPT and GFR were a combined team, but we served different functions. As part of ICPT, I focused on the mental health component and helped to train doctors, psychologists, social workers, and other mental health workers in both San Juan and Ponce. All told, we worked with about 50 people using the model of “Training the Trainers.” Many of our students were participants in the outreach teams. Our hope is that they will be able to train their peers to recognize and alleviate symptoms of acute and chronic stress disorders. Some of the techniques taught include patient education, relaxation training, breath work, visualization techniques, mindfulness training, narrative therapy, art therapy, and other expressive techniques.
What the PMSF did
Before Maria, the Ponce Medical School Foundation was in the process of facilitating the transfer of medical records into an electronic format. After the hurricane hit, however, PMSF’s program director, Antonio Fernandez, led a shift to disaster recovery work. PMSF got involved in airlifting dialysis patients off the island to safety, provided health care, and also collaborated with the Primary Care Psychology Program at Ponce Health Services University to assist in locating patients, identifying their health needs – including mental health – and providing for those needs to the extent possible.
At the time of our visit, Puerto Rico’s network of more than 90 largely rural federally funded primary care clinics mostly had reopened, but nearly half remained on back-up generators. Even with the medical centers open, patients were not coming in for one reason or another. People had medical problems, but the daily reality of survival, obtaining food and water, took precedence. Some patients were not showing up because they had left the country, or they were in shelters without transportation. Some people did not have fuel. Some could not keep track of their appointments without cell phones and electricity allowing them to access electronic planners. Some, having been without their medications since the storms, were too sick to travel. Outreach teams were necessary to locate patients, identify their needs, and provide medical and psychological care.
Community outreach
Nydia M. Cappas, PsyD, director of the Primary Care Psychology Program, told us that the outreach teams – consisting of doctors or other medical professionals, social workers, and psychologists, were being sent out to communities once a week. They visited homes for the elderly, orphans’ homes, and children in foster care, as well as individual patients. A similar service was provided by Vargas Medicine (VARMED) in the San Juan area.
Team members found that many people were suffering symptoms of posttraumatic stress disorder, even people who did not have prior psychiatric symptoms. They were having flashbacks and nightmares. Those flashbacks and nightmares were being triggered by clouds, by rain, by supplies beginning to run out.
Another trend we observed is that terrain changes prompted by Maria triggered PTSD symptoms among many veterans. The defoliated trees and brown earth were causing them to have flashbacks to the deserts of Afghanistan and Iraq. Children were showing regressive behaviors, loss of developmental milestones, and symptoms of separation anxiety such as wanting to sleep with their parents. In severe cases, they were having psychotic symptoms and auditory hallucinations. The children were grieving the loss of their homes, toys, pets, and family members, in some cases. , including medications, food, toiletries, and other household goods.
Puerto Rico’s future
Two and a half months after Maria, we learned from our students that things gradually had begun to improve. For example, the public schools had just reopened, and that change was expected to have a stabilizing effect on the children. We also learned that, of the 80 shelters that had been set up housing about 12,500 people, 40 shelters had closed. The five medical shelters that had been set up and funded by FEMA also were in the process of closing, and private donations were beginning to slow down. People were slowly returning to their tarped or otherwise repaired homes, albeit all too often without power.
During the storm, nearly 500,000* homes were destroyed. FEMA offered to airlift about 3,000 people who had no home 2 months past Maria to the U.S. mainland – either Florida or New York.
According to our students, people living in the mountains, mainly coffee growers and retired people and comprising about one-third of the population, remain in acute crisis. Part of the challenge is being able to reach this population: Some roads are still impassable, and supplies – such as drinking water – can be delivered only by helicopter. Despite current conditions, FEMA reportedly has announced that it would end emergency operations on the island.
Our team is currently involved in applying for grant funding that will enable us to return to provide additional training to physicians’ and teachers’ groups. Over the course of the next year, we would like to make six trips to Puerto Rico and focus each trip on a different region and different group of professionals so that the entire island has resources. In addition, we will offer follow-up consultations to professionals we trained previously. The regions to be trained would be San Juan, Ponce, Utuado, Mayagüez, Guayama, and a sixth to be determined upon need. We also would like to address the needs of any ongoing relief workers so that they will be more effective in their ongoing role. Meanwhile, financial assistance from the mainland remains uneven.
Many months after Maria (and Irma), the physical and mental health needs of the Puerto Rican people remain great. However, as mental health professionals, we have the tools to help them move forward.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee and Membership Committee for the American Academy of Child and Adolescent Psychiatry.
*Correction, 2/12/2018: An earlier version of this story misstated the number of homes reportedly destroyed by Hurricane Maria.