Being woken up frequently during the night with my first child was a familiar experience after six years of overnight calls during my medical and psychiatric training. When I wake up because of a crying baby or the sudden, jarring beep of an on-call pager, my sympathetic nervous system kicks in to help me become alert enough to manage the situation. I go through the checks of a medical issue or what the baby might need, try to solve the problem, and then get back to sleep as soon as possible until the next wake-up call. Attending to others’ needs in the middle of the night evokes within me a range of feelings, from the desire to help and care and be needed to fatigue and finally annoyance that can rapidly take the shape of outright rage. If you’ve ever felt angry when your child wakes you up repeatedly during the night or their needs interrupt your dinner, rest assured there is a biological reason for your emotions. States of deprivation of sleep, food, or water stimulate the hypothalamus of the brain. Coincidentally, the hypothalamus maintains reciprocal connections with the amygdala, the part of the brain that modulates feelings of anger. The concept is well described in Amygdala and Hypothalamus: Historical Overview with Focus on Aggression. This relationship within the brain has an evolutionary purpose; in ancient times, hunger caused anger, a response sufficient enough for humans to kill an animal to satisfy their hunger and survive. Despite us having the ability to walk upright and the development of the frontal brain providing us with the capacity for rational thinking, these neural connections persist. I’m not sure whether the use of these connections has been outlived as much as expressing negative feelings is now discouraged.
On a basic level, training in medicine and psychiatry allowed me to practice frequent sleep disruptions and hours of unsatiated hunger or thirst, which greatly helped me manage as a new mom. On a deeper level, the training prepared me for the two most difficult issues I have encountered thus far as a parent: withstanding the emotional intensity of my young children and managing my emotional response to the stress of parenting. I began noticing that as the challenges of being a new mom presented, although I didn’t have any knowledge of childrearing to fall back on, I had knowledge gathered from my psychiatric training. I am not a child psychiatrist as I treat mainly adults, but I hope that sharing these experiences will help people struggling with such parenting challenges.
Managing your emotional response
In D. W. Winnicott’s classic psychoanalytic article, Hate in the Countertransference, the author makes a comparison between the hatred a psychoanalyst or psychiatrist may feel toward certain patients and the hatred a mother might hold for her newborn baby. Most psychiatrists enjoy working with their patients and care about their well-being just as mothers love and care for their children. However, for the psychiatrist, being in close proximity to those distressed can evoke intense feelings. Similarly, managing the behavior of young children can naturally prove trying at times. Countertransference refers to the feelings of a psychiatrist toward their patient during the treatment, In 1949, when Winnicott wrote that article, psychiatric medications had yet to be invented, so psychiatrists worked with patients primarily in psychoanalytic psychotherapy. Anna O, the first analytic patient, called this process “the talking cure.” Sigmond Freud’s mentor, Josef Breuer, an internist in Vienna, treated Anna O’s intense physical problems and emotional disturbances. Breuer noticed that as she spoke out her thoughts and feelings over time, the unhealthy ways in which her feelings manifested as physical illnesses and problematic behaviors seemed to lessen. Decades later, D. W. Winnicott contributed to the field of psychiatry by focusing his psychoanalytic work on early life, including the importance of the parental role and the parent-child relationship in the development of psychological states.
When Winnicott describes the feelings of a mother toward her baby, he states, “The mother hates the baby from the word go.” He lists eighteen reasons a mother may hate her baby; many of them still ring true or appear quite odd or even amusing given the antiquated language. Keep in mind that the paper was written in 1949. My personal favorites include the following:
“The baby is an interference with her private life, a challenge to preoccupation.”
“She has to love him, excretions and all, at any rate at the beginning, till he has doubts about himself.”
Some of the reasons depict a dark context, such as the following:
“He is ruthless, treats her as scum, an unpaid servant, a slave.”
“His excited love is cupboard love, so that having got what he wants, he throws her away like an orange peel.”
The next time you feel like an orange peel, consider the following.
Winnicott says that a deeply regressed psychiatric patient is like a baby, neither of whom can identify with the psychoanalyst or sympathize with the mother, which naturally leads to the feeling of hate. The hatred in either circumstance is a logical outcome, given the behaviors of the patient or the baby. Hate itself is not a problem; rather, denying the feelings of hate can cause unfortunate consequences. Winnicott writes of the analyst, “above all he must not deny hate that really exists in himself.” He argues that only through the process of acknowledging and managing the hate toward the patient, “the less hate and fear will be the motive determining what he does to his patients.” Winnicott recognized that intense, negative emotions can occur in either relationship and that acknowledging and processing such emotions is imperative for the analyst and the mother to continue providing the necessary nurturing environment and avoid acting in unhealthy or unhelpful ways toward the patient or the baby. In summary, acknowledging and working through the feelings helps one become a better psychiatrist, therapist, or parent.
A way in which our society makes this process difficult is by discouraging the expression of negative thoughts regarding parenting or parents’ negative feelings toward their children. When my son was a baby, it was hard for me to feel comfortable expressing thoughts such as, I want to go to a bar for the evening to eat sitting down, drink wine and talk with my friends rather than go home and play with a toddler. Likewise, I felt frustrated that I was always tired and sometimes bored playing with my baby and never had time for the usual outlets I previously enjoyed: reading, writing, making art, and doing yoga. I heard other moms say things like “I wish I could just quit my job and stay home all day with the kids” or “Isn’t being a mom the best job in the world? I wouldn’t trade it for anything!” When I heard these statements, I felt alone because I didn’t always feel the same way. The first time I was able to talk about this was when my son and I were invited for a play date with his friend from daycare. Mid-Sunday afternoon, the mom of my son’s friend offered me a glass of wine and we talked about our kids and the stress of parenting. Over the next few years, I met several working moms through my son’s daycare and these relationships served as vital supports for me. Now, with my second child, I am aware of the importance of talking about my thoughts and feelings and getting support from others. In the article addressing the amygdala and hypothalamus, the conclusion notes that anger and aggression can be intense emotional and behavioral states to manage, and these are best controlled with the help of a multidisciplinary team. I like to think of my support network as my team (partner, friends, family, other parents, therapist, or online community) that will help get me through. Regardless of the feelings, I encourage parents to find their team, express their feelings in a safe space, and work through their emotions to ensure that they can be the best parents to their children. This is similar to the part of the process of becoming a therapist and psychiatrist, wherein exploring the thoughts and feelings about one’s work helps one become most useful to their patients.
Withstanding emotional intensity
The first time I witnessed a behavioral code (i.e., an agitated patient) in the hospital was similar to the first time I witnessed my son throwing a tantrum. On both occasions, I felt surprised and overwhelmed by the intensity of the emotions displayed, and I was not sure how to manage the situation. My son seemed to miss the “terrible twos.” His disposition was mostly happy, and I enjoyed him learning to speak because it helped me feel closely connected to him. He had genuine enthusiasm for activities, and if he wanted something I didn’t agree with, he could be easily redirected and engaged in something else. However, one summer day a few months after his third birthday, I took him to a local coffee shop under the subway and ordered my afternoon coffee and a juice box for him. He was smiling and saying hello to the people behind the counter in his usual friendly way, which was quite endearing. He asked me if he could get a cake pop, and I said, “No, but I’m getting you a juice box and we have animal crackers.”
While I stood at the register, he began kicking the counter. “Please stop,” I kindly said to him, but he wouldn’t stop. He began kicking harder and louder.
“I want pop! I want pop!” he yelled. People turned to look at us. “Stop it,” I said, which was met with a screaming no. He then dropped to the dirty floor of the coffee shop, crying and yelling for a cake pop. Watching this happen, I was surprised and embarrassed but also anxious because I didn’t know what to do next. My son had gone from a sweet boy to a monster in a matter of seconds. Taken aback, I stopped to think. From countless hours of psychiatric training, I was conditioned to act in similar situations at work when one of my patients lost control. In my desperation, I fell back on what I did know –a well-known acronym used in psychiatry for how to manage an agitated patient with R-E-S-O-L-V-E.
Reading to engage: Clear the area, remove possible dangerous objects, and make a safe space. I moved my son off the busy line of irritated millennials and over to the corner of the coffee shop. While dealing with an agitated patient or a child throwing a tantrum, staying calm and remaining with them is the best course of action. If they are in danger of hurting themselves due to being physically out of control, you may be required to physically restrict them for a brief time. In this case, I needed to carry my son, who was kicking and yelling, over to a quiet area, which presented as a brief restraint situation.
Engage: Keep your voice low and slow, identify their wants and needs, and validate their emotional state with active listening. I sat on a chair next to him and said, “I see that you’re mad. You wanted that cake pop and mommy wouldn’t get it for you. That is frustrating!” He seemed to calm down a bit, stopped crying, and began looking more intently at me, appearing curious and somber.
Solving Problems and Offering Solutions: Offer choices whenever possible to help them feel in control. With kids, too many choices can be problematic; however, a choice between two reasonable things is manageable and helps capitalize on the newfound agency of the toddler. I asked, “Do you want to sit down or stand up? Stand? Okay, do you want a juice box or animal crackers?” He replied, “Juice.”
Limit setting: Set clear boundaries on behaviors. Everyone is allowed to have feelings, but there are limits on how kids (and adults) can behave. As he sipped his juice and munched on the crackers, we talked. I acknowledged that he was mad and encouraged him to use his words to say that, but also told him he can’t yell, kick, or lay on the floor because he was angry.
Validating perspectives/feelings: Find something to agree on or agree to disagree on. I acknowledged that what had happened was tough, and we both agreed that we needed a break. I continued drinking my coffee, while he finished his snack.
Ending the event, debrief: Ask what can we do to help you feel better. I asked him what would make him feel better, and he told me that he wanted to go to the park and run through the sprinkler. I replied after two more errands, we could stop at the park on the way home.
When I later read books or online materials regarding toddler temper tantrums, the advice they gave was similar to the psychiatric approach – stay calm and close, allow and validate their feelings, set limits on aggressive behaviors, and talk it through later. With regard to the mind, much of what is known in psychiatry and psychology is composed of studies on child development, since how we view the world and act within it is derived from what we learn as children. Likewise, certain choices made in parenting can either give rise to difficulties or help children respond well to the challenges of life as they grow into adults. My training also helped me acquire knowledge of how the biological brain and its components work, and this information became vitally relevant during this important new venture in my life.
More on the mind and brain next!