Maria, gratia plena

I went to a carol service last night expecting to have a warm Christmassy experience, and to some extent I did. I’ve read enough feminist theology to have plenty of woman-centric Advent and Christmas messages floating around my mind. There’s a lot about Mary, Mary’s yes, Mary pondering things in her heart.

I used to really like that, as a teenager with a deep interest in women’s independence and zero interest in sex. I made lots of nativity scenes but had trouble making the Joseph figure because my idea of the perfect family was mother and child, no men around. I usually put him in the back taking care of the donkey.

I loved being pregnant at Christmas time, loved the whole season echoing the expectancy of pregnancy. I loved the story of Mary’s visit to Elizabeth and the description of the baby leaping in her womb, that feeling so familiar. The lessons and carols I went to yesterday used the word “womb” five times (in Latin or English). How many religious occasions get that gynecological?

But there’s nothing to douse these feelings like hearing the actual Bible interspersed with medieval Marian texts. Mary didn’t say yes, for one thing — Gabriel has already informed her that she will get pregnant when she says that’s all right with her. And the medieval texts are very clear that it’s her purity from the sin of Eve and her virginity that are so wonderful.

As a mother, some of these texts now feel like a slap in the face. “Mary’s so great because she produced a baby while a virgin, not like all those OTHER pregnancies which were caused by SEX,” is basically what I hear. I cried during the carol service for all the people that message has hurt over the centuries.

Another part of the Christmas repertoire that doesn’t quite add up for me is the emphasis on the infant Jesus’s divine humility. I see how it makes sense in a context of an all-powerful being choosing to come to earth in a powerless and vulnerable form, but it somehow never clicks with me because all babies are so vulnerable. When Lily was born I was so enchanted by seeing her tiny blood vessels, like threads, under her skin. A newborn’s windpipe is the size of a drinking straw, a fact which terrified me. All infants are “so tender and mild” while also relentless in their needs. A divine ruler can be a king of kings, more powerful than all others, but a baby can hardly be more fragile than babies already are.

In the spirit of taking joy in the merely real, here are some things I’d like to celebrate at Christmas:

  • Families.
  • The tenderness and generosity of parents despite exhaustion and frustration.
  • Adoption. There are some nice modern tributes to Joseph as Jesus’ adoptive father.
  • Long-wanted pregnancies, IVF, and surrogacy, in honor of Elizabeth conceiving after menopause.
  • Filling the hungry with good things.
  • The courage of women giving birth.
  • The curl of newborn fingers, and the incredible fineness of newborn hair.
  • Making do with mangers and whatever else is at hand.
  • A church packed with people coming in from the winter night to sing together.
  • The miracle of DNA that unfolds a baby from a tadpole, to someone who stares at a bright new world with eyes that can’t yet focus, to a child who can joke and jump, to an adult who can teach and invent and care for others.
  • The valiance of refugee parents, like Joseph and Mary fleeing to Egypt to save their son.
  • Every stranger on the subway who’s smiled at my babies and tried to make them laugh, like so many shepherds and angels paying their dues.
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Grocery delivery in old kids’ books

I think of grocery delivery services as kind of a posh Silicon Valley thing, but old kids’ books and housekeeping manuals have made me think differently about it. Here’s a scene from Curious George Rides a Bike, 1952.

People are delivering mail, newspapers, groceries, and baked goods. The milkman has presumably already been by. In an era when 78% of households had one or no cars, compared to 42% now, this made perfect sense.

Given that our house has nine people and no cars, I think we can feel fine and even historically accurate about using Peapod.

Children’s lit as source for intuitions about animals?

People have wildly different intuitions about what kind of lives wild animals have and whether their lives contain more enjoyment or suffering.

I suspect that opinions about this vary a lot by how you view nature. Before the Romantic era, nature/wilderness was not seen as a charming place. Nature was what made you die of exposure or starvation.

I don’t know what people in a pre-industrial society would say if you ask what kind of life a mouse has. Maybe they’d think the question too silly to answer. But I suspect they wouldn’t have the intuition I had for most of my life, that being an animal would be kind of charming and fun.

Some of this is being raised in the era of the environmentalist movement, with its emphasis on the beauty and wonder of nature and the importance of preserving habitats so that wild animals can do their thing.

But In raising kids, I keep noticing another influence: almost all the depictions of animals they see are cute anthropomorphized ones.  There are old Aesop-type animal stories with anthropomorphized animals that talk to each other, but the genre really expanded in the 20th century, starting with Beatrix Potter’s 1902 The Tale of Peter Rabbit. The illustrations make the depictions especially salient.

(There’s a whole other topic of how farms and farm animals are depicted  which is only on old-fashioned non-industrial farms run by the like of Old MacDonald — but I’ll stick to wild animals here.)

In many books the animals are just stand-ins for humans: think Goodnight Moon or The Berenstain Bears where the characters live in houses and go to school. But even the ones where animals do animal activities leave out most of the things that might be unpleasant for actual animals, like starvation or being eaten. The Very Hungry Caterpillar‘s only problem is a stomachache after eating too many pickles and cupcakes.

Another factor is that children’s books are designed to be read at bedtime, so a large portion of them end with the characters going happily to sleep. My favorite cozification of animals is Ashley Wolf’s illustration of the Raffi song “Baby Beluga”, where the (fish-eating) whales snuggle fish as we read

When it’s dark, you’re home and fed
Curl up snug in your water bed.

So naturally kids conclude that wild animals have charming, pleasant lives.

These animals aren’t living in a dirty hole getting rained on without enough to eat; they’re nice middle-class animals. And we definitely don’t talk about r-selection.

Beatrix Potter, The Tale of Two Bad Mice

How second children illustrate nature and nurture

content note: eating disorders

There’s nothing to make you realize which parts of how your kid turned out are beyond your control like having another one. Your special parenting methods, to which you had attributed your previous success or failure, often produce different results with a different child.

Sleep

Anna is an easy sleeper; after the bedtime routine you just lay her in the crib and she curls up and goes to sleep. If she had been my only child, I might assume people who had trouble getting their children to sleep were doing it wrong. But I know that the same procedure didn’t work with Lily; we went through looooong stages of holding her, leaning over the crib bouncing the mattress, patting her and singing, reciting stories in the dark, etc.

If we’d had an easy sleeper the first time, we’d probably congratulate ourselves on our excellent methods. As it is, we realize that we just got lucky the second time.

Play

Both our kids love care-taking play with dolls and stuffed animals, but Anna also likes car play. Lily had no interest in pushing a car around the floor the way Anna does.

(Not to say that gendered socialization doesn’t happen. My favorite example was the time Lily and I were at the park with a father and his toddler son. The boy hefted a basketball into a doll crib. “He scores!” said the father, at the same time as I asked, “Is the ball going to sleep?”)

Food

In this case, the first child was plenty to change my understanding of how much power I had.

When discussing picky eaters my parents always quoted the pediatrician I saw as a child: “No child ever starved in the presence of food.” This is not exactly true, but I generally embraced this strategy before I had kids. Why were parents always heating up bottles — surely if a baby got used to cold milk they’d like it just as much? Why fix your kid special food — won’t they eat what they’re served if they’re really hungry?

Then Lily was born, and we watched her slowly sink from 82nd percentile for weight to 1st percentile. We tried breastfeeding, pumped milk, formula, nasty strawberry-scented Pediasure, three lactation consultants, two specialists, and medication to increase her appetite. Nothing seemed to be wrong, except that she didn’t feel like eating. At eight months she was kicked out of daycare and because she wouldn’t drink a bottle for the provider. At one year, she was diagnosed with failure to thrive. When she still wasn’t walking at 16 months, the doctor’s guess was “Probably not enough calories.”

So you can bet we weren’t refusing to heat bottles for her or insisting that there would be no dinner except what the rest of us were having. Despite some early successes with adult table food, at age three she’s now eating a typical picky American toddler diet: toast, chicken nuggets, ice cream, pasta, meatballs, rice, cheese, pancakes, fruit. She still isn’t very interested in food and would rather play than eat. But she’s up to a healthy 20th percentile weight.

I know the picky-toddler phenomenon is partly cultural. (See French Kids Eat Everything.) When I volunteered at a childcare center in Ecuador, I was amazed to see one-year-olds gobbling up their meat-and-vegetable soup every day. But many of those kids weren’t getting enough food at home, and the older children were kept at the table and spoon-fed by the staff if they didn’t finish their meals. Watching three-year-olds sit passively with women scooping potatoes into their mouths, I resolved never to do that to my children. I want them to have autonomy over their bodies more than I want them to eat the same dinner as the adults.

My embarrassment about my child’s “beige diet” is my problem, not hers. (Anna, meanwhile, happily eats the same tofu and asparagus as the adults — we’ll see if it lasts.)

I have a lot more understanding now for parents who do whatever works to feed their kids with reflux, tongue-tie, sensory processing problems, low appetite, or just garden-variety pickiness. And given that children largely grow out of picky eating, I no longer see accommodating it as the lazy way out.

Resource on handling mania and psychosis

A lot has been written about handling depression and anxiety, and with good reason! They are very common and can be very debilitating.

But this piece addresses some less common problems: mania and psychosis. These are not as commonly understood, so people are often ill-equipped to recognize or handle them when they come up.

I originally wrote this piece for the EA/rationality community, which has a lot of young adults and a lot of traveling, and thus has people particularly likely to experience these problems while in areas where they don’t have good access to supports and resources.

I think this information is worth knowing for anyone who knows a lot of young adults.

How common are these problems?

The National Institute of Mental Health estimates a 12-month prevalence for the following illnesses (the chance that an adult in the US met the criteria during the last year):

  • Bipolar disorder: 2.6% (a proxy for people who experience mania)
  • Schizophrenia: 1.1% (a proxy for people who experience psychosis)

In other words, if you’re friends with 100 random American adults, around four of them will likely meet the criteria for one of these disorders this year. This doesn’t include people who experience psychosis but don’t meet all the criteria for schizophrenia (for example, because the psychosis is drug-induced).

A person is most likely to have their first manic episode between age 20-25 (source). Men are most likely to experience a first psychotic episode between age 18-25, and women age 25-35 (source).

About mania

What is mania?

Mania (or, in its lesser form, hypomania) is a period of heightened emotion, activity, and energy. Some people experience both periods of mania/hypomania and periods of depression, while others experience only mania/hypomania — these are both forms of bipolar disorder.

Hypomania might include some of the below signs but be shorter and less intense and not disrupt the person’s life as much. Mania is a more intense version that impairs a person’s normal functioning (for example, through risky behavior).

A hypomanic or manic episode might look like:

  • Decreased need for sleep
  • Talking more or faster than usual
  • Feeling euphoric or giddy, “on top of the world”
  • More irritable or hostile than usual
  • Feeling your thoughts are moving fast or won’t stop
  • Feeling very motivated, engaging in lots of activities at once
  • Lots of energy
  • More sociable than usual, talking or arguing with everyone
  • Easily distracted by unimportant details
  • Unusually high self-esteem
  • Pursuing fun and risky activities more than usual: shopping, sex, gambling, drug use, driving fast, unlikely business schemes, grand plans
  • Feeling your brain is working on a whole new level, everything suddenly makes sense
  • Might lose touch with reality (seeing, hearing, or believing things that aren’t real)

These symptoms can last from days to months. Some people experience some of these at the same time as depression (a “mixed episode.”)

  • Common triggers of mania in people who are prone to it:
  • Sleep disruption, including due to crossing time zones
  • Stress
  • Recently starting or raising dose of antidepressant medication
  • Stimulants: caffeine, nicotine, cocaine, amphetamines, steroids, appetite suppressants, ADHD medications
  • Some cold medicine and thyroid medicine
  • Season/light changes — more common in summer
  • Missing doses of psych meds

Is hypomania always bad?

Some people feel that the euphoria and creativity that comes with hypomania works well for them. Many others find that periods of hypomania, while enjoyable, are often followed by periods of depression or full mania which cause serious problems for them.

About psychosis

What is psychosis?

Psychosis is losing touch with reality.

This may look like:

  • Hallucinations (hearing, seeing, smelling, or feeling things that aren’t there). Sometimes people recognize that these aren’t real, while other times they’re very sure they’re experiencing something real. This can be very distressing for them.
  • Delusions (strongly held beliefs despite evidence to the contrary). Common delusions include:
    • Belief that people are trying to follow or harm you (paranoia)
    • Belief that things refer to you: thinking strangers are talking about you, that insignificant events have special importance, that mass media like TV has special messages for you
    • Belief that something is wrong with your body, in the absence of evidence
    • Belief that people are romantically or sexually interested in you, in the absence of evidence
    • Hugely overestimating your own importance and abilities
  • Unusual or bizarre behavior
  • Changes in physical motion: repeating meaningless motions, or not moving at all
  • Thoughts and speech seem disorganized, not making sense
  • Showing and feeling no emotion, “blank” look
  • Loss of interest in usual activities, apathy

Many of these symptoms may also occur for other reasons. Some may come from physical problems with the brain (for example, a stroke). This is one of the reasons it’s a good idea to get medically evaluated if things seem off.

Early symptoms

Some people may experience these symptoms before a full psychotic episode:

  • Trouble concentrating
  • Feeling your mind is playing tricks on you
  • Hearing things like your name being called
  • Seeing glimpses of that aren’t there out of the corner of your eye, or seeing moving patterns or shadows

Common triggers of psychosis

  • Extreme sleep deprivation
  • Trauma or extreme stress
  • Some medications or drugs, especially marijuana, psychedelics, MDMA
  • Withdrawal from some drugs, especially alcohol
  • Physical illness or injury (head injury, infection, blood sugar imbalance, electrolyte imbalance, brain disease such as Parkinson’s)
  • The weeks after childbirth
  • No special trigger, just underlying genetic predisposition

Does someone who experiences psychosis have a particular illness?

A psychotic episode may or may not indicate an ongoing mental health problem. After a first episode, about ⅓ of people will have another episode within 3 years (source). In some circumstances, like sensory deprivation or bereavement, hallucinations are very common and not predictive of future problems.

Some people have only one episode and recover fully. Others have multiple episodes and benefit from ongoing treatment but retain basically normal functioning between episodes. Others get progressively worse. People with recurring episodes would probably be diagnosed with one of the schizophrenia spectrum disorders.

Family history

Bipolar disorder and schizophrenia seem to have some common genetic risk factors. People with a family history of either disorder are more likely to develop one of them.

Drug use

Drugs that may be relatively safe for some people may be much less safe for others.

There’s not clear evidence as to whether marijuana increases risk for psychosis, but it seems very plausible that it worsens existing psychosis and makes people who already have risk factors (like a family history) more likely to develop psychosis.

While drugs such as MDMA have been tested as therapies for conditions like PTSD, the findings of these studies may not be very generalizable because:

  • The studies screen out participants that are seen as being at high risk (for example because they already had other medical or mental health problems).
  • The participants were given actual MDMA, while what’s bought on the informal market is often diluted with other substances, ranging from harmless (chalk) to ones that may cause unwanted effects (methamphetamines, which like other stimulants can kick off mania in some people).

In other words, what was safe for carefully selected study participants with carefully selected drugs may not be safe for you.

The Drug Policy Alliance’s statement on psychedelics:
“An individual’s experience using a psychedelic drug is strongly influenced by two key factors: set and setting. The set is the internal mental environment, and the beliefs, of the person who has ingested the substance. Setting is the external environment. If someone uses a psychedelic in a threatening or chaotic set or setting, that person is more likely to have a threatening or chaotic experience. Likewise, if psychedelics are used in a safe, supportive environment, it will be easier for the person to allow his or her experience to develop in a coherent, potentially meaningful manner – though some parts may still be overwhelming or psychologically jarring.”

How to help

Most people don’t get help soon enough. Someone who experiences psychosis usually doesn’t get treatment until more than a year later. Someone with bipolar typically isn’t diagnosed until more than three years after their first mood episode.

A survey by the National Alliance on Mental Illness asked people who have experienced psychosis who helped them during the early stage of their illness. The most common answer was “no one.” (Parents, psychiatrists, and therapists were the next most common answers.)

In the survey, people who had experienced psychosis listed ways others had helped them:

  • Identifying problems early
  • Listening patiently and compassionately, without making judgments
  • Making suggestions without being confrontational; remaining gentle and calm
  • Keeping them from harming themselves
  • Taking them to an emergency room or making appointment and taking them to a doctor
  • Providing a safe place to rest or recover
  • Traveling long distances to be with them
  • Explaining the nature of the illness and what was happening
  • Building trust by making decisions together
  • Prescribing the right medication
  • Prescribing cognitive behavioral therapy
  • Providing child care, cooking, or taking on other daily chores
  • Providing financial support
  • Encouragement that “normalized the experience,” such as to finish school or return to work

They also listed their most important needs during periods of crisis:

  • Getting rid of voices and paranoia
  • Knowing the difference between what was real and unreal
  • Hospitalization, medication and stabilization
  • A safe place and protection
  • Access to a good psychiatrist or counselor
  • Sleep
  • Validation of their experience; someone to listen who could be trusted
  • Information and explanation
  • Financial assistance

Professional help

Seek medical care if you’re concerned that you or someone else isn’t doing well. This is the standard advice for a good reason, which is that things may get worse if you try to just wait it out. You may miss the opportunity for treatment that would have been helpful. The problem may be due to something you don’t expect (like a neurological problem, a substance you didn’t realize the person took, or an infection). Or it may get beyond what you can safely handle.

US

  • In an emergency, call 911 or go to an emergency room (would be called A&E in UK) at a local hospital.
  • Many areas have a psychiatric crisis team that can send trained mental health staff to where you are; call 911 or the local non-emergency police number.
  • National suicide prevention chat or hotline: 1‑800‑273‑8255
  • Suicide crisis text line: Reach a counselor 24/7 by texting 741-741
  • National Alliance on Mental Illness (NAMI) hotline: 800-950-6264

UK

Other types of help

If for some reason you decide not to get medical help, here are some basic safety tips.

  • Get the person to a calm, quiet environment.
  • Help them establish a regular routine of sleeping, eating, and quiet activity. During mania, trying to “work off” excess energy through activity is counterproductive; getting lots of rest is better.
  • Help them stay hydrated, particularly if they’ve had a lot of alcohol or MDMA.
  • Contact someone who knows more about what’s been helpful to them in the past, like their family.
  • If they’re agitated or aggressive, take this seriously. Keep yourself safe and re-consider calling for medical help.

Other resources

Someone I know is in crisis from Treatment Advocacy Center

Harm Reduction from Robot Hugs

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Some people find that mood/sleep tracking apps help them recognize when a manic episode is approaching.

Advance directives for mental health, sometimes called wellness plans or mad maps. These are plans for what steps you want to take when. This includes information like:

  • What I’m like when I’m well
  • Things that have helped in the past
  • Symptoms that indicate I’m no longer able to make decisions for myself
  • People I do and do not want involved in my care
  • Preferred treatments and treatment facilities
  • Contact information for people you would want to contact in a crisis

How to get therapy from Kate Donovan

Things that sometimes help if you have depression from Scott Alexander (including info on why people with bipolar need different treatment from people with depression).

Navigating Crisis from Icarus Project

Supporting a person with mania or hypomania

Reducing bipolar triggers

Helping a loved one manage a manic episode

Dealing with Psychosis: A Toolkit for Moving Forward with Your Life

National Alliance on Mental Illness

Antisocial personality disorder in prisoners

(I’ve been sitting on the raw material for this post for almost two years and finally wrote it up.)

When I worked in the jail, I asked myself fairly often whether my clients had anti-social personality disorder.  Supposedly almost half of male prisoners have it, and in that setting you do have to constantly ask yourself whether someone is trying to take advantage of you in some way.

“Anti-social” almost seems redundant in a jail, but it’s not clear what the term should mean. It’s also been called sociopathy and psychopathy, and people don’t agree about whether those are actually different things. The seminal work on the topic is Hervey Cleckley’s The Mask of Sanitywhich describes psychopaths as not truly experiencing emotions, especially love. Lots of other books give advice on how to avoid such people.

The DSM IV-TR, which we were mostly using at the time, required three or more from this list for a diagnosis of antisocial personality disorder:

  1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
  2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
  3. impulsivity or failure to plan ahead;
  4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
  5. reckless disregard for safety of self or others;
  6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
  7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

Jails obviously have a lot of people with these characteristics. But they are also full of people with addiction and trauma histories, which can explain almost all the symptoms:

  1. Everyone in jail has been arrested, so that’s a given.
  2. Lying and conning for personal benefit are probably adaptive behaviors in harsh environments like the foster system, abusive relationships, and homelessness. (As my supervisor told me the first time I had my feelings hurt by a client who successfully conned me into making a phone call for her, “This is how she’s survived.”)
  3. Impulsivity and failure to plan ahead: A ton of people are in jail because of this. Executive function is not the strong suit of prisoners. You see a lot of ADHD, a lot of traumatic brain injury, and a lot of substance use (which is both cause and effect of impulsivity).
  4. Irritability and aggressiveness: again, aggression can be adaptive in a dangerous environment. A lot of young men learn this as a way to avoid being victimized. The irritability could also be substance use or withdrawal.
  5. Disregard for safety: A common response to trauma.
  6. Irresponsibility: I read this as “often unemployed,” which isn’t surprising in someone coming out of an unstable family and/or a broken school system. Also would be pretty predictable as a consequence of substance abuse.
  7. Which leaves us with lack of remorse: the only one I can’t explain away even in this population.

I met very few clients who obviously met the “no conscience” model. They were particularly likely to be pimps, I guess because that’s a career particularly well-suited to remorselessness.

The most obviously low-on-conscience guy I worked with got offended once when I asked why he did the right thing in one case when it didn’t seem to benefit him, which made me think he had occasional moments of decency and maybe thought of himself as a decent person. But there were so many other examples of him doing the non-decent thing whenever convenient that this might have just been a front.

Another client was terminally ill and decided during his last weeks that he’d like to discuss his life history with someone. He told me about a variety of horrible things he had done (starting with arson) with no apparent remorse. But he appeared to have genuine love for his dog and spoke fondly of how he hoped to be released in time to go visit it.

At one point I went over my client list and picked the last 60 clients that I had talked with enough and remembered well enough to have an idea of whether they seemed to have a lack of empathy or remorse. 11 (18%) had said something that indicated this (though again, not consistently so—everyone in the sample at least appeared empathetic in certain situations). Another 10% were maybes in that they seemed to maybe have done really callous things but I wasn’t sure. And the remaining 72% didn’t seem to be deficient in empathy. They were mostly locked up for things in the “poor impulse control” department.

I came away from this feeling that:

  • a lot of the diagnostic criteria only make sense for someone coming from a basically ok background where you wouldn’t normally expect to see survival-type lying, violence, etc. The DSM 5 criteria seem much better in this regard, since they now ask you to rule out socio-cultural environment, substance use, and head trauma as causes.
  • this thing seemed a lot more like a spectrum than like a separate category of people.