Hi, everbody!
We have with us today, Miguel Estrada.
He's a pediatric and neurodevelopmental psychoanalyst.
He was trained in the UK, and worked for several years at the NHS, the National Health Service.
And also for private entities, also in the UK.
He was the clinical director for two daycare centers for autistic children.
And responsible for the project Targeted Mental Health in Schools (TaHMS).
He came back to Portugal in 2012, and works nowadays in the private sector, and he's the clinical coordinator of the satellite project
for TaHMS in Portugal, Cuidar da saúde mental pediátrica [Taking care of pediatric mental health].
He's the author of the books, Um mapa para chegar ao coração da criança [A Map to Arrive at the Child's Heart],
and Ouvir o que a criança não diz [Listening to What the Child Doesn't Tell].
Today's interview will focus on his most recent book, co-authored with Prof. António Coimbra de Matos,
which I have here with me,
A vida é um sopro [Life is a Breath].
It was published very recently.
And, as I said, it will be the theme for today's interview.
And, in principle, this interview will also serve to promote the book, via its publisher, Oficina do Livro.
So, to begin with,
the book tells us about the story, in the first part, of two people,
Peter, a child, and his mother, Lisa.
Let's leave out the particularities coming from that story, also to
let people discover it by themselves, by reading the book.
But, we're going to focus mainly in the psychological and psychoanalytical subjects that are central to this book.
And, the first one, and it seems to me to be one of the most important ones, is depression,
and the relation it has with suicide.
And so, the first question I would pose is
in what ways is depression the result of genetic factors,
or the result of people's individual experiences, notably
the relationship between children, and their fathers and mothers, during their formative years.
And also what is the relationship between depression and suicide.
And that's the golden question, right?
Right.
Well,
in fact,
depression as a hereditary component to it.
That hereditary component...there are several studies
notably according to epigenetics, that is,
the result of the environment on the gene.
But none of them is conclusive.
This doesn't mean it's not hereditary.
There's still a lot to discover about it.
So...
It's normal that...
we have already identified some genes
which seem to have a real function
in relation to depression.
And there are people who are more predisposed to depression.
That with certain life events can develop a diagnosis of a depressive state.
That means, they are more vulnerable.
And...
Certainly there are life events which really
can, and do contribute to the manifestation of depression.
There's a thing here about depression. I think
the even today, in 2018, we have a problem here. And that is
the depressive person is not diseased,
ij the eyes of society.
And in a big part of the medical circles,
there's still a stigma.
Not in a good part, but...
a good part is not the best way to put it,
but there's still a lot of it.
A depressive patient is seen as a maladjusted person.
This is very bad.
Really bad.
In order for us to cure depression,
we have to have...and now,
in regards to children,
we have to have systems of support.
Those systems of support have to be exclusive to the family, and the child.
But they have to have a continuous consistency.
Not simply a meeting every two months.
And, for that, we have to really invest in mental health. But now,
to address the question,
it's extremely difficult, if not impossible,
still today,
to say what is...
what is the part related to the life event, and the part related to genetics.
That would be an exercise that
even though we already talk about biomarkers, to identify
some of the contributors to depression,
the truth is that we have no test for it.
A clinical test, a blood test,
where we can identify
I believe that we could have it in the near future, but not at the moment.
Now...
what is the genetic part, and what is the part
related to the environment? Well,
sometimes we can deduce, but this is nothing more than a deduction,
so we cannot take this as science.
That
in depression, for example, where at a certain time
a child or a young person became depressive,
and the family has a history of depression or anxiety,
or even schizophrenia, etc.
That it could really be the case that there's a convergence of some of those genes that induce the depression in the child.
And, here, I'm talking about a situation where the child is apparently happy,
she has no problems at school,
she has good parents,
but, suddenly, pum!
This is what we can deduce as being
genetic.
Because there's not apparent motive for this child to become depressive. Now,
obviously if you have a child who was sexually molested
just to give an example,
and that becomes depressed,
we
can deduce that it happened due to the life event, right?
We have the parents' story, and neither of them suffered from depression,
neither of them had any other kind of problem, like autism, schizophrenia,
not even an anxiety disorder.
And after that traumatic event,
the child became depressed, or developed PTSD and depression.
Then, we can deduce that
it was really a life event that changed the brain's neurochemistry.
Now, to be sure of this, I cannot.
Science hasn't yet arrived there.
What is really due to biology? What is really due to the environment?
And the relationship with suicide?
What is, perhaps, the correlation between depression and, at least, suicide ideation?
Okay.
The majority of the cases of suicide ideation,
and the majority of cases, in the literature and according to my own professional experience,
there's a strong correlation
to suicide.
This means that the majority of people who went through, or are now going through, a depressive phase,
a melancholic phase, or even have some sort of depression, liek the major type,
or depressive agony.
Where we can really find it.
But now let's...
that's where we find the suicide ideation, but now let's
distinguish between suicide ideation
and "I only care about getting out of here", and "I want to die", which is a big difference.
Yes.
The "I just want to get out of here",
is common to every human being.
Thinking about jumping from the window,
and that it would be the end of it,
is not irrational.
Irrational is to want to die.
And, beware, it's irrational because I'm saying so. But if it really is so or not, that already a philosophical debate.
Right.
Now...
if we distinguish that, we immediately get a fewer number of people
by making that distinction we get a fewer number of people in regards to suicide.
Because there are some people who really want to die. Be it to revenge themselves, and hurt someone.
That means, they can't take it anymore, and are tired of it all.
That means they are seduced byt the entire idea, by the wrapping of suicide.
And they romanticize it completely.
And...
and the other people
okay,
they are giving a voice to the necessity they have of getting away from here.
They feel they've lost their strenght, they're tired, fed up, even if they are right about it, or not.
They have the right to be fed up with everything.
And...
Now, if you ask me...
What types of people really kill themselves? To talk about suicide.
I also don't have an answer, and there's no straightforward answer to it.
I don't know if they belong more to the first group, of to the second.
But they really kill themselves. And, then, we also have another group, a third group,
that is,
people who suffer, for example,
impulsivity, or if something very traumatic happened in their lives. For example, they've lost their wife and children.
Even people who didn't suffer from depression, nor did they have a history of anxiety,
not in their family, nor a diagnosis.
Nor any other psyhicatric diagnosis.
And they also do it. In this case, it's an impulse that derives from despair.
A big despair.
Right.
And another theme of the book, and that is related to
the fact that people get disappointed with interpersonal relations.
That is, when, derived from this disappointment, people resort to a scheme of creating a scapegoat, in another person.
And that person turns into the primordial cause, the source and explanation for every problem people experience in life.
Could you talk a bit about this question surrounding scapegoating and its importance, and also relate this to narcisism?
Of course.
For example, after the revolution in Portugal, Salazar was to belame for everything.
The, in 1980, PCP was to blame. [PCP is the Portuguese Communist Party]
Then, in 1982, the blame was to put on [didn't get this part of the audio].
Then, in 1985,
we wanted to blame...I don't know...
What I mean is that, what happens is that humans have an innate thing
in its ability to mentally reorganize things.
He has to construct a narrative which is significant, and that explains and gives meaning to the surrounding environment.
Okay, but this is organic,
and it's been installed for millions of years. Other animals also have it.
Now...
The scapegoat comes from...why do I call it a scapegoat?
The scapegoat is part of culture.
A millennial culture.
Contrary to what Traditional Chinse Medicine, which states that it is 3000 years old,
it isn't. The scapegoat is much more ancient than that.
The scapegoat works to
mentally organize a
way of looking at the world through which I can understand,
someone can understand
the surrounding environment. And it also has a great religious wrapping to it.
That is...
5000 years ago, for example,
many of the sacrifices done to appease the gods,
they were done in order for the gods to not become angry with people.
To invalidate their anger.
Okay.
That means...
The collective behaved badly,
they would kill, rob, or whatever.
And then they would chose a random guy
or a virgin woman, or whoever.
They would chop off their head, and then, okay, now everything is alright.
This is more or less the logic to it.
Then, what happens?
In the scapegoat we have a strong
a very strong side to it.
I refuse to look at myself,
because the devil is in the other people.
You are to blame.
If you're guilty,
I don't have to feel what I really feel.
I don't have to look inside of me.
I don't have to self-reflect on how my actions damage other people.
How my own narcissism might be interfering with other people's lives.
How my egoismo, or my greed,
might really be corrupting my relationships.
And so, we get a scapegoat.
And so, it's precisely in that projection that people make, in which they project all that is bad in their lives into other people,
that narcissism can develop, in this case.
Well,
it certainly has a narcissistic component to it. But I would put it another way.
I agree, yes, but I would put it another way.
That is...
let's evaluate what is narcissism.
Narcissism in psychoanalysis is a very wide theme.
It encompasses almost every kind of psychoanalytical theory.
In a way or another.
And several people attributed different meanings.
But one of them, coming from the American relational school, and with which I agree,
is that we have to look at narcissism as a necessity.
If we need air, we breathe. If we need to eat, we eat. If we feel hungry, we eat. Etc.
That means, narcissism is
an investment
in which we take things from the environment.
And this is healthy, to a certain point.
Healthy narcissism is when people brush their teeth to...I don't want to say to avoid cavities, but to
feel good when in the company of others. They comb their hair.
They are recognised here, there, etc.
That is healthy narcissism.
It startis being pathological when
we make of others an extention of ourselves.
That means, there's no investment from our part in other people.
And so, we only absorb what other people have to give us.
In order for, and this is very important, other people to voluntarily go along with our needs.
And not with our affection.
That's a big difference.
I think that now it's not that important, but there was a time when
there was a great line of thought in which relationships
were seen as
"I have to find someone to meet my needs."
And that, well, never ended well.
It never ended up well because
the person is not in love
or she doesn't want to invest in the other person.
She wants the other person to invest in herself.
But not in herself, but rather in the idealized life, in the fantasy life.
That means, she wants the other person to invest in something that doesn't exist.
It's a component of obsessive neurosis.
That is, then the person is seen according to that paradigm, amd everything the person might do
and doesn't correspond to the idealized version,
can generate angst.
It can generate angst in the person. "You're worth nothing". "You don't know how to do things".
And this is pure narcissism. It's me, me, me, me, me.
There's a bit difference here.
And you referred to Dr. António Coimbra de Matos,
and he recently talked about that.
For many years, a teacher of mine, from psychoanalysis,
from the psychoanalytical theory,
she told us, and I remember it perfectly well, that,
people say that narcissism is self-love, but it's not.
Love is love, narcissism is narcissism.
Love...there's no self-love
without investing in other person, and that perso invests back in us.
We can look at this as a relationship between mother and child.
One loves the other, and vice-versa.
That narcissism is not love.
It's merely a necessity.
That is, no one feels fulfilled
only by receiving
to satisfy their needs.
And that's why a lot of people feel empty inside.
Because what they look for, is looked for to satisfy something that doesn't exist.
And they don't give back. They don't feel the pleasure, like a mother feels,
of caring fro a child.
Right.
I think that we already got to know a bit better what is narcissism about.
And now to go to another topic of the book,
about impulsivity disorders and, in this case, I would like to focus on impulsivity disorders when they affect children.
And so I will pose a two-way questions.
In first place, and also thanks to the work you've done in the UK, and now are doing in Portugal,
throught the project,
I would like to ask you if you think that in schools,
people who work in schools, the teachers, the staff, etc.,
if they deal well with these questions surrounding impulsivity disorders in children.
And if you think that this might be somehow related to the fact that
schools are structured in a wrong way, making children, in a very early age, to sit for too long in classes,
and very little time dedicated to play, etc.
And, on the other hand, and this now related to the drugs used to control impulsivity disorders,
if you think there's a certain fear in the part of the general public in regards to them.
Great question.
No, the teachers are not prepared to deal with this, and neither do the schools.
And, before I explain why, let me just answer the last question.
People don't fear the drugs themselves. They rather fear some medication because of pseudoscience.
And there's a big difference. But we will get there.
Because it's pseudoscience, and ignorance, that inform these people.
And they fo along with
these ideas about medication, etc., due to bad and false information.
Which is very dangerous.
Now,
Schools are not the least prepared, the majority of them,
to deal with mental health problems in general, in children.
And many times
big stigmas
that come from teachers toward children.
From colleagues as well. Families are ashamed.
But to talk about impulsivity,
and I think it's important to nominate ADHD as an example.
In which
I think it must have been one of the neurological conditions
that
in great part contributed the most, during decades,
to poverty in the country, to the number of inmates in prisons,
to school dropouts,
and to poverty.
Because people cannot stay in school, they can't get a job, due to alcoholism, etc.
Before, ADHD
which is a disease rooted in genetics and neurophysiology, in neurochemisty,
where we can find low dopamine levels.
In the studies that tell us about that.
We didn't have that diagnosis before. And the childen were simply said to have bad behavior.
Delinquents.
Or, rather, as mad
"Look at this crazy guy." And this went on for decades.
Now, what happened? Those children were removed from the educational system.
Then, there weren't any systems to support the child, as we have nowadays.
And...
And what happened? Thousands of children, children who weren't diagnosed with ADHD were
in a way,
punished for their problem.
And they have no fault of their own. No one of them asked to be like this.
And not even the majority of
the children want to be like that.
Now, when there's a genetic basis, a neurochemical basis,
in the brain, it's almost impossible for someone to stop being like that, only because she decides that she doesn't want to be like that.
Only because she's told not to be like that.
What happens?
This children need medication
like methylpehnidate,
which is the most effective form,
to control ADHD.
And it has to go together with
psychological and educational follow-up.
Why do they need psychological and educational follow-up? Because many of these children suffer from depression or anxiety.
And the family no longer knows what to do.
These children affect a lot their parents mentally, and interfere a lot with their parents' relationship.
Because they absorb all of the couple's energy, in order for them to deal with the daily problems the children have to go through.
So, when that happens,
all the angst that is generated by the situation turns into...
the couples get a scapegoat. "You don't do that.". "You don't do this."
And instead of uniting themselves for the good of the child, and to do what is necessarity consistently,
no.
There's divorce, which is extremely good, in families with cases of ADHD.
There's divorce, there's separation, fights, sometimes even domestic violence.
And this can escalate.
That's why I say that this condition,
ADHD, is extremely badly understood, and is very important.
And we don't give it the importance that it deserves.
The consequence, the consequence of that is very heavy for the country.
Recently, in Coimbra [Portugal], researchers went to a prison,
and they concluded that
over 70% of all inmates have some sort of ADHD condition, which was never diagnosed before.
This was last year, or two years ago.
So, just for us to see the scale of it, and to give more consistency to what I'm trying to explain here, to what I'm saying.
Now, about the schools.
I...TaMHS was created to solve this issue.
Because we believed that it's in schools that mental health teams should be, to deal with the parents, and with the teachers, on a weekly basis.
And we know that works.
With that we know that the parents, in fact, can count on the school as a unit of support.
They no longer have to resort to scapegoating.
They can go to the school once a week, and they can be there with the family psychotherapist.
Who help them
to deal with this problem. Helps them looking at themselves in a new way.
And then to expand that knowledge progressively.
According to their introspective capacity, to allow for change.
And this doesn't have to be something very deep. Sometimes we only need to change something here and there.
And the teachers need support to
know what to do with each student individually. Strategies for their classes,
strategies to adopt with the parents, to work with the parents consistently in a behavioral plan
personalized to the child.
And, and it does so, what is the school doing?
It's providing the best possible education.
That is, the emotional regulation of the child, and her family.
And then, she can have enough mental and psychological space to learn.
Children, a lot of times, don't have mental and psychological space to learn.
Now...
that's why I think that the idea of a psychologist in each school [in Portugal] is nothing but a joke.
And we can't even take it seriously. First of all, because it's not fair for these professionals.
How can a single psychologist deal with
very serious problems in a school that has to encompass the family, the teachers, the mediation, etc?
It's also not a pedopsyhciatric meeting every three months that's going to solve the problem.
So,
science tells us, and this is very well studied,
and parents can go to Cochrane, for example. It has everything about this there.
That really the most effective way
to solve these issues surrounding impulsivity and ADHD,
is to consistently work, without failure,
with the parents, the family, and the teachers...and the child. All together
working toward the same goal, that is to help this child.
To help this family.
And that's how we should build a new model of intervention in schools...a scientific model.
A model which works. A model where people feel supported.
Because, in the future, the children who received this support, will profit from it.
And they will also learn a new degree of empathy.
Another degree of altruism.
The idea that the child only goes to school to learn,
that's not enough.
Very well.
So, you already talked a bit about TaMHS, and how it is applied.
And it is probably being apllied in the same way in the project you have in Portugal.
The pediatric project, in fact, was interrupted.
Ah, okay, okay, thank you for...
It's been interrupted since the elections.
Okay.
So, you also referred to the parents there.
Don't you think there's a certain generalized tendency,
mainly on the side of the pople who are part of the educational system, and even some psychologists,
to blame the parents
for behaviors from the children people don't like, let's say?
Yes, it's scapegoating.
And, you're really, this happens even in the health system.
You blame the father for being mad. You blame the father for being drunk. You blame the mother for being mad. You blame the mother because she's sleeping around with everyone, and doesn't care about the kids.
The child is this way because...
Sometimes, it seems that we're back to the Stone Age.
It's unbelievable.
Instead of using our reason to
notice that there's a dysfunction here. This person...let's see what kind of help to give people.
To solve this problem, and to help the child.
Okay, that's a good way to make diagnoses.
It's a good path.
And to make a good assessment.
But now, this, and it happens a lot in schools,
if the child behaves badly, it's because the parents don't educate her.
But people have to make an effort
to try to be less
narrow-minded.
And to try to really understand what's happening. Okay, this
if this child behaves like this, what's happening in that family that renders it more difficult for the child to adapt?
To be able to learn, etc.
And where can we facilitate this child's learning.
Those are good questions. Those are constructive questions, and that help people. The other ones
only discriminate, don't explain anything, and have no value whatsoever.
"The child is like this, because the father is mad."
Right.
But, unfortunately, you're absolutely right, and that happens a lot.
For example,
I recall from last year, in Sintra, about psychiatric healthcare,
we gave support to the family
not only through weekly psychotherapy to support the family,
for the project working in schools, and to try to facilitate the communication bertween the parents and the teachers, which was sometimes on a daily basis.
To help the child.
And, what did we do?
For example, a mother who was a victim of domestic violence
not only got psychotherapy, but
we also gave her support here, and there, judicial support, etc.
So,
in order to solve a child's issue, sometimes we have to go a long way. We have to support the person
the mother, in this case, has to be supported to try to find a way of sustaining herself.
A job.
So, mental health is not this. The idea of a psychologist in the school is very dubious. And then, there's another problem.
Just to end this.
Time.
Time doesn't help.
Time is essential in disorders...
in impulsivity disorders, and ADHD.
Why?
The longer you go without doing anything,
the more molded and restructured is the child's brain
to react. From the lymbic system, that is
from impulsivity to the way of thinking.
To react this way.
And then a year has gone by, two years have gone by...
and the child is already depressed, in the family as well. Divorce, etc.
Because, unfortunately,
there's no sense of urgency.
In these pathologies.
Many times, we just wait to see what happens.
Best wishes. Best wishes is the same as going to church and to pray, "Change this, please".
Exactly right.
And just to avoid ending the interview without people understanding this issue a bit better.
And since you're a pychoanalyst, and you do work in psychoanalysis,
people still have a tendecy to associate psychoanalysis with what it was traditionally, and with people like Freud, Jung, and so on.
Could you explain briefly what modern psychoanalysis incorporates now, and that renders it different from what it was 100 years ago, for example?
Yes.
First of all, I want to make it clear that I have nothing to do with it.
With psychoanalysis.
I really do psychoanalytical psychotherapy.
I'm no longer sure if that's really what I do, because I include everything that's necessary.
But at least my way of thinking is psychodynamic, yes.
Let's see. Psychoanalysis was born in a time
where, for its time,
it was a very important discovery.
Discovering the unconscious.
It's not really a discovery, because 2000 years before the greeks already talked about it.
But, at least, the perception of the unconscious,
of the structures of personality, like the ego, the superego, etc.
and a component of things associated with
the world, and the relations between people.
And neuroses, and psychoses. Even though
psychoanalysis explains nothing about psychosis.
Biological psychiatry is the one that can really explain something. The rest is nothing more than theories, and opinions.
Now, it changed a lot.
And it had to change, otherwise it would have died.
In a way, psychoanalysis
and we have to be critical
of our occupations.
To separate the wheat from the chaff.
The problem with it, is that it was too philosophical.
It was too based on what Freud said. On what Klein said. On what Jung said.
It were 4 or 5 people thinking for a million.
This is terrible, at the very least.
Now,
I'm going to give you an example. In 1985,
the International Neuropsychoanalysis Societywas born.
Psychoanalysis had to join the neurosciences,
neurobiology,
biological psychiatry,
otherwise it would have died.
Not only would it be ridiculous,
in terms of knowledge,
biologically,
but, as a method,
to try to help people, it's tasteless, it doesn't make sense
for someone to go 4 or 5 times
a week to a psychoanalyst for 15 years.
And they don't even know why they keep going there. It's just a habit.
So,
all of this is a cliché. But psychoanalysis had one thing. In my opinion, when I was a student
I would say that
in the world of psychiatry and psychology, psychoanalysis would be at this level,
and the rest would be here.
And it was still very big, and important, and so on.
And psychiatry still
was dominated, to a certain degree, by psychoanalysis.
But less and less.
Now, it's a bit more.
But it's not psychoanalysis, but rather psychodynamics.
Because psychoanalysis, Freud's theories,
they were centered arround impulses, and not relational.
And he created excellent theories, but also others that were extremely dubious.
Which is normal, because we're talking about a time where people still did bloddlettings to cure people.
Psychoanalysis took some time to develop. For example, in terms of neurdevelopment, in autism,
psychoanalysis explains absolutely nothing about autism.
And, in the 70's, psychoanalysis still blamed mothers
for autism in children.
This doesn't make any sense. But then as science developed,
somethign very interesting happens, in certain psychoanalytical domains.
Science develops, and certain circuits
with research, and so on. And there are circuits where psychoanalysts get together, and think that
it might not be the way they thought.
As if their opinion counted for anything in termos of criteria.
This doesn't exist.
But some very intelligent psychoanalysts
understood that, either psychoanalysis allied itself with science,
with medicine,
I don't even like to use the name "integrative medicine", because alternative medicine comes immediately to mind.
With biological psychiatry.
With neurobiology, etc.
With neuroscience, etc.
Otherwise, it would have died then and there.
And today,
there's something I really like. There's a phenomenon
that is that, more and more, language is less psychoanalytical, as it used to be.
When I studied it,
only people who studied it understood that language,
and other people thought we were all mad people.
Talking about...
penises, and things like that.
Things that don't matter at all.
And today, the language is different.
We talk about the lymbic system.
We talk about
epigenetics, in terms of its capacity to emotionally regulate the relationship between mother and child.
So,
I think that the salvation of psychotherapy,
not only because it works,
is for it to have adapted
to the development of science.
That was really important. And I hope that it gets even more important.
We don't need the jargon. We only need to be able to help people.
Exactly. Very well. So,
and just before we end, again,
for everyone to see it, the book, "A vida é um sopro" [Life is a Breath].
I really liked it. And thank you for having sent it to me, and for the dedication.
It's a very easy read.
The first part, the story of Lisa and Peter. The second part, the conversation with Prof. António Coimbra de Matos.
So, Miguel, thank you a lot for having accepted my invitation, and for being on the show.
And keep uo with the good work. I really think what you're doing is very useful for society.
Thank you for your kind words.
And it's already time for me to go.
That's why I wanted to end it here. So, take care, and thank you again.
I thank you.
