Unlikely Bedfellows: Neuroscience and Family Therapy

by Marilyn Wedge, Ph.D.


  Many parents come into my office already having a diagnosis for their child firmly planted in their heads. “My son has ADHD” is a refrain I hear all too frequently. Equally often, I hear a mother say: “I was reading an article in a magazine on childhood depression, and my daughter has all the signs. I think she’s clinically depressed.”

     In our society, diagnosing mental disorders in children has become an acceptable, even fashionable, way of categorizing sad or angry or inattentive kids. If we pause for a moment and ask ourselves why parents so readily embrace these diagnoses for their youngsters, one answer immediately jumps to mind. A diagnosis of mental illness shifts responsibility for a child’s troubling behavior away from parents. Parents cannot be blamed for their child’s ADHD or clinical depression or oppositional defiant disorder any more than they can be blamed for their child’s diabetes or asthma or any other medical condition. Biological psychiatry has banished all trace of Freudian parent-blaming.

Because we are a pill-taking society, it is socially acceptable to give a child a pill to ease her suffering: a pill for school problems, a pill for sadness or moodiness, even a pill for temper tantrums. In an effort not to blame parents, we see these difficulties as problems inside our children’s biological make-ups, rather than the result of the child’s social environment. It’s nature at fault, not nurture. It’s the wiring of the kid’s brain gone askew or a “chemical imbalance” (although the exact chemicals involved in these maladies still remain a mystery). Even a child as young as three years old can be diagnosed with a serious mental illness.

     This biological point of view, so prominent in the past three decades, now seems to be at odds with the latest advances in neuroscience; for neuroscientists are telling us that we must look to nurture as well as nature to understand a child’s difficulties. The wiring of a child’s brain, neuroscientists argue, is structured in large part by the child’s nurturing environment. If a child’s family environment is disrespectful or stressful, this factor actually impacts the neural wiring of the child’s brain. In a fascinating article in the January 5, 2011 issue of the Huffington Post, neuroscientist Dr. Douglas Fields tells us that environmental stress is actually a “neurotoxin”, especially during the development of the brain of a child. Our brains, argues Fields, are not fully formed at birth, but are actually products of “the environment in which we are nurtured during the first two decades of life.” And research shows that harsh words in the parenting environment are as toxic to the brain of a child as harsh blows. If I understand Fields correctly, this means that the child’s social environment can create a biological condition in the child’s brain. Although the child’s problem did not begin as biological, it can become biological.

     But just as a stressful, toxic environment can etch the eminently plastic and shapeable brain of the child, so a positive change in the parenting environment can create healthy changes in the child. If parents change their behavior to become more respectful, their child’s brain can change accordingly. This does not mean that we need to go back to blaming parents. It only means that we must educate and instruct parents as to how to create the nurturing environment that will produce a healthy brain in their child.

     All of this neuroscience becomes especially relevant to the family therapist, who must strike a delicate balance between changing a stressful family situation without placing blame on parents. In practice, this is not as difficult as it sounds. Every family therapist is aware that in order to help a child, the therapist must have a good relationship with the parents, while at the same time changing parental behaviors that are toxic and cause the child to feel unhappy or misbehave.

     A few weeks ago, I met for the first time with a twelve-year-old boy named Howie (not his real name) and his parents Belinda and Victor. Howie had been refusing to go to school for several months. He was recently diagnosed with ADHD–which has become a catch-all diagnosis for any kind of school problem–and was taking stimulant medication. After two months, the medication still was not helping. Howie still refused to go to school. A half hour conversation with Howie’s parents revealed a significant problem in his family environment: Howie and his father had come to blows one day, after Howie refused to do his homework. In daily power struggles, Victor often yelled at Howie to get him to do his chores around the house or do his homework. The parents also argued about how to discipline Howie. These stressors in Howie’s environment seemed to be a much more significant factor in his refusal to go to school than any purported biological condition. Healing the relationship with his father, I believed, would help Howie more than any bottle of pills.

     Without heaping blame or shame on Victor, who already felt terrible about hitting and yelling at his son, I suggested some strategies to heal the relationship. I earnestly told Victor that every parent “loses it” occasionally, and the important thing was to apologize to Howie. Victor apologized right there in the session. In a session with the parents alone later in the week, I asked Victor to tell Howie two good things about himself every day, and to take Howie out for an enjoyable activity on the weekend. Victor readily agreed to this. I also told Belinda and Victor that together we could figure out an agreement about discipline that would work for both of them. After meeting with the parents for three sessions and having them make changes at home, Howie began going to school.

     If children’s brains are continuously developing in response to the parenting environment, labeling a child with a purportedly biological “mental disorder” and giving him pills doesn’t make any sense. When the child’s social environment changes to become more respectful and thus less toxic to his brain, the child’s mental structure will change accordingly. The recent theories of brain plasticity mean that damage from the nurturing environment–as long as it has not been severe and chronic-can be reversed with the help of the correct family interventions. Family therapists have known this for years. Now neuroscientists are providing us with a scientific underpinning for just how this occurs.

Web Source: http://www.psychologytoday.com/blog/suffer-the-children/201101/unlikely-bedfellows-neuroscience-and-family-therapy

How Cool Is Your Sleep?

by Rubin Naiman, Ph.D.


When I was a little boy and happened not to be feeling well, my mother would routinely ask me three questions. Having grown up in an old-world village, she clung to simpler, traditional views of health, including her folksy health assessment.

Her first question was always: “What did you eat?”

Today, more than ever, we are aware of the impact our diets have upon our health. Despite this, much of the modern world remains overfed, yet simultaneously undernourished. We simply consume too many empty, high-glycemic calories that provide quick energy, but limited nutrition. Such eating habits have been strongly linked to chronic inflammation — the most overlooked issue in our disturbed sleep epidemic.

Inflammation is hot. Chronic inflammation has emerged as a critical factor underlying most major illnesses from diabetes to cardiovascular disease and autoimmune disorders to depression. It refers to a subtle cellular smoldering caused by a confused and overactive immune system that is actually attacking its own host. This “friendly fire” results in a slight but clinically significant increase in body temperature that can impede sleep.

Chronic inflammation is not just about poor food choices; it’s about a widespread practice of consuming excessive energy. If we broaden our perspective, it becomes evident that in addition to food, we also “consume” light, oxygen, and information — all powerful sources of energy. And in today’s world, all are consumed in excess.

We are unquestionably overexposed to light at night. This not only energizes us, but also results in the suppression of melatonin, a neurohormone that both reduces inflammation and promotes sleep. Some specialists are now raising interesting concerns that we also over-breathe, consuming excessive oxygen that energizes us, but also contributes to inflammation. And who would argue with the fact that we are all inundated with excessive amounts of information? The over-consumption of information results in a unique kind of stress — a form of mental indigestion that can also contribute to inflammation.

The earth is hot. There is a striking parallel between our personal failure to cool at night and global warming. Satellite images of the Earth at night taken over recent decades reveal that the planet is growing measurably brighter with each passing year. Not long ago, Al Gore suggested that our planet has a fever. Global warming clearly results from the same general pattern of excessive energy consumption that contributes to our personal inflammation.

Consuming energy is, of course, a natural and necessary part of healthy life. Problems arise, however, not only when we consume more than we need, but also more than we are able to release or discharge.

My mother’s second question was: “Did you poop?”

If food might serve as a metaphor for all that we consume, then this question is about what we are, in turn, releasing. As a reflection of a broader, common tendency to hold on, it’s not surprising that constipation is also epidemic in our world. Natural, healthy sleep is about letting go. Letting go of the ways of the waking world — letting go of energy.

Sleep is cool. One of the most important yet overlooked features of sleep is that it is strongly linked to a decrease in body temperature. In fact, we are designed to do exactly what the outside world does when the sun goes down. At nightfall, the Earth releases its energy into the atmosphere, continuously drawing temperatures down until the sun returns at dawn. Likewise, our body temperature gradually decreases through the night, reaching its nadir just before we arise, when it returns to its waking levels. 

Dreaming is the coolest part of sleep. When body temperature hovers near its depths, dreaming reaches its heights. Dreaming involves a kind of psychological cleansing and renovation that supports our emotional and spiritual health. And we dissipate a lot of heat in the process. Unfortunately, the same forces that interfere with healthy sleep impede our dreams, leaving us at least as dream deprived as we are sleep deprived.

Not surprisingly, my mother’s third question was: “How did you sleep?”

Sleep is a kind of nightly energy fast that encourages the dissipation of heat. Could it be that sleep itself is a potent anti-inflammatory? I believe so. Research has confirmed that compromised sleep impairs our immune function and triggers inflammation. Healthy sleep and dreams keep us cool. Minimizing inflammation will improve our sleep, and improving our sleep will minimize inflammation. Here are eight basic suggestions for doing so:

(1) Eat an anti-inflammatory diet — the kind advocated by Dr. Andrew Weil. Consider reducing your caloric intake and increasing fruits, vegetables and sources of omega 3 fatty acids like salmon.

(2) Get adequate daily exercise, which has many important benefits including both improved sleep quality and reduced inflammatory markers. 

(3) Learn to slow your breathing by practicing breathing exercises. The Koran teaches that we are each given a specific number of breaths at birth, suggesting the benefit of slowing our breathing.

(4) Consider an information diet, including a news fast. Instead, enjoy time in nature, a walk or meditate instead.

(5) Cool your body and mind before bed. A warm bath can help drop body temperature. Consider an evening ritual including gentle yoga, as well as relaxation practices such as meditation and breathing exercises.

(6) Optimize your bedroom by keeping it cool, dark and quiet–try 68 degrees or lower (20 degrees Celsius).

(7) Befriend your dreams. Think, speak and write about them. Avoid excessive alcohol and sleeping tablets, which can interfere with dreaming. Remember that good dreaming accompanies good sleep.

(8) Practice letting go — a kind of spiritual cooling. If there is a secret to sleep, it is about learning to surrender our waking ways of being. Incorporate this surrender into personal spiritual, religious or meditation practices you have.

In summary, I am suggesting that we become more mindful of the flow of energy into and out of our lives. Consume less. Let go of more. Be cool.

Web Source: http://www.psychologytoday.com/blog/mindful-sleep-mindful-dreams/201101/how-cool-is-your-sleep-0

The Arizona rampage: Analyzing the analyzers

by Karen Franklin, Ph.D


After every high-profile crime, experts charge out of their corners with their pet solutions: Restrict high-capacity gun magazines. Increase mental health services. Revise school or workplace procedures.

Conservative media psychiatrist Sally Satel is even using the Arizona tragedy as a platform for laws requiring schools and businesses to report to authorities any student or employee who it “ejects or otherwise removes …. out of concern about behavior and dangerousness.” Talk about a civil liberties nightmare!

Memorial crime control

Such opportunistic crime-control advocacy works best during moments of public crisis. When the hysteria reaches critical mass, politicians appease anxious constituencies through yet another feel-good law. Then, the latest crisis dies down and people get back to their normal lives. Watching Fox-TV, they remain blissfully shielded from the dark side of memorial crime control.

Rather than capturing the monsters of the public’s imagination — lunatic rampagers, sexual predators, and homicidal gangsters — this inexorable web of draconian laws ends up ensnaring the most vulnerable, mainly young African American and Latino men from poor communities.

Do you recognize the name Rodrigo Caballero? Unlikely. He is just one tiny speck in a mass of captive and unknown dark bodies, a 16-year-old mentally ill California boy sentenced to 110 years in prison for attempted murder. Any cathartic efforts of memorial crime control are short-lived, while the costly and unanticipated social costs live on. Young Mr. Caballero isn’t due out of prison until 2110, long after he and all of the rest of us will be dead.

No profile of would-be assassins

There will always be the next rare event to fuel this cycle of knee-jerk response, ostensibly aimed at protecting us from every remote contingency.

Hindsight bias is a powerful heuristic that obscures an unfortunate truth: It is very hard to accurately predict — much less prevent — individual-level violence. As I wrote four years ago, after Cho Seung-Hui’s deadly rampage at Virginia Tech:

Many people — and especially many adolescent and young adult men — are troubled. Many are severely depressed. Many express disturbing, violent fantasies. Fortunately, only a tiny fraction commit lethal acts against others. And unfortunately, those who do often do not stand out ahead of time.

This is what forensic psychologist Robert Fein found when he conducted a Secret Service study of all political assassins and would-be assassins in the United States over the past 60 years. Contrary to popular mythology, the assassins fit no singular “profile.” They were neither monsters nor martyrs, Fein said:

The reality of American assassination is much more mundane, more banal, than assassinations depicted [in movies].

The myth of the deranged killer

Jared Loughner’s delusional ramblings, revealed to the world by intrepid Internet sleuths, are the only explanation some people need. But they are something of a red herring.

First, as advocates for the mentally ill are quick to point out, the link between psychosis and violence is far from settled. Most people with severe mental disorders do not become violent. Any increased risk is miniscule compared with the risk posed by use of alcohol or drugs, according to large-scale studies. As Vaughan Bell puts it in his lucid summary of this research:

Psychiatric diagnoses tell us next to nothing about someone’s propensity or motive for violence…. It’s likely that some of the people in your local bar are at greater risk of committing murder than your average person with mental illness.

But even when an assassin does harbor delusional beliefs, this is not sufficient explanation. Loughner’s gender likely played a role, too, as men commit far more violence than women. Yet we would never think we had explained the Tucson rampage with the statement: “Loughner was a man.”

In fact, the Secret Service study found that the assassins who were delusional — about one-fourth of the total — acted out of the types of motivations as non-delusional assassins. As reporter Douglas Fox summarized:

Some hoped to achieve notoriety by killing a well-known person. Others wanted to end their pain by being killed by Secret Service. Still others hoped to avenge a perceived, idiosyncratic grievance unrelated to mainstream politics. Some hoped, unrealistically, to save the country or call attention to a cause. And some hoped to achieve a special relationship with the person they were killing.

Selecting one’s lens: Micro or macro?

In our professional role, forensic psychologists use a micro lens, focusing on the individual level of analysis. But when commentators focus solely on individual-level factors, they divert the public from contextual factors that may be more amenable to prevention.

In other words, at the micro level there is no question that Loughner is a troubled young man. But at the macro level, his choice of targets certainly reflects the political tensions in the United States and especially in Arizona, which even the local sheriff described as a “Mecca for prejudice and bigotry.”

Sarah Palin is able to evade responsibility for her violent rhetoric by strategically refocusing on the culturally entrenched myth of the dangerous schizophrenic, and calling Loughner “deranged” and “evil.”

Ironically, it is the mentally unstable like Loughner who are most vulnerable to extremist rhetoric, and other memes floating around in our cultural ethos. As prominent forensic psychologist and law professor Charles Patrick Ewing noted:

These influential politicians and commentators who use violent rhetoric and images — such as putting a member of Congress in the crosshairs, telling supporters that it is time to ‘reload’ and suggesting that voters unhappy with Congress resort to ‘Second Amendment remedies’ — must realize that they have an incredibly wide audience. At least some members of that audience (both sane and insane) will view their inflammatory statements as an invitation to violence…. The blame for these killings does not lie with the perpetrator alone.”

“Stochastic terrorism” is the term invoked by one professor of communications to describe this phenomenon, of “use of mass communications to stir up random lone wolves to carry out violent or terrorist acts that are statistically predictable but individually unpredictable.”

What if Abdul had done it?

That the micro lens is a deliberate choice becomes clearer if we ask ourselves how media coverage might be different if a Muslim from the Middle East had shot U.S. Rep. Gabrielle Giffords. Would the focus still be on individual pathology? Or would it be on his political affiliations and the content of his rhetoric?

The din of rhetoric about mental illness drowns out the voices of those framing Loughner’s attempted assassination as an act of political terrorism. People like Jesse Muhammed, Sahar Aziz, and Cenk Uygur, who asks incredulously:

Is this a joke? He shot a politician in the head. He called it an “assassination.” What part of that was unclear? … [W]hy does the act have to be either psychotic or political? It’s obviously both…. The conservative hate-mongers don’t create psychos…. [But] they channel their fear, anger and paranoia…. They load them up them up with violent imagery, whether it’s talk of cross-hairs or second amendment remedies or the tree of liberty being refreshed with blood. Then when they get a violent reaction they pretend to be surprised and outraged that anyone would suggest they were the least bit culpable. The reality is that it is a simple formula — violent imagery in, violent results out.

In the final analysis, the causes of violence are multifaceted and difficult to disentangle. And it is impossible to predict which troubled, angry and alienated young man will engage in lethal violence. But one thing is certain: More laws are not the answer. They cast too wide a net, and distract from the search for deeper solutions.

Web Source: http://www.psychologytoday.com/blog/witness/201101/the-arizona-rampage-analyzing-the-analyzers

F.D.A. Sees Promise in Alzheimer’s Imaging Drug

By GINA KOLATA


An advisory committee to the Food and Drug Administration recommended unanimously Thursday that the agency approve the first test — a brain scan — that can show the characteristic plaques of Alzheimer’s disease in the brain of a living person. The approval was contingent on radiologists agreeing on what the scans say and doctors being trained in how to read the scans.

The F.D.A. usually follows advice from its advisory committees, and Alzheimer’s experts anticipated that the scans would be approved. The additional requirement would not be a big hurdle, said Dr. Daniel M. Skovronsky, chief executive of the company, Avid Radiopharmaceuticals, that applied to market the scans.

“We don’t know exactly what F.D.A. will want,” Dr. Skovronsky said. “But it should take months to generate this type of data, not years.”

The committee vote is “a very positive thing,” said Maria Carrillo, senior director of medical and scientific relations for the Alzheimer’s Association. “This is nothing but a positive for our families.”

More than five million Americans have Alzheimer’s disease.

Plaques are part of the criteria for having Alzheimer’s — if a person with memory problems does not have plaques, that person does not have Alzheimer’s. But without the scan, the only way to know if plaques were present is to do an autopsy.

Alzheimer’s specialists said they expected that if the scan were approved it would come into widespread use.

“This is a big deal,” said Dr. Pierre N. Tariot, director of the memory disorders center at the Banner Alzheimer’s Institute in Phoenix. Asked if he would be using the scans, Dr. Tariot replied, “Absolutely.”

Dr. Tariot is an investigator in studies by Avid, now a subsidiary of Eli Lilly & Company, and its competitors.

The approval would be for a dye that homes in on plaque in the brain, making it visible on PET scans. Such scans would be especially valuable in a common and troubling situation — trying to make a diagnosis when it is not clear whether a patient’s memory problems are a result of Alzheimer’s disease or something else. If a scan shows no plaque, the problems are not caused by Alzheimer’s and could be from tiny strokes or other diseases.

If a person has Alzheimer’s, though, there is as yet no treatment that can slow or reverse the disease, although new drugs are being tested that are intended to reduce plaque.

Nonetheless, doctors said, having a diagnosis is important for planning and for understanding what lies ahead. It also is important for family members to know because they are at increased risk if a mother or father, sister or brother has the disease. And people, they say, often want to know what is wrong with them, even when the news is bad.

The panel’s vote “has moved us a monumental step forward,” said Dr. Reisa Sperling, adding that with the scans “we will not just be guessing clinically.”

Dr. Sperling, director of the Center for Alzheimer’s Research and Treatment at Brigham and Women’s Hospital in Boston, is an unpaid consultant to Avid Radiopharmaceuticals, which makes the dye, and said she paid her own way to speak at the F.D.A. meeting in White Oak, Md.

The question about interpreting the scans arose because in the Avid study, radiologists did not establish a firm cutoff point that would say whether a person had significant amounts of plaque. Instead they did a graded analysis. What is needed in practice is a set level that would say yes or no, and distinguish significant plaque accumulation from insignificant amounts. And the company must show that its cutoff points are accurate and that different radiologists assess the same scan in the same way.

Some people have plaque without having Alzheimer’s, so if a scan shows plaque, doctors will have to use their clinical judgment, taking into account a patient’s symptoms, in deciding what the scan results mean, noted Dr. P. Murali Doraiswamy, an Alzheimer’s researcher at Duke University and a clinical investigator in the Avid trial. But if a scan shows no plaque, the situation is simpler, Dr. Doraiswamy said. It means the doctor should focus on other causes for the symptoms.

“This technique will allow family doctors to feel confident ruling out Alzheimer’s,” he said. “Until now we had to guess whether someone had plaques.”

In 2008, an advisory committee to the F.D.A. said that in order for the dye to be approved for amyloid imaging, the company would have to show that the scans were detecting the same plaques as were found on autopsy.

Avid did that, using people at the end of life who agreed to be scanned and then to have brain autopsies. The company also tested young healthy people who, presumably, would not have amyloid plaque in their brains. The scans found no plaque in those younger subjects.

At the meeting Thursday, a parade of medical experts testified about the need for the scans. Dr. Norman Foster, a professor of neurology at the University of Utah, came at his own expense even though he is a consultant to GE Healthcare, which is developing its own brain scan for plaque, to urge approval of the Avid scan.

“Physicians currently have little confidence in their ability to determine the cause of dementia, and as a result they often don’t even try,” Dr. Foster said. As a result, he said, families are left in limbo, unable to plan for the future if it is Alzheimer’s and, if it is not, delaying getting treatment.

“The preventable costs are enormous,” Dr. Foster said. “The emotional toll is incalculable.”

He told of three patients he had seen in the past two weeks who would have benefited from a scan. One is a 70-year-old man with memory problems and depression. He was given a diagnosis of depression, but only after he continued to get worse over two years did it become clear that he most likely had Alzheimer’s.

“I wish I had had the ability to do an amyloid PET scan to allow an earlier diagnosis,” Dr. Foster said. Approval of the scan, he said, “would be a historic advance in neurology and in the daily management of patients with memory complaints.”

With the committee’s vote, Dr. Doraiswamy said, “It’s a landmark day for our field.”

Web Source: http://www.nytimes.com/2011/01/21/health/21alzheimers.html?_r=1&partner=rss&emc=rss

Symbolism Versus Substance

Chris Weigant


The House of Representatives, as expected, just voted to repeal the landmark healthcare law, which President Obama signed less than a year ago. This vote was a symbolic victory for Republicans, but not any sort of substantial change. To truly repeal the law, the Senate would have to also pass the bill the House just passed, and then both houses would have to muster a two-thirds majority vote to overcome Obama’s veto. None of which is going to happen. Democrats still control the Senate, and Harry Reid has all but pronounced the bill “dead on arrival” in his chamber, meaning that today’s House vote is the only victory (and a symbolic one, at that) Republicans should expect in their mad dash to repeal healthcare reform.

Which is probably fine with them. House Republicans know full well that their vote today is nothing more than empty symbolism — but it is important empty symbolism, as far as they’re concerned. The Tea Party Republicans who campaigned on the issue of “Repeal!” have proven their bona fides to their fervent supporters, and now they can throw up their hands and blame the expected inaction on Senate Democrats — thus paying no real political price for spending time on such a Pyrrhic victory. In other words, Republicans in the House have won a single “news cycle” — even though the more honest among them fully admit that the effort is ultimately going nowhere.

The entire exercise is nothing more than “politics for politics’ sake,” really. Which is fine — both political parties do this sort of thing at times, to toss some symbolic red meat to their base. And as political red meat goes, this was the juiciest symbolism Republicans had at their disposal. The last time Republicans engaged in such potent symbolism was when Newt Gingrich took control of the House, and quickly passed all the items on his “Contract With America” — only to see virtually all of the bills screech to a halt in the Senate.

Republicans can bask in this symbolic victory, but when Congress really gets down to business (after next week’s State of the Union speech by President Obama), things are going to get a bit more complicated. The campaign slogan many of these Republicans ran on (in relation to what they called “Obamacare”) was “Repeal and replace.” In other words, throw the whole thing out and then start over and replace it with the wonderfulness of the Republican plan on healthcare reform. The only problem with this scenario (other than the fact that repeal isn’t going anywhere after the bill leaves the House) is that there is no “Republican plan on healthcare.” It doesn’t exist.

This is where the substance comes into things, after the symbolism becomes yesterday’s news. Republicans aren’t just going to pat themselves on the back for their symbolic repeal vote and then move on to other things — they’re going to try to tinker with healthcare all year long, apparently. This action will happen on several fronts. The first of these is using Congress’ traditional “power of the purse” to starve “Obamacare” of the funds it needs. Republicans may try to write into the Health and Human Services budget a ban on using one thin dime to implement the healthcare reform law passed last year. This will likely result in only symbolic victories, since (again) the Senate is going to have its say on the budget, and since many of the provisions of the healthcare reform law aren’t actual budget issues and thus can’t be gotten rid of with the blunt instrument of Congress de-funding them.

The next effort is going to happen (if it does) when Republicans mull over exactly how they want to tinker with the existing law in various House committees. This is where they’re going to have to admit (implicitly, at least) that some of the provisions of the new law are actually quite popular with the public. Now that they’ve made their symbolic point with today’s repeal vote, Republicans will be able to tell Tea Party voters: “We tried to get rid of the whole thing, but now we’re going to have to change it piecemeal.” Conveniently, the pieces that the public likes the most will likely escape such efforts to rewrite the law. About the biggest change that could actually make it through Congress might be getting rid of the individual mandate — which has few defenders, even among Democrats.

Other than repealing the mandate, however, things get complicated awfully fast. It wouldn’t surprise me to see Republicans struggle with exactly what to do on healthcare for months. There’s a reason Democrats took more than a year to hammer something out, and the reason is that there simply aren’t easy answers to the problems in the system. So Republicans are going to spend an awful lot of time figuring out which tactic to try in their overall efforts to get rid of “Obamacare.”

It remains to be seen what the public is going to think about this effort. Polling is pretty evenly split on the Democratic healthcare reform, and it’s probably a safe bet to say that polling will likely be all over the map on the ideas Republicans come up with. But the overarching question will likely not even be asked by the pollsters — at what point does the public begin to wish that Republicans end their “Obamacare” obsession, and get on with some other important business? After all, we’ve spent a goodly portion of the past two years on the healthcare reform debate, and if Republicans decide to devote a lot of time to rehashing the issue for the next two years, at some point the public is going to get a little tired of hearing about the subject (if they’re not already).

This week in the House was set aside for symbolism. The Republicans achieved the symbolic victory they had planned today. Which is all fine and good — as I said, both parties occasionally delve into such blatant political gamesmanship. Congress traditionally doesn’t get much done in January anyway, other than getting sworn in and listening to the State of the Union speech. And now Republicans have their symbolism to talk about next week, after Obama speaks to a joint session of Congress and the country at large. But that will be the only tangible result of today’s action in the House — a talking point for Republicans to use for a while.

In one sense, this week will mark the end of Republicans’ political coyness and over-reliance on symbolism. Because after the president’s speech, they’re going to have to actually put some cards on the table. Substantive cards — not mere symbolism. Republicans are going to have to finally tell the public how exactly they’re going to be cutting spending from the federal budget, instead of blithely insisting that they’ll find enough “waste, fraud, and abuse” to balance the budget in a year or so. They’re going to have to start coming up with actual legislative ideas on the budget, and on healthcare reform, and on a number of other subjects and issues. Up until now, it has been “campaign season,” where politicians can get away with gauzy promises without answering any questions about specifics. This week marks the end of this happy-talk season, and the beginning of the “nuts-and-bolts” season of writing their campaign promises into actual legislation.

So Republicans should enjoy their symbolic moment in the sunshine. It certainly is fun to pass a bill that everyone knows isn’t going any further. But the time for such symbolism is fast drawing to a close. And the substance that follows is not going to be anywhere near as much fun for the Republicans, as they will be forced to present concrete proposals to the public on how to solve the nation’s problems. Republicans should indeed enjoy their symbolic holiday while they can, because what comes next is going to be a lot more real than tossing symbolic red meat to their base.

Web Source: http://www.huffingtonpost.com/chris-weigant/symbolism-versus-substanc_b_811363.html#