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Friday, December 23, 2011

Keys to a Positive Marital Relationship--Understanding the Difference between Arguing and Fighting

Language is a very powerful tool in relationships.  It can hurt; it can heal; it can solve problems. 
It useful to think through how we use language with our partners--to know how we are using it with them and how they are using it with us.  Through such knowledge we have more control over ourselves and more power to improve our relationships. We can mold our  language to be useful and healing rather than hurtful..

Let's look at three of the most important types of language in relationships: problem solving, arguing, and fighting.  These are not the only three ways language can be used, but they are three of the most common forms.  They might be referred to as "the good, the bad, and the ugly."

First, let's consider one of the most important of the positive ways that language is used in relationships--problem solving.  Problem solving can begin with providing information.  One spouse says, "The garage door is broken."  There is not necessarily an explicit call for something to be done here, although that may be implicit.  But this is just mainly providing information.   Asking questions is also important in problem solving.  "Do you know if it is under warranty?" would be an example.  The exchange of information can then be followed by suggesting alternative solutions and discussing the merits of the different possibilities. 

In problem solving, each person is open to hearing good ideas.  There may be disagreement, but each person is listening and considering what the other person has to say.  There is an old saying that two heads are better than one.  If each brain contains four billion neurons, then eight billion nerve cells working on a problem are better than four billion working on it.  But that only happens when we are open to hearing the other person's ideas.  Problem solving is generally positive, helpful, and constructive.  It hurts no one.  It fixes things.  It generally goes more smoothly than the next two forms of communication I am going to discuss.

A second way people relate to each other in difficult situations is arguing.  In arguing, we become angry. We become defensive.  It usually does not fix anything.  It is like two debaters.  They are not going to convince each other.  They are constantly thinking how to outwit the other person and win the debate.  They want to show that their own ideas are correct and superior.  They are figuring out how to create arguments that are more powerful than the arguments of the other person.  Arguing doesn't solve problems. but if it is brief and not prolonged it may not create many lasting problems either.  Arguing creates tension, but if arguing does not occur too much, then the tension usually dissipates. 

When we start arguing, we need to become aware that that is exactly what has happened.  Nothing productive is going to come of it because we are determined not to lose.  We are not interested in the truth because we think that we already know the truth.  We are not interested in the best problem solution, if it is different than what we already think it should be.  We want to win because we know we are right.  Our ears are stopped up, so to speak.  Nothing good comes of it, unless one or both parties shift back into a problem solving stance.

A third way of interacting in problem situations is fighting.  In my way of thinking, I make a strong distinction between arguing and fighting.  This may just be a definition, but I think that it is a very important distinction.  The difference between the two is the main reason I decided to write this post.  The way that I am using the term "fighting" here is that it involves intentionally hurting the other person emotionally or physically.  Fighting goes beyond arguing.  In arguing we may hurt the other person, but if so it is unintentional.  In fighting, we want to hurt the other person.  We curse; we push; we throw things; we hit.  We dredge up things out of the past which can be used to make the other person feel bad.  Fighting doesn't solve problems.  It creates problems.

Of course, there are many other types of communication--playful, sarcastic, nurturing, emotive, and so on.  Some of these have an important role to play in relationships; some don't.  But the point I would like to make in this post is the importance of being aware of where you are in the problem solving/arguing/fighting cycle. 

The cycle can be thought of vertically.
We may start by problem solving. (Some couples skip this stage.)
Then we may devolve into arguing. 
Then we may devolve into fighting.

By trying to stay focused on the problem solving stage of an argument, we may prevent some types of misunderstandings.  For example, sometimes a partner may mistake the other person asking for information as being sarcastic, commanding, or aggressive. I think most couples have at one point time or another misunderstood the intent of the other: "Have you taken out the trash yet?" can be misinterpreted as, "WELL, HAVE YOU GOTTEN OFF YOUR BUTT AND TAKEN OUT THE TRASH YET?" As Freud said, sometimes a cigar is just a cigar. And sometimes a spouse's question is only a question and not a command or criticism.  By trying to stay in the problem solving mode, some of this can be avoided.

More importantly, by avoiding the fighting phase and staying as much as possible in the problem solving phase (with a unavoidable detour now and then into the useless arguing phase) we can keep from hurting our spouses and improve the overall health of our relationships.

Monday, December 12, 2011

On Forgiveness

Psychologists are increasingly looking at the importance of forgiveness in mental health.  It appears to have a positive impact on both physical and mental health.

What does forgiveness mean? The current research focuses on two types of forgiveness: the behavioral decision to forgive, and emotional forgiveness. We can decide not to do anything against someone (decisional forgiveness), and we can also emotionally let go of hard feelings (emotional forgiveness). In my way of thinking, forgiving means that we no longer are blowing on the embers of out anger towards someone. Moreover, when we forgive, we no longer want any retribution against them.  We not only decide that we are not going to retaliate against them, we also quit wishing them any bad luck or misfortune.  If we have really forgiven, we are free to wish good things to happen to them. That can be a very liberating freedom.  But forgiveness does not mean that we take someone back as our best friend and tell them our secrets.  It does not mean that we loan them money when they have proven to be untrustworthy in the past.  We do not forget in that sense.

In some ways, forgetting is impossible.  Our brains won't let us simply wipe events from our memories.  Consider the following example:
     Don't think about an elephant.
     Please, don't think about an elephant.
     Really!!! Don't think about an elephant!!!
And, of course, what do we do?  We think about an elephant.

But emotionally, we can do something similar to forgetting.  In forgiving, we let go of the energy and the attentional focus we are putting into a grudge.  Active forgetting may be impossible, but we can passively let our minds allow the offense to slide into the past, where it is remembered less and less.  The opposite of forgetting is to rehearse something.  We blow on the dying embers of a flame of anger to keep it alive.  When we hold a grudge, we want to make sure that we keep thinking about it.  Not rehearsing a grievance is possible.  We can be determined not to blow on the embers of a grievance just as we could choose not to blow on the red hot coals of a fire to keep it alive. 

What we can do is let the whole event drift away from us. It is like being on a boat in the middle of the lake.  We place something which floats into the water--a leaf, a toy boat, a piece of paper.  We can try to push it away, but it will only go so far when we push it.  But we can choose to let it drift away over time.  On the other hand, we can choose not to let it drift away; we can reach out and try to keep it near to us.  It's our choice--let it drift away or keep it near.

And that is how our mind works.  I know my mind does.  If I don't rehearse something, I tend to think of it less and less.  It is a positive aspect of the way that our brains work that we have the capacity for emotions to die down and slip into the past.

Her is another issue.  Can we--should we--avoid the person thereafter?  There is a great scene from the musical Fiddler in the Roof.  A man approaches the rabbi of a small Russian village.  He asks, "Rabbi, is there is a blessing for the czar?

"A blessing for the czar?" the Rabbi echoes.  "May God bless the czar and keep the czar, far away from us."

So maybe instead of the phrase "forgive and forget," we could use the phrase "forgive, let go, and avoid."  Maybe  avoidance is the wrong word here; it does sound kind of harsh.  But I am not sure what the right one would be.  As the rabbi said, "May God bless the Czar and keep the Czar--far away from us."  There is no sense continuing to expose ourselves to possible harm.

But let's end on a positive note.  When we forgive someone, we are free to wish them good and positive things in their life.  I don't necessarily mean mean money, or winning the lottery, or fame.  "Good things" are all in how you define them.  If someone has offended me, then when I forgive them, the good things I wish for them are happiness, good character, harmonious family relationships, and so on.  All of these are much more satisfying to most people than money--at least that's what I think the psychological research indicates.  This attitude of not carrying a grudge can free us up and be quite liberating.  It costs us nothing but can make our lives freer and happier.

Thursday, December 08, 2011

How Do You Use Your Power?

People have a variety of reactions to the word "power."  Some want it and crave it.  Others try to be "nice" to the point that they seem to be trying to avoid exerting any power.  Some believe that that they don't have any power.

But power comes with being human.  Perhaps not the Donald Trump kind of power.  But there is always power to be constructive or damaging towards those around us.  There is always power to have a positive or negative impact on the people.

It may be true that as we get older our power wanes, but we still have some until we can no longer speak and/or move.  We still have the power to curse or to bless by our words and actions.  (I can tell you that doing testing on geriatric wards in the hospital, I have been cussed out a few times.  I have also had times that were truly delightful working with elderly patients.  Our power to bless or to curse remains until the very end.)

As children we discover that we have power, even before we understand the meaning of the word.  We can taunt or tease others and hurt their feelings.  I remember once as a child that I called a child "Pat, the Brat."  It was a taunt based on a comic cartoon strip.  It hurt his feelings, and I just kept saying it that day because I found it had an effect on him.  Without knowing what I was doing, I was finding that I had the power to hurt someone's feelings.  I liked it.  Fortunately, hurting others was not a major temptation of mine, and I generally chose not to use my power to hurt people's feelings after that.  Young boys tend to be fascinated by the power of fireworks, and they may go through phases of trying to blow things up.  In the worst case scenarios they use the power of the fireworks to hurt animals or people.

Children need to be taught to use their power and to use it for good.  I remember a conversation I had with one of my sons when he was in elementary school. I told him to make sure that he used his influence to make others around him feel good--not to feel bad.

Now the example of me calling a kid "Pat the Brat" was a trivial example, but we all know that our forays into using our power may start small but end up in adulthood in much more important, powerful ways of hurting people.  The power to hurt people in really bad ways generally comes later on in our lives.

Then, on the other hand, there is the "myth" of the nice person.  Some people believe that power is a bad thing and that they should always be nice, never offending.  They believe that they can be a better person by NOT being powerful.  That is wrongheaded.  The point of life is not to be "nice" to the point of avoiding power.  The point is to use power for beneficial purposes, to build people up rather than putting them down.  It is not loving to be powerless.  It is loving to use your power in beneficial ways.

Even Gandhi and Jesus exerted power, but it was different.  We normally think of them as "meek and mild."  After all, didn't Jesus say to "turn the other cheek"?  Wasn't Gandhi a believer in non-violence?  However, they used non-violence as a specific type of power.

Jesus said to turn the other cheek.  But this was actually not teaching people to be passive.  It was actually teaching them a form of active expression of power but in a paradoxical way.  It would show love but with great restraint.  When Gandhi started his protest movements, he was out to hurt no one.  But he was also intending to bring down an empire.

So I believe it is important for us to accept the fact that we do have power.  Then we can spend a lifetime honing it so that it blesses rather than harms those around us.

Sunday, December 04, 2011

A Theory of Life

As I work with patients, I often am confronted with horrible stories of childhoods of neglect and abuse.  The level of suffering that some of my patients have gone through as children leaves me wondering about the meaning of life.  After all, finding meaning in the midst of pain is one of the ways that people attempt to cope with life's difficulties.  Is life just a Woody Allen movie, searching for meaning but never finding it?  We live, we feel pain, we have a few laughs, and then we die, and that's it?

Well, no.  I don't believe that.

My clients come from a variety of religious and philosophical belief systems, and I try to work within a philosophical framework which makes sense to as many of them as possible.  I believe that life does have meaning and purpose.  Many of my patients also believe that, or at least hope that it is true.

My view is based on a belief that no matter how terrible a client's life has been, there is a point and a purpose to their living.  I do not believe that life is just random suffering.

And so my theory helps me to think of each life, and each person's suffering, from a perspective which attempts to be both psychological and spiritual at the same time.  Sometimes I share this idea with my clients, and sometimes they find it useful.

So, what is my theory?

First, we are born.  So far, so good.  Everybody can agree with that part of my theory.  Existential philosophers talk about our "thrownness."  We are "thrown" onto the stage of life.  We cannot choose to whom we or born, in what time era we live in, or in which culture we will live.  No matter what our belief system, I believe that we can agree that the infant or child is in a sense tossed onto the stage of life.  They are somewhat bewildered, at least about some things.  They don't have a rule book.  Or more accurately, they are given a rule book by their culture.  But the rule book of the family and of the culture they live in is often full of mistakes, and they don't have a perfect one to correct the one that they have been given.  They have to figure out for themselves a better way of living.

For some people, traumas and problems start very quickly. They might have a deformity.  They might have physical pain.  They might begin life addicted to drugs because their mother was on drugs during the pregnancy.  They might be born into an abusive family, or have a mother who is emotionally withdrawn because of post partum depression.  And so on. 

Almost all of us experience some form of problem or dilemma in our childhood.  At least most of us do.  Maybe all of us do.  The dilemma may be obvious, such as sexual abuse, or having a deformity, or being an unwanted child.  Or the dilemma may be subtle, such as having everything handed to us on a silver platter.  (How is this a dilemma?  I think that having things too easy creates difficulties for people later on in life.)  I'm not sure that anyone makes it through childhood without some kind of a dilemma.  Maybe they do, but I've not met that person yet.

We are immersed in the dilemma.  We are totally unprepared for it.  We don't even know that we are in a dilemma, but we experience the negative effects of it.  As a child we generally blame ourselves for the problems we experience.  We are immersed in them.  But we don't understand them.  We experience the fear of abuse or the uncertainty of war or the pain of hunger.  We don't know that we are innocent.  We are innocent, but we don't know it.  We are victims.

As the child grows older, their ability to think logically and abstractly gives them the ability to think more abstractly.  They no longer blame ourselves for everything that happens to them.  They start to blame their parents and other people (and sometimes rightly so) for what has happened to them.  If they are being abused, they may start to realize that what is happening is the abuser's fault, not theirs.

They may start to rebel or withdraw from the problem.  They may run away from home; or maybe they get pregnant or married in order to leave home..  They are sick and tired of being treated the way they have been.  They rebel.  They fight with their parents. Or they use drugs to try to make the problem go away.  They try to escape the pain.

But all too often, whatever their form of escape, the teenager has not actually escaped the problem.  They have internalized it. They thought they had gotten away from it; but they hadn't.  If they were abused by an alcoholic father, they may have picked an alcoholic husband to "act out" the problem over and over again--perhaps choosing several alcoholic husbands.  Women who have been sexually abused sometimes become promiscuous.  And sometimes they totally lose interest in sex.  They have not escaped the sexual problem.  They are only acting it out in various ways.

Next in life's sequence of events, the person's brain reaches maturity.  The frontal lobes reach maturity around age 25 (or later).  The frontal lobes give the person the ability to think and to act in fully mature ways.  The person has the ability to see their problems from a new perspective.

And at age 30, I think we may perhaps grow up in a different way.  The brain has theoretically matured by 25 or so, but at 30 I think that we may start to realize that things are not magically going to "just get better" by getting older.  We realize that if things are going to change (i.e., not being abused by alcoholic husbands) we are going to have to start making different decisions and doing things differently.

We can then use our mature brain and our emotional maturity to break free of the cycle of acting out the internalized dilemma.  We can opt out of the old dysfunctional cycles.  We can quit doing what we were doing, which was thinking we were escaping the dilemma when we were actually perpetuating it. 

And if we realize what we are doing, why we are doing it, and then stop acting out the dilemma then we have OVERCOME the dilemma. 

We gain wisdom from overcoming the dilemma.  Whenever we overcome a dilemma by refusing to act it out anymore, we have gained a type of knowledge that can be described as wisdom.  It is existential wisdom.  It cannot be learned out of a book, and to some degree it is unique to us and no one else.  Your wisdom is different from my wisdom, even if we went through somewhat similar dilemmas.  The dilemmas were never exactly the same, and so our wisdom can never be exactly the same.

And wisdom may just be the point of life.  Not just happiness.  Not wealth.  Not fame.  But deep understanding and mastery--existential wisdom learned the hard way that means that a particular dilemma will never again have control over us.

Now as we get older, we start to become less flexible in our thinking.  And if we live long enough, we are all likely to develop some form of dementia, such as Alzheimer's.  At that point, our ability to overcome our dilemma is lost.  We no longer have the self-awareness, the abstract thinking, the flexibility of personality, and the decision making power to overcome such powerful issues.  Probably we are best equipped to overcome dilemmas from the ages of 30 to 65.  That does not mean that we cannot do it before or after that time period, but the likelihood of doing so decreases in our later years.

Now, this theory of life is inadequate in some ways.  Notice that it does not really mention the importance of relationships, having children, spirituality, love, creativity, giving, and so on.  All of these could be fit into my theory, but each of these could be a theory of life in its own right.

My theory also does not take into account dilemmas that crop up in the middle of life rather than childhood (such as war, a severe car accident, death of a child, etc.). 

And it leaves open the question of what the meaning of life is when someone does not overcome their dilemma.  What if they are simply broken by the dilemma rather than overcoming it?

But the theory does, I believe, get at one very important issue.  If life is not random, and if it is more than a cruel joke, then there is a purpose.  And I think that the purpose of life if to learn and to love--to be people  of beauty and character--despite our dilemmas.  And that leads to wisdom.

Thursday, December 01, 2011

A New Kind of Contest

As a psychologist who has concerns about the state of the world and humankind (and who doesn't?), I am aware that one thing which will be needed in the future will be a greater level of cooperation between people.

Cooperation always exists in a tension with competition.  I doubt if that will ever change.  Competition has always been around, and I think it is built into us.  At the same time, the world's survival may also depend on cooperation as much or more than our competitive drive.

One way that we train out children in both cooperation and competition is through sports.  Sports almost always involves competition.  But it always involves cooperation as well.  Only the football team on which players cooperate well has a chance of winning.  Even two tennis players competing with each other have to at least agree on a set of rules and cooperate in the sense of abiding by the rules.  Without that type of cooperation, there could be no game, no fun, and no sense of accomplishment.

But I would suggest that there is a type of competition which could be an even better experience for our children, teaching them to cooperate through competition.  Here is my idea. 

This could be easily be done with elementary schools, high schools or colleges.  It would not have to do with sports but with any activity that requires problem solving and creativity.  Let' say that the contest subject matter is not a sporting event but more like a science fair competition, or a contest of technological innovation.  A pair of teams would be given a goal to achieve, such as building a better mousetrap (or a computer, or a robot, whatever).  They might be a given assortment of materials or tools to use.

Then let's say that the "league" of teams consists of eight school teams.  Each competition date links up two teams together.  (So, for example, in a league of eight teams, there would be four pairs of teams on any given day of competition.)  The two teams linked together on that day then work together towards the goal.  All of the four pairs of teams would have their outcome judged by a single set of judges and given scores.  There would be four scores each week.  Each team would make the same score as the team they were paired with for the week (eight scores but only four different scores.)

Each week, a team would be paired up with a different team, so that by the end of the "season," they would have been paired up with each of the other teams in the "league."  (Seven overall contests in this example.)  The team that would win would be the one with the highest score at the end of the season.  Thus, there would still be competition.  All eight teams would end up with different scores; but in the process, each team would have to learn how to cooperate with another team every week.  Only through such cooperation could they obtain the highest score at the end.  If they failed to cooperate and to use the best skills of the other team, then they will not score well.  Each day of competition would require that they look for, understand, appreciate, and utilize the strengths of the other team members to the maximum extent possible.

Maybe this is already being done somewhere.  If not, I would like to see it tried.  I think that it could be very interesting and that it could train very prosocial values important to our national and global existence.

Wednesday, November 30, 2011

Unbelievable! One More Note on the Overuse of of Psychiatric Medications

I just had to write one more post regarding psychiatric medications. 

Last night I was watching TV and saw a commercial for Abilify.  This is a neuroleptic medication being used as a supplement for antidepressants by physicians in the treatment of depression.  This combination has been used for several years now.

My objection is not to the use of the combination by a trained professional.  My objection is to the direct marketing of the combination--the so called "drug cocktail"--to the American people.  Do we really want to be sending this message out to America?  The message is no longer simply that "You may need an antidepressant to help you out of your depression."   The message is now, "You may need two (or even more) drugs to help you out of your depression."  I put part of that sentence in parentheses because I believe that there is an implicit idea here.  If two medications may be needed, then isn't there an underlying implication that three or four may be needed?

Let's imagine the TV commercials of the future.

"Have you been taking three or more psychiatric drugs and still feeling depressed?  Has the combination of methylphenidate, Zoloft, and Provigil left you listless and unsatisfied?  Scientists have now found that the addition of one more medication--Prohazard--helps many whose depression was not responding to only three drugs.  With the addition of a fourth--Prohazard, you may be able to feel zest and happiness in your life again."

While the above commercial seems laughable, what is unbelievable today is the fact of tomorrow.  What is outrageous today may be commonplace and taken for granted tomorrow.  Where do we draw the line in the marketing of pharmaceuticals as a necessity of life?  When do we wake up as a society and realize that we are giving exactly the wrong message to our citizens?  While pharmacotherapy may be needed now and then, the main message that we need to be sending to the populace is that there are a variety of ways of coping with stress and that medication is only one of these.  Psychological coping skills offer a way of being calmer and more self-reliant.  For most people, medication is not the first option that needs to be considered. 

Now readers of my blog know that I am not against pharmacotherapy for psychological problems.  However, I am against the direct marketing of drug cocktails to our citizenry.  The basic message is this, "You are so flawed and so helpless in the face of emotional distress that you need one or even several medications to make you right."  This is a message which saps the very fiber of the American people.  You need this.  You need that.  You are unable on your own to cope.

If a psychiatrist believes a patient is in need of more than one medication (and they often do), then I will leave that to their discretion.  But what are we teaching ourselves and our children with these TV commercials?

Saturday, November 19, 2011

Some Final Notes Regarding the Book Anatomy of an Epidemic

Some final thoughts on the use of psychiatric medications.

--There is no doubt that many people need psychiatric medication.  Their depression, psychosis, or anxiety is so severe that it disables them.  And they need treatment--NOW.  People have to get back to work.  They have to pay the mortgage. Children may have misbehaved so badly due to ADHD that if they do not quickly change they will be expelled from school.  Parents may need to quickly calm their explosiveness so as to not emotionally injure their children.  Persons with a severe case of mental disorder may be so sabotaging their life that to wait for long term improvement with counseling or psychotherapy is not feasible, even if long term counseling or psychotherapy is the better treatment in the long run. 

--But troubling issues remain.  How do we know that psychiatric medications are safe and efficacious over the long run, when they are taken for years or decades?  I do not believe that there is data to support this.

--I wonder if all of the relevant research on this issue has been published.  Has any been withheld?  It is generally known that journals will generally not print studies which show that no significant experimental effects have occurred.  So if a long term study existed that did not show a beneficial effect of medication over placebo, would it be printed?  One important study, the Harrow study*, apparently was turned down by American psychiatric journals.  Was it because they considered it poor science?  Or because the results went against the grain of accepted psychiatric beliefs?

--Long term effects are hard to research.  It is hard to conduct a randomized study for more than a few months.  People don't want to abide by a tightly controlled treatment regimen.  People on medications during the acute phase of a study may, in the followup phase, want to start psychotherapy or may want to be on no treatment at all.  People who have been treated with psychotherapy may want to start medication.  And when people do change their treatment, it is not random.  They may get off of medications because the medications have made them feel better or made them feel worse.  All of this makes controlled comparisons over the long term very difficult indeed.  (Hopefully, some very bright researchers will find a way around these problems.)

--If science is providing better and better treatments, then why are rates of mental illness going up rather than down?  Why are rates of bipolar disorder going up?  The increase in the use of antidepressants and mood stabilizers has been suggested as one possible explanation of increasing chronicity.  But very long term trends are difficult to interpret.  There are concurrent, ongoing social changes which confound easy analysis.  There are changes in the public's use of street drugs, changes in the welfare system that reimburse people who are mentally ill, changed attitudes about reporting symptoms that make people more open about talking about their difficulties, changes in the diagnostic criteria, and changes in the social fabric and social support available to persons.  The increasing stresses of modern society also cannot be overlooked as the possible culprit causing a long term trend causing elevations in some psychiatric diagnoses.

--Is there a conspiracy to get people to take drugs that they don't need?  Hardly. Is there an economic system which rewards doctors and pharmaceutical companies for treating mental illness with psychotherapy?  Absolutely.  There is no way to get around the fact that a decreased use of psychiatric medications would severely impact the viability of both psychiatry and much of the pharmaceutical industry.  It is a merry round which it would be difficult for them to get off. 

--There is no doubt that there are clearly biological foundations for many mental disorders.  The research is voluminous.  I believe it is incontrovertible.  Many mental disorders have biological correlates.  Period.  But that does not necessarily mean that in all cases, these disorders will respond best to a biologically oriented treatment.  It is still theoretically possible that the body remains the best healer, or that psychotherapy is the best approach.  (Psychotherapy can be conceptualized as clearing away obstacles which would inhibit the body from healing itself.)

--Some psychologists and mental health professionals would argue that psychological avoidance is the source of many if not most mental health problems--avoidance of internal thoughts and feelings, and avoidance of dealing with problems.  Are we as a society encouraging avoidance by advocating the widespread use of medication?  And in so doing, are we thus actually making psychological problems worse?  Iatrogenesis is the causing of problems through medical treatment.  Is that occurring here with an over reliance on psychiatric drugs?  If there are natural healing forces in the brain, are the biological treatments we are using helping or hindering them?

--On the other hand, if everyone suddenly went off all psychiatric drugs, would there be enough counselors to deal with the number of patients?

--In the long run the scientific method will correct any current fallacies.  Science tends to correct itself.  However, in the short run, journal editorial decisions, and grant funding decisions at a federal level could impede some of data which is negative about pharmacotherapy from being collected or published.  Science eventually corrects itself, but it sometimes takes a long time.  As one author I once read put it, referring to Einstein and the quantum revolution in physics, old scientists don't change their minds, they just pass away. (I'm sorry I don't have the reference; it was in a biography of Einstein). 

--People sometimes talk about drugs as being a crutch. They sometimes talk about psychotherapy in the same way.  But I believe that misses the important point.  Crutches are good things.  Or at least I would think so if I broke my leg.  But a crutch is a temporary thing.  It allows healing by taking the stress off of the body.  All medical treatments, whether they are pharmacotherapy or psychotherapy need to encourage the body in its own natural healing.  And if they cannot encourage natural bodily (or brain) healing, they at least need to permit it to occur.  (This may seem to contradict my point about the use of psychiatric medications being a way of avoiding dealing with problems.  There is considerable complexity in this issue.  I believe that in an ideal situation, the psychiatric drugs would be used for a short period of time alongside a psychotherapy plan of helping the person to psychologically deal with issues.)

--Psychiatric research is not necessarily objective.  In one research program in which I participated, the results of a study indicated a slight advantage of the antidepressant condition over psychotherapy, at least in the short run (the acute phase of the study; in the followup phase, the cognitive therapy did better than the medication.)  A nationally known psychiatrist was highly bothered that the benefit of the medication was not found to be stronger.  He insisted that a new more powerful statistical technique be used to look for differences between the different treatments (essentially pharmacotherapy versus psychotherapy).  Now, you need to understand that we already had TOP statisticians on the project.  But with the use of the new statistic, the effect of the medication condition was a little stronger.  This was an example of statistics being used in the service of ideology.  It is not for me to say whether the statistic was valid or not.  I assume that it was.  However, if there had not been such ideological devotion to the medication condition being superior by this one influential psychiatrist, there would never have been such an impetus to look around for another statistic and to perform a reanalysis.

*M. Harrow, "Factors Involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medication."  The Journal of Nervous and Mental Disease, 195 (2007): 406-414.  The study seemed to show that psychotic individuals who went off of their medications did better than individuals who stayed on them.  The data is open to various interpretations; but it is surprising that it did not receive more prominent journal coverage.  In general, it is surprising that it has not been talked about more widely.

Wednesday, November 16, 2011

If Not Medications, Then What--Natural Healing?

This is a second followup to my post, Anatomy of an Epidemic. 

I was somewhat reluctant to use the phrase "natural healing" in this title, but I decided upon it anyway.  Why was I reluctant?  Because over the years, "natural healing" has generally meant people avoiding scientifically proven treatments in favor of something like changing their diet.  Steve Jobs postponed surgery and chemotherapy for his pancreatic cancer in favor of natural healing methods.  I had a patient in psychotherapy who did the same thing when he was diagnosed with cancer.  Eventually, he chose to go with more traditional scientific treatments, but it was too late.  The "natural healing" route led to his death.

So why am I now writing about natural healing?  Well, if you have read my posting on Anatomy of an Epidemic, you will see that there appear to be some problems with psychiatric drugs.  They may work well in the short run but pose problems in the long run.

Secondly, while I love my profession of psychology and while I posted a column on psychotherapy as an alternative treatment to medication, I am well aware that the world got along fairly well without psychologists, social workers, psychiatrists, and counselors for a long, long time.  It is the height of pride to pretend that people cannot heal from psychological problems without the help of psychologists or other mental health professionals.  There were healing mechanisms in the human race before there was ever a Carl Rogers, B.F. Skinner, or Aaron Beck.  Moreover, not everyone can afford psychotherapy.  Furthermore, if everyone that needed it started utilizing psychotherapy, there might not be enough trained therapists to go around.  I'm fairly sure that there would not be.

So I want to write some about natural healing mechanisms.  How powerful are they?  I'm not sure.  In some cases I think they are more power than all of the professional means of treatment.  In other situations, they are probably less powerful.

Let's divide the natural healing mechanisms into two sorts.  One sort is what happens in everyday life to build us up and make us better and stronger mentally, whether or not we are sick, and whether or not we are depressed.

The second type of healing mechanism is the kind which occurs in response to psychological illness.  We'll start with general psychological strengthening factors which serve to help prevent mental illness.

Natural Healing Factors

Good diet nutrition.  Okay, this is the one I am not crazy about.  The brain can actually get by on junk food to a great degree without any mental illness occurring.  On the other hand, there are some studies about the importance of nutrition in mental health.  Here is a quote from an article by Serdar M. Durson, MD. PhD, Professor of Psychiatry and Neuroscience at the University of Alberta:

"Vitamin D and receptors have been increasingly implicated in the pathology of cognition and mental illness. Vitamin D activates receptors on neurons in regions implicated in the regulation of behaviour, stimulates neurotrophin release and protects the brain by buffering antioxidant and anti-inflammatory defences against vascular injury.  There is growing evidence for a relationship between vitamin D receptors in the brain, hypovitaminosis D and abnormal executive cognitive functions, major depression, bipolar disorder, and schizophrenia."  I use this one quote because of its directness and clarity.  There may be many other examples of where nutrition impacts mental health/

Fun and recreation.  Recreation is used as a therapeutic modality in the elderly and hospitalized patients, but here I am referring to the normal building up of the mind and body through having fun and activity. 

Exercise.  Exercise is also being used as a therapeutic method.  Exercise has been shown to have strong antidepressant effects.  But generally people use exercise for its preventative qualities.  Exercise improves blood flow to the brain and probably promotes neurogenesis (growth of new nerve cells).

Spiritual life, prayer, meditation, contemplative reading.  While this can be thought of as a type of therapy, spirituality is at its heart a normal part of everyday life for some people. It helps people have a sense of meaning and purpose in life.  It promotes a feeling of calmness in the face of adversity.

Staying off of drugs (including nicotine), excessive prescription medication.  A healthy lifestyle is undoubtedly going to lead to better mental health.  Studies are beginning to suggest, for example, that using illegal drugs can sometimes lead to psychotic breaks.

Natural problem solving processes.  People normally have to solve problems.  Learning how to solve problems and then using these abilities to deal with life issues removes sources of stress in life.

The distraction of work and life in general.  Going to work can be a great distraction from certain types of stresses.  Without work and recreation, we can easily get trapped into a cycle of worry, rumination, and dwelling on the negative. 

The enforced use of the frontal lobes of the brain.  Having to go to work and having to solve problems in life is most likely stimulating to the frontal lobes of the brain.  When we use a part of the brain, then we are most likely increasing the regional cerebral blood flow to it and most likely improving its overall physiological functioning.  I believe that using the frontal lobes in a positive way is good preventive medicine.

Jerome Frank wrote a book decades ago called Persuasion and Healing.  He looked at psychotherapy as being a form of healing which had previously taken place in shamanic rituals and even in frontier revivalism. Society has rituals of many sorts: church, football games, presidential inaugurations, and so on.  I believe that participating in rituals of the larger society gives us feelings of belonging, meaning, and security.

I believe that another form of normal positive mental health is the learning of virtues.  We may be taught these by our parents; or we may be inspired by those among us who are exceptional persons and particularly positive in their outlook.  In religion, we call these people saints.  In secular life, we call them leaders or creative geniuses.  Marten Seligman and Christopher Peterson have recently combed through the world's literature, cultures, and religions to catalog positive virtues.   

Natural Healing Factors in Response to Mental Illness

One non-medical form of healing comes in the form of practical help when people have started to become dysfunctional.  Often when someone is depressed, others come to their aid in practical ways, bringing food, helping them repair something, and so on.  The importance of practical assistance is twofold.  It helps eliminate a tangible stress (such as repairing a house which has been flooded), and it shows caring.  When people come to visit us to show that they care, they communicate this by their presence, their words, and their nonverbal gestures.  I believe that this probably elicits a positive response in the brain of the recipient which is hardwired.  That is, I believe that the brain is genetically prepared to have a beneficial response to these types of caring gestures.
Corrective brain processes.  The brain most likely has its own physiological healing processes.  Just as the rest of the body can heal from an injury, so, too, the brain probably has its own healing powers.

Distance from the stressor in time.  Time itself can probably heal.  As we move farther away from a stress, most stresses seem smaller and smaller to us.  This can be thought of as a healing mechanism. 

Distance from the stressor in space.  If we move away from a stressor, it can be less of a problem for us.  We can start to forget it.  An example would be moving away from an area where an ex-spouse who was abusive lives.

Increased family cohesiveness.  When patients are hospitalized, it is often the case that family members will come to express concern for them.  Family members will often tone down conflict in order to be supportive of the hospitalized patient.

Social rituals may be helpful in general, but they may also be used in response to stressful life events.  One example would be people going to a revival for faith healing or being prayed for in a prayer group.

Social help normalizing and metabolizing the stressor.  When we have a problem, it can at first seem outrageous, unbelievable, impossible, and even scandalous.  It is outside of our realm of experience or outside of our range of known coping abilities.  When we talk about our problems with others, they can intellectually and emotionally help us to digest them.  They listen to our problems, empathize with us, and then think through the problem solving process with us.  This has been conceptualized as helping the distressed person to "metabolize" the problem.

In conclusion, I think we need to remember that medication and psychotherapy are new treatments of the last one hundred years or so.  There are other healing processes which have been available to humans and which are available to us.  In some cases, these may be more powerful than medical and psychological treatments.

Sunday, November 13, 2011

If Not Medications, Then What? Psychotherapy.

In my last blog post, I wrote about the book Anatomy of an Epidemic and the possible dangers posed by long term use of some psychiatric drugs. 

So what are the alternatives?  Well, the logical alternative to psychiatric medication is psychotherapy.  As a psychologist, I actually view psychotherapy as not just an alternative, but actually the first line of treatment for most psychological disorders.   However, I am a realist, and I know that in this technological age filled with advertisements of every kind for psychiatric drugs.  Many people may not longer see psychotherapy as the first line of treatment as I do.

The research literature is too voluminous to try and analyze it here, just as actually analyzing the effects of psychiatric drugs cannot be done in a small blog post.  If you are really interested in the research literature on the efficacy of psychotherapy, try the National Library of Medicine web site,  Then type in "efficacy of psychotherapy" or "metaanalysis of psychotherapy outcome".  If you want even more information, try Michael Lambert's latest edition of the book titled Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (only $185.20 in hardcover!).

Numerous types of psychotherapy are available.  Psychotherapies used to be classified in the following ways: cognitive, behavioral, psychodynamic, client centered, eclectic, group therapy, family therapy, and so on.  However, these days classifications of therapy tend to focus on diagnostic categories and which of the types of therapies listed above have been found to be efficacious.  These are referred to as empirically verified therapies.

Here is a list of therapies proven to be efficacious in research research studies.  This list was created through the American Psychological Association and was copied from the American Psychological Association web site.

Examples of Empirically Validated Treatments

Well-Established Treatments Citation for Efficacy Evidence


Cognitive behavior therapy for panic disorder with and without agoraphobia ...... Barlow et al. (1989); Clark et al. (1994)

Cognitive behavior therapy for generalized anxiety disorder............................ Butler et al. (1991); Borkovec et al. (1987)

Group cognitive behavioral therapy for social phobia..................................... Heimberg et al. (1990); Mattick & Peters (1988)

*Exposure treatment for agoraphobia.......................................................... Trull et al. (1988)

*Exposure treatment for social phobia......................................................... Feske et al; Chambless (1995)

Exposure and response prevention for obsessive-compulsive disorder............. Balkom et al. (1994)

*Stress Inoculation Training for Coping with Stressors................................... Saunders et al. (in press)

Systematic desensitization for simple phobia ............................................. Kazdin et al; Wilcoxon (1976)


Cognitive therapy for depression ...............................................................Dobson (1989); DiMascio et al. (1979)

Interpersonal therapy for depression.........................................................................................Elkin et al. (1989)


*Behavior therapy for headache................................................................. Blanchard et al. (1987); Holroyd & Penzien (1990)

*Cognitive behavior therapy for irritable bowel syndrome................................ Blanchard et al. (1980); Lynch & Zamble (1989)

*Cognitive behavior therapy for chronic pain .............................................. Keefe et al. (1992); Turner & Clancy (1988)

*Cognitive-behavior therapy for bulimia........................................................ Agras et al. (1989); Thackwray et al. (1993)

Interpersonal therapy for bulimia ................................................................ Fairburn et al. (1993); Wilfley et al. (1993)


*Behavior modification for enuresis............................................................. Houts et al. (1994)

Parent training programs for children with oppositional behavior ...................... Walter et al; Gilmore (1973); Wells & Egan (1988)


Behavioral marital therapy......................................................................... Azrin, Bersalel et al. (1980); Jacobson & Follette (1985)


Behavior therapy for female orgasmic dysfunction and male erectile dysfunction LoPiccolo & Stock (1986); Auerbach & Kilmann (1977)


Family education programs for schizophrenia ............................................... Hogarty et al. (1986); Falloon et al. (1985)

Behavior modification for developmentally disabled individuals ....................... Scotti et al. (1991)

Token economy programs ......................................................................... Kazdin (1977); Liberman (1972)

Probably Efficacious Treatments Citation for Efficacy Evidence


Applied relaxation for panic disorder ........................................................... Öst (1988)

*Applied relaxation for generalized anxiety disorder....................................... Barlow et al., (1992); Borkovec & Costello, (1993)

*Exposure treatment for PTSD................................................................... Foa et al. (1991); Keane et al. (1989)

*Exposure treatment for simple phobia........................................................ Leitenberg et al; Callahan (1973); Öst et al. (1991)

*Stress Inoculation Training for PTSD ......................................................... Foa et al. (1991)

*Group exposure and response prevention for obsessive-compulsive disorder .. Fals-Stewart et al. (1993)

*Relapse prevention program for obsessive-compulsive disorder..................... Hiss et al. (1994)


*Behavior therapy for cocaine abuse .......................................................... Higgins et al. (1993)

*Brief dynamic therapy for opiate dependence.............................................. Woody et al. (1990)

*Cognitive therapy for opiate dependence.................................................... Woody et al. (1990)

*Cognitive-behavior therapy for benzodiazepine withdrawal

in panic disorder patients ...................................................................... Otto et al. (1994); Spiegel et al. (1993)


*Brief dynamic therapy ............................................................................. Gallagher-Thompson & Steffen(1994)

*Cognitive therapy for geriatric patients....................................................... Scogin et al; McElreath (1994)

*Psychoeducational treatment ................................................................... Lewinsohn et al. (1989)

*Reminiscence therapy for geriatric patients .............................................. Arean et al. (1993); Scogin & McElreath (1994)

*Self-control therapy ................................................................................ Fuchs & Rehm (1977); Rehm et al. (1979)


*Behavior therapy for childhood obesity ...................................................... Epstein et al. (1994); Wheeler & Hess (1976)

*Group cognitive-behavior therapy for bulimia .............................................. Mitchell et al. (1990)


Emotionally focused couples therapy ......................................................... Johnson et al; Greenberg (1985)

Insight-oriented marital therapy.................................................................. Snyder et al. (1989, 1991)


*Behavior modification of encopresis .......................................................... O'Brien et al. (1986)

*Family anxiety management training for anxiety disorders............................. Barrett et al. (in press)


Behavior modification for sex offenders....................................................... Marshall et al. (1991)

Dialectical behavior therapy for borderline personality disorder........................ Linehan et al. (1991)

Habit reversal and control techniques ......................................................... Azrin, Nunn et al; Frantz (1980)

Azrin, Nunn & Frantz-Renshaw (1980

It is an encouraging list.  It is somewhat outdated now, but it shows just how far psychotherapy conceptualization and research has come. 

It is important not to let the TV commercials subtly influence you into thinking that medication for psychological problems is all that exists.  The problem is not that other treatments do not exist; the problem is that they have not been adequately publicized to the public.

Sunday, November 06, 2011

Anatomy of an Epidemic--the Explosion of Psychiatric Drug Use in America

I'm reading a new book, Anatomy of an Epidemic.  And I find it both interesting and disturbing.

The book takes a look at the abuses of psychiatric drugs which has increasingly arisen in our culture.

Now, I am not generally one to bash such drugs.  My own background is of a psychologist trained in medical settings, where psychiatric drugs were used routinely and responsibly to help people.  I have also worked in clinical research trials where medication was being compared with psychotherapy, and I have seen the data showing that in the short run, medicines work about as well as psychotherapy, and sometimes better.  The settings I have worked in have usually, but not always, involved collegial relationships between the MD and non-MD professionals, so that patients could receive the best of both types of treatment.

Another reason I have been comfortable with patients receiving medications is that I am aware of the empirical literature on their effectiveness.  My graduate school training taught me methodological theory and how to analyze outcome studies, to know what was a good outcome research study and what was not.  I generally have kept abreast of research on outcomes of both medication in general and psychotherapy.

But after years of being in private practice and away from more intensive contact with research findings, I feel that perhaps I have been caught napping.  This book has been a rude awakening.  The author has done his homework extremely well, and he is getting invitations from prestigious groups in the U.S. and abroad to come present his point of view.  He has ferreted out numerous studies and facts to back his statements.  Everything he says is based on either a research study or on the opinions of biologically oriented psychiatrists and psychologists.

What is it that he points out?

  • When outcome studies have been published, the positive aspects of outcomes have been touted, and the negative aspects, such as side effects or negative effects after drug withdrawal, have been downplayed almost to the point of being hidden.
  • Outcome studies have often focused on the 12 to 16 week initial treatment period.  This has always seemed to me to be logical.  Most psychiatric drug effects would become visible and obvious during that time period.  But in the very long run, some medications, such as lithium and neuroleptics (antipsychotics), may be having negative outcomes on cognitive functioning.  (See my blog on dementia and bipolar disorder; I did not mention there the possibility that medication itself might be the cause of cognitive decline.)
  • The 12 to 16 week studies generally do not spend much time or space talking about drastic withdrawal effects from some medications.  Some antidepressants and some anti-anxiety medications are very hard to stop taking once they have been started.
  • Some medications stop working.  The NIMH sponsored study of stimulant medication for ADHD found a clear "winner" in medication for the first acute study period, but no clear advantage to medication over the long run.
  • Some studies which did not find efficacy for medication have never been reported.  Studies with results inconsistent with the prevailing viewpoints of biological psychiatry may be relegated to less well read journals and refused for publication by the top of the line journals.
  • Pharmaceutical companies have often used psychiatric researchers as consultants. This compromises their objectivity by paying them salaries.
I am worried about the possibility that some psychiatric drugs may be causing cognitive decline and deterioration in the long run.  I recall one particular patient, Barbara.  After starting my first job at the University of Oklahoma Health Sciences Center, I "inherited" this patient from a long time psychiatrist and researcher.  She received medication from a psychiatric resident, and she was in group counseling with me.  She was part of a long term maintenance group of bipolar patients.

Barbara had been somewhat of a child prodigy in piano.  She had been quite brilliant.  But she also had a very dysfunctional family and almost surely had inherited the bipolar gene set.  By the time I had started treating her she was 50 years old.  She spoke slowly, deliberately, and emphatically, making her appear to be of borderline intelligence.  There was a childlike, regressed manner to her speech.  I did not test her IQ, but I believe that if I had, it would have probably been around 80.  Why had this woman declined so precipitously?  I asked senior colleagues, and they did not know.  The thinking at the time was that she must have had some form of undiagnosed schizophrenia.  It was known that schizophrenia had a long term course which could result in severe deterioration.  But the problem was that there was absolutely no evidence that she had schizophrenia.  Her symptoms were controlled with Lithium, a medication for bipolar disorder.  I lost track of Barbara after I left OUHSC, and then later I heard that she had died.  I believe that it was due to complications of her severe smoking habit.  I am left wondering if her fall from brilliant child pianist to a fairly simple minded existence was due to her medication.  I suppose I will never know, but it is certainly a possibility.  No other explanation made any sesne then or now.

The issues raised in this book will put some patients into a dilemma.  Their trusted mental health professionals say one thing, that the medications are safe and efficacious, and this book implies something else.  Is the glass half empty or half full?  It also puts me into somewhat of a dilemma since I work very closely with psychiatrists.  I respect them, their knowledge, and their experience.  I respect their caring for their patients. 

But let's say that the premise of the book is true and that there are significant negative effects of psychiatric medications in the long run.  Let's go further and say that the positive effects from psychiatric medications decline for many patients in the long run, after a year or so.  The research literature is still relatively strong in showing that these medications work in the short run (although the negative outcome literature may have been unreported).  Let's say that I am the treating psychiatrist for a man with severe depression and anxiety.  He is functioning poorly on the job, and he may lose it if he does not do better.  Doesn't he need to improve as quickly as possible to keep his job?  Imagine how my patients would feel if I said to them the following: "Just hold on without the medications.  Using psychotherapy you will eventually do just as well and even better than with medication; but in the short run, you are not likely to improve as rapidly."

The outcome picture is more complicated if a person is on medication and receiving psychotherapy at the same time.  They would receive the best of both worlds.  But there might also be some withdrawal effects coming off of the medication.  I certainly encountered that with one college professor I treated.  He was convinced that his Xanax was a major culprit in causing him further problems.  I doubted it at the time, but now I believe that he knew himself and his body fairly well and that he was correct.  In that situation, coming off of the Xanax meant that we had to extend the psychotherapy to help him through the process of getting off the medication.

Not everyone has a negative reaction to medications.  Not everyone has difficulty coming off of them.  There are obvious ethical problems here.  A person may lose their job if not rapidly treated.  A person may be in needless pain due to severe depression and anxiety.  (It is probably not overly dramatic to refer to moderate and severe anxiety as a form of torture.)  A person with severe depression or anxiety might commit suicide without the relief available from medication.  Rapid treatment is often necessary to prevent a person from doing things which are irreversible--not just commiting suicide but also making mistakes on the job or severe mistakes in parenting.  If a person loses their job, their marriage, or their children, then the long term job of the psychotherapist becomes all that more difficult.

Patients need to be made aware of the positive and the negative outcomes from medication.  This is true of psychiatric and non-psychiatric drugs.  For my own practice, I am left in somewhat of a dilemma.  Here are the resolutions I have made to myself.

1.  To do more research on the negative outcomes of psychiatric drugs.
2.  To tighten up my criteria for when I do and when I do not recommend medication evaluation.  (I do not perform psychological testing and then recommend medication.  I come up with a diagnosis and then recommend a medication evaluation for some patients.  There is a difference.)  Similarly, I will be more conservative in making those diagnoses which most often lead to medication (ADHD, bipolar disorder, psychosis).
3.  To emphasize to patients that the medications may not be a long term treatment.  I will encourage them to talk with their treating MD about just how long they would be on the medication and when it might be feasible to start coming off of it.

I will be writing more in future columns about this.  There is a great deal at stake here for all involved.

Sunday, October 30, 2011

Be Kind to Your Therapist and Say Goodbye

I sometimes have clients leave therapy not by saying goodbye (having a termination session) but by just not showing up again.

I'm not sure why this is.  Maybe the client is afraid I will try to talk them out of stopping therapy.  They may be concerned that I will tell them they are not ready to leave therapy.  Maybe they feel embarrassed. Maybe they don't know how to say goodbye.

This type of termination leaves the therapist hanging and not sure what happened.

Perhaps the client may be worried that the therapist will try to convince them that they are not ready to leave therapy.  But actually, in a strange sort of way, having difficulty saying goodbye to the therapist could actually be evidence that the client is not ready to end therapy.  Put another way, being able to be assertive and to say directly to their therapist that they are ready to stop therapy, is a sign of taking responsibility for one's life and being assertive.  It can be seen as a sign of health.

It's not like therapists don't expect termination.  The last statistics I saw were that the average number of therapy sessions for a client is eight, and the median number is six.  Quitting therapy after even a few sessions is not unusual.

Unfortunately, it leaves the therapist hanging when there is no explanation, no goodbye, and no termination.  There is a sense of incompleteness.  And perhaps there is some lack of closure for the client as well.

Let your therapist know your specific reasons, such as not feeling that you are making progress, not being able to afford it, or not feeling that you need it anymore. 

Be kind to your therapist and say "goodbye" when it is time. But be good to yourself, too. Take responsibility for your feelings, and if it is time to leave therapy, then do so in a straightforward manner. 

Friday, October 21, 2011

Dealing with Our Hidden Neuroses

Sometimes when I get into the elevator, there is a mirror in front and a mirror in back.  The result is that I can see the back of my head by seeing the reflection of the reflection.  This would not be a problem, except that I have a bald spot back in the back of my head that I would rather not see.

This got me to thinking about the fact that all of us have a blind spot.  We think we know ourselves, and we think we know how others see us, but there is always some part of us that we are not aware of.

In my case, there are two reasons I don't think about my bald spot.  One is I normally can't see it, even in a regular mirror.  The other is that I don't want to think about it.  The latter is a defense mechanism.   I only want to think about what I want to think about.  For some people, the things they avoid thinking about are just too painful for them.

Defenses can be healthy or unhealthy.  We can't think about painful things all of the time.  We can't contemplate world hunger and misery all of our waking hours and still function.

Psychologists have divided psychological defense mechanisms into the more or less healthy ones and the more or less unhealthy ones.  An example of a healthy defense would be sublimation--the taking of aggressive energy or sexual energy and turning into something useful for ourselves or for society.

One of the least helpful defenses and the most primitive (primitive because its develops at a very early age and involves a high degree of distortion) is denial. In denial, we disown a part of ourselves--some type of thought or feeling.  In the most extreme form, a person can have dissociative periods in which they later don't remember what they did.  They may deny that they did it.  (This is different from an alcoholic blackout which is chemically induced.)  Another primitive defense mechanism is projection.  I project all of my own negative feelings and concerns onto you.  You become the evil one, the bad one, and the source of all of my problems.  At its strongest, this might cause paranoia.

One of the purposes of therapy is to help us to quit disowning parts of ourselves.  If we feel secure enough in the therapy relationship, we may be able to reincorporate aspects of ourselves that we didn't want to acknowledge.

An excessive use of primitive defense mechanisms can lead to neurosis.  Now this term has been used in so many different ways that it has become confusing.  Many professionals refuse to use it at all because of the multiplicity of meanings and because of its association with somewhat outdated Freudian meanings.  However, I find the term useful in a particular way.  Many of us have a behavior which:
  • Harms us and/or others.  I say "and/or" here, but what I really mean is that it harms us in some way and it may or may not hurt others as well.  If a behavior only hurts others, the I would not use the term neurosis.  It might be a part of a personality disorder.
  • It is repetitive.  That doesn't mean that it happens every day or every week; but it happens enough that it becomes a pattern in our lives.
  • It is beyond the understanding of the individual.  In traditional terms, one could say that it is unconscious.  However, I am not sure that all repetitive self-defeating patterns come from unconscious issues.  Nevertheless, they are definitely beyond the understanding of the individual.  If we understand what we are doing, then they are merely a choice.  In a neurotic behavior, the individual is getting blind sided by their own past memories, hurts, needs, defenses, and so on.
So what is one to do?  If we are blind to something, then we can't fix it, right?The resolution of neurosis is hard to achieve on one's own.  Maybe even impossible.  We all have our blind spots, and we are not aware of them.  We are not even sure where to look for them.  Thus, if we don't know that we have a blind spot, and we don't know where to look for it, we are surely not going to find it.  But even if we find it, we are likely to rationalize its existence.  We are likely to think something like the following: "There is a reason I do this [particular behavior].  I know that other people have neurotic issues, but this is not neurotic.  What I am doing is logical."Our blind spot protects itself.  The defense mechanism does not want to go away.

Many neuroses start with experiences of hurt, pain, and fear.  The neurosis forms a wall or barrier so that we don't have to deal with the true pain; and we sense at some level that if we give up our neurosis, we may be faced with a loss of meaning.  Without it, we may be forced to deal with painful memories; or we may be left without a sense of direction left in life.

Because of our vulnerability to very painful feelings in childhood, and because of our lack of sophistication, we can develop unhealthy ways of thinking and behaving to defend ourselves psychologically.  Then later in life, we generally stick with the belief systems we developed in childhood  (for example, "Men can't be trusted," or "I must have a woman in my life to feel worthwhile," etc.) 

The above explanation(s) are the typical ones found in the psychological literature.  However, I think that in addition to these there may be other possible causes as well.  I think one reason we might stay with old, neurotic beliefs and behaviors is that doing so conserves energy.  A second reason might be that staying with old beliefs makes us more stable.

We can't change our paradigms (basic templates for how we look at the world) and basic rules for understanding ourselves without a considerable energy expenditure. If we changed our paradigms very often we would be unstable people. Something major needs to happen to make me change something so fundamental. I am not going to suddenly change from being staunch Republican to staunch Democrat without a really good reason. I am not going to suddenly going to believe in Communism or Buddhism, without a darn good reason. Thus, I remain more stable and energy is conserved.  Unfortunately, I may then also hold onto beliefs which are not good for me.  It might have worked for me as a child to believe that I should never question authority and that I should always follow the lead of others; but this would definitely be a bad idea as an adult.

The opposite of neurosis (at least in the way I am defining it here) is openness.  Openness to our own feelings.  Openness to our own thoughts. Openness to feedback from others and how they see us. Openness to the possibility that we are not perfect.  Under these conditions, we can grow psychologically.  We can start to see where we need to grow.  We can see when our old coping skills are not working and when we need new ways of approaching things.  That takes effort and a mindset that realizes that change can be good. 

Friday, October 14, 2011

Has the Narcissistic Generation Finally Arrived?

For a long time, I have been hearing from some therapists that the primary psychological problem of the next generation will be narcissism.  The logic behind this is that many youth today were raised to look after their own needs first and the needs and rights of others secondarily, if at all.   However, I have never been convinced.  First, I am a hopeful person, and I thought that this idea was overly pessimistic.  Secondly, I knew that such a statement would have to be an overgeneralization.  I don't trust overgeneralizations.  There are always differences between members of a generation.  Not everyone in the "Greatest Generation," written about by Tom Brokaw, was really great, or even good.

When things change, they change slowly, until something is strong enough that it hits you in the face.  Well, maybe something has happened to make the trend to narcissism real to me.

I had the opportunity the other night to attend a party for a new startup company.  It was attended by a group of mostly young, mostly good looking, and mostly very intelligent people.

Ourderves and drinks were provided.  It was a fun party.  After people had a chance to eat and talk for awhile, the business executives sponsoring it wanted an opportunity to say a few words.  But surprisingly, when they started talking, a significant minority, maybe a third or a fourth of the people there, just would not stop talking.  This continued throughout the speeches--about twenty minutes.  The acoustics of the building made everything worse.  It was absolutely maddening for the people trying to listen.  Even speaking with a microphone, the hosts could not be heard very well.  The older ones of us present, and some of the younger ones, couldn't quite believe the lack of manners being shown.

Why did the guests keep talking?  I don't know.  But their thinking must have gone something like this:  "These speeches are only a formality.  They don't really expect me to listen.  And I am just one person, so it won't matter if I talk.  Besides, what I have to say to this person in front of me right now is really soooo important."

Well, I'll never know if that was what was going through the minds of the talkers.  But it seemed to me at that moment that the narcissistic generation had arrived after all.

Tuesday, October 11, 2011

Finding Motivation in Life No. 2--Wanting to Want to, or Creating Motivation For Ourselves

(This is a followup post to my previous one on finding motivation.)

I have many clients who want to do more with their life.  However, for one reason or another they find themselves being lethargic and not doing the things they would really want to do in the long run--the big goals in life.  In the short run, they come home, fix dinner, watch TV, and go to sleep.  The next day they start over again.  They do what comes naturally and what is right in front of them.  Or they do what is easiest or what absolutely has to be done.

For many of my clients that is not how they want it to be.  They want to do more with their lives.  But they can't find the energy.  Or they can't find the motivation.  Or the time never seems to be there.  (Another thing which stands in people's way is a fear of failure; but that is a different post.)

Sometimes, in this situation people call themselves "lazy."  But as you know (if you have read my previous blogs), I consider the word "lazy" to be a confusing non-explanation, and one which is likely to lead to low self-esteem, depression, and perhaps more lethargy.  So let's not go there.  Calling ourselves "lazy" explains nothing and fixes nothing.

And so as a counselor working with a client facing this issue, what we may be left with is a big gap between them "wanting to want to do something" and actually doing it.

And if you have read some of my other blogs, you probably realize that I would first look for the explanation of such a problem in the executive functions associated with the frontal lobes.  These executive functions are shaped by our genes, our biological history, and our life experiences.  Sometimes depression, aging, ADHD, or some other issue interferes with our motivation to do things.  (All of these can involve the frontal lobes and executive functions.)

So I am left with trying to help people who want to to want to [do something] but don't.  I think that when this happens, there are possible detours around the lack of motivation.

Here are some possible strategies.

Number One.  The lethargy is not permanent and 100% of the time.  Otherwise, there would be no problem in the person's mind.  They would never want to do more, and there would be no problem.  When the moment of wanting to want to [do something of significance] strikes, do something which commits you.  Join a club.  Call a friend and make arrangements to do something.  Commit yourself.

Number Two.  Find a weekly venue.  For me, I have jazz piano lessons every two weeks.  I have oil painting lessons every week.  So, when my motivation wanes, I know that I will still have to be at my next lesson.  (I don't really HAVE to go, but I will.  If my teacher is expecting me, I will show up.  That's just my personality).

Number Three.  If I pay money for something ahead of time, I am likely to follow through with it.  Go ahead and buy tickets.  That may give you the motivation to follow through.  (I know this doesn't always work.  Look at all the people with gym memberships who don't go.  But it works for some people.)  My art lessons require a monthly payment up front.  That encourages students to go ahead and show up.

Number Four.  Join a group.  Sometimes they will urge you to come along and even drag you along even if you don't have the motivation to go.  My social group sometimes plans get togethers at the lake, at a musical, or something like that.  I would probably not plan one tenth of these for myself and my wife, but I will go along with everyone else.

Number Five.  Prime the pump.  Sometimes, if I lose interest in painting, just walking the aisles of an art supply store will help me get interested again.  I have suggested to clients that they go to the sporting goods store and just look at the hunting or fishing supplies to see if that will stimulate some motivation.

Number Six.  Have goals that can be worked on at the spur of the moment.  My blog is a great activity for me because I can do it a little at a time.  I can do it if I'm bored.  I can do it if I get a new idea.  I can do it if I wake up in the middle of the night.  It's easy to log on to my computer and type.

Number Seven.  It is helpful to make a list.  It doesn't have to be a big list.  In fact, I wold recommend that there is a primary list with only three to five items on it.  There could be a secondary list with more items.  Put it someplace that you will see it often.  Mine comes up when I bring up my online calendar of things to do.

I hope some of these ideas are helpful.  If you have some more ideas about how to motivate yourself, please leave a comment.

Sunday, October 09, 2011

Finding Motivation in Life No. 1--Finding a Passion in Life

I was meeting with a group of fellow psychologists the other day. We meet once a month to discuss professional issues.  The issue came up that some people do not seem to have any kind of passion in life.  They go to work.  They come home.  They have some fun now and then.  But to  a great degree, their actions are guided by what they just have to do next or what is right in front of them in the moment.

Many of us want to do something important with our life but don't  know what it could be.  We may end up just doing what is in front of us rather than setting golas and accomplishing things that would be really satisfying in the end. We may become bored or dissatisfied with our lives.

Ideally, each of us will find at least one passion in life.  Finding a passion in life means finding something worthwhile in life beyond just doing our job and what we have to do.  And something beyond just pursuing the pleasures of the moment.

Another way of saying this is doing more than just the social and biological imperatives.  Let me explain what I mean.  To some degree we are programmed to do certain things.  We might say that we are programmed to eat, move around, have sex, and sleep.  To some degree we are programmed by society to go to school, get married, have kids, and advance in our career.  The programming may be social, biological, or both.

But some people seem to go well beyond these imperatives.  They volunteer.  They find sports that they really enjoy.  Or they are involved in the arts.  Or they become involved in a hobby.  Or in spirituality and religion.

For some people their job is their passion, and that may fit what I am talking about here if it fully utilizes their creative powers.  But when I talk about finding a passion, I am talking about something different from just being a workaholic.  Being a workaholic can actually be an excuse not to be creative and not to discover what is truly self-fulfilling.  Being a workaholic can mean just putting one foot in front of another and not really having to think about what is important. On the other hand, starting a business can be a passion, and it can take tremendous time.  It can be self-expressive.  And that is why I might make an exception for that type of work.

There is one area where I think it makes sense for our biological imperative to be our passion.  And that is our biological programming to raise children.  Our passion could be our children.  I may be biased here.  I just had a new grandchild, and so I am fairly enamored of him and focused on him.  Some people have said, and rightly so, that the most important thing we can do in life is raise our children well.  But even child rearing can be a trap, however, because in the end the children leave home.  If that is our only passion, then we may end up feeling aimless after the kids leave home, at least until the grandchildren arrive.

Another biological imperative could be just staying alive.  Finding ourselves in extremely stressful financial circumstances or facing a terminal disease, I think that the healthiest thing one can do is to pour all of one's energy into staying alive and putting food on the table for one's family.

But what about when such circumstances don't exist?  When leisure time exists and when there is enough money to do more than just stay alive? 

What makes it hard for some people to have a passion, I think, is that they come out of a very under stimulated childhood.   It used to be that as children they were simply left to grow up on their own.  After doing their chores and going to school, if there was any time left, they could do what they wanted.  There is much to be said for that.  It allows for play and spontaneity. 

But I also believe that ideally children need to be encouraged to try things out.  They need to be exposed to things--allowed to see things and do things and hear things that may stimulate them.  Soccer, basketball, painting, music, volunteer activities, travel--all of these give a child a chance to sample the world and learn that there is more in life than just their own neighborhood and what is on TV.  If a person comes from an under stimulated childhood, then the motivation to do more and seek out more may never develop.

Another thing which may assist in this or impede it is biological temperament.  Some people just have more energy and enjoy things more than others.  Some have a higher capacity to take risks, and some people are more likely to just stay home and avoid risks.  Someone with a "hyper" temperament is more likely to pursue physical activities than someone with a more passive temperament.  So I don't want to turn this into a moralistic lecture.  This isn't about being bad or good.  Sometimes, we just are what we are, and there is no sense moralizing about that. 

But there are other times, when a little reflection on our short time on this blue sphere might lead us to take some risks, get off the couch, and try something new. 

This leads to the question, "What do we do if we want to do more but we just never get around to doing it?"  I am going to try to tackle this in my next blog on "Wanting to Want To," which discusses strategies for motivating ourselves.

Monday, September 26, 2011

What If There Is a Drive to Dis-Affiliate?

Under the "What if?" category:

Many times in counseling, therapists are confronted with families torn apart, brothers from sisters, children from parents, friends from friends, business partner from business partner.  This often follows, and maybe always follows, an angry episode.  And usually I would interpret this as a result of anger.  People cut off from others simply because they are angry and perhaps don't handle anger well.

But what if there was an additional reason related to anger but going beyond it?  What if there was a a drive in humans to affiliate and also a drive to disaffiliate?

It happens in families, and it happens in organizations.  In churches, we sometimes see a life cycle.  People come together.  They enjoy the advantages of affiliation and bonding (social, emotional, intellectual, and financial).  Then some issue (often not really that big when looked at objectively by a third party) drives a wedge between groups, and people leave.  Churches split.

The issues which drive wedges between people often mystify counselors because they simply aren't as big as one would think they would have to be to cause such a rift.  There are many psychological reasons why a seemingly small event could cause an overreaction.  But what if there was a drive in people to disaffiliate?

Oftentimes, family divisions occur after the funeral of the parent.  The splitting up of the parent's belongings can be a particular trigger.  Again, this has always seemed logical to me from a psychological point of view.  If in childhood, the children felt they had to compete for their parent's attention and love, then it would seem to make a least a little bit of sense that they might squabble over these remnants of their parent's love in the form of belongings left in the estate.  Mixed in with the squabbling over possessions would be all the old resentment and anger, leading them to cut off from each other, now that the "glue" of the parent was gone.

The fact that families sometimes split up after the funeral of a parent may also suggest that the tendency to divide and separate from one another is continuous and ongoing.  Perhaps, it is the presence of the parent which keeps that from occurring.

Freud famously postulated in one of his theories that there is an eros drive (love, sex, and the desire for the other) and a death, or thanatos, drive.  The theory may have been stimulated by World War I and the death and destruction which came from it.  The possibility of a disaffiliation drive would be analagous to thanatos because there is a destructive quality to it.  But it doesn't involve killing people.  It involves killing bonds of affection and attachment.  It kills group loyalties. It would probably have to be rooted in some evolutionary need (such as the need to strike out from one's own cave to cover new territory).  After all, what made our ancestors leave Africa and spread to Europe and Asia and the Americas?  The search for food and territory would certainly have caused the human species to spread.  But what if there was actually a drive to split off and break bonds of attachment?  That would have caused the species to spread, too.

I am not suggesting that we take a fatalistic stance towards the loss of relationships and group loyalties.  I would personally tend towards the religious value which promotes harmony and attachment.  Or the Rodney King point of view, "Can't we all just get along?"  But sometimes, despite our very best efforts, nothing works.  And maybe there is a just a grain of solace in thinking that perhaps, just perhaps, we are made that way.

Friday, September 23, 2011

Life Interrupted--When the Curtain Comes Down in the Middle of the Fourth Act

For many of my clients, they have been planning thorughout their lives for some positive ending: retirement, time with their grandchildren, time together with their spouse, or maybe a time of travel and cruises.  Perhaps they were just looking forward to some calm years doing woodworking.  Or maybe they would have been content with having a good reputation in their career field and being respected for the way they had lived their lives.

For many of my clients, that anticipated life has been interrupted.

Imagine that we all live lives of five acts.  Let's say some of us want to live out romantic plays, some of us comedies, and some of us just nice sentimental plays where everyone gets along, the hero overcomes obstacles (but not too difficult obstacles), and so on. 

Life begins in the first act.  They are born; they start growing up.  Act two, they finish high school and go to college.  They date.  Act three, they are married and have children.  They have a career.  Problems arise.  (But again nobody wants really bad problems, so let's assume that the problems aren't too bad in this imaginary play.)

And then in the middle of the fourth act, something unexpected happens.  Something major.  Something which can't be surmounted.  The fifth act which they anticipated is not going to happen after all.  The romance is now a tragedy.  The comedy is no longer a comedy but something else, maybe a mystery.

Perhaps a person's spouse dies.  Perhaps someone is laid off and can no longer find work in the area they were trained for.  Perhaps they have been swindled out of their retirement savings.  Or their children no longer let them see their grandchildren.  The director announces that act five is not going to happen after all.

It is as if they were playing Hamlet, and in the middle of the fourth act someone walks in and says, "We are moving next door to another theater.  We are shutting down this theater.  And you will no longer being playing Hamlet; you will be playing MacBeth."  The trajectory and continuity of acts one through five is broken.  Things no longer make any sense.  "I trained as a physicist; now I am a Walmart greeter."  Or, "I spent my life raising my children, and now they won't let me be with my grandchildren."  Life no longer feels like it makes sense. There is not the feeling of meaning that they have been trying to create for years and years. 

It is as if they were living in a Thomas Kincaid painting of pleasant colors and cottages, and now they have to play out the fifth act as Job of the Old Testament, bereft of family and cattle, and covered with boils.

But what I am talking about is not just that things have taken a turn for the worse.  Life seems to have lost its meaning because the trajectory of their life no longer has continuity.  It is as if an artillery shell is fired into the air, and just as it starts to come down and reach its target, instead of continuing on its arc, it crashes into an invisible barrier, stops, and falls to the ground.  Or it's as if the shell suddenly turns and goes off in a different, wholly unanticipated direction.

When this loss of continuity and meaning happens to my clients, it can not only be depressing, it can make them feel disoriented, as if there is no meaning in life.  Whatever has happened to them may be relatively unique (coming down with a dread disease which occurs in .001% of the population), or common to others (becoming disabled by an accident). 

I try to help my patients see that even if their situation is somewhat unique, the overall issue of life interrupted is not unique.  They are part of a much larger and distinguished group of people (starting with Job of the Old Testament) who were in just the same predicament.  It may be that the desirable situation of life acts one through five flowing in logical sequence doesn't really exist for anyone.  Or maybe a lucky minority of people get to enjoy that progression.  I don't really know.  I do know that for many of my clients, life has been interrupted, and there is no choice but to piece together a new plan and a new sense of meaning.