Dr. Beckham's Blog

Substituting One Feeling for Another

2012-02-02T08:06:00.000-06:00

One interesting coping mechanism in stressful situations is learning how to substitute one feeling for another. If done in one way, it is probably a very healthy mechanism. In another way, not so healthy.

I first learned this lesson as a novice skier. I was skiing for the first time and came to a small blue slope (blue being a slope of intermediate difficulty). I fell down three times. For the next two days, I avoided the slope. Then on the last day, when it was time to leave, I decided that I hadn't had enough fun. I wanted to ski the slope--for the fun of it. I fell down three times--and laughed all the way down.

What was different between the two times? I fell down three times on each occasion. My heart was beating just as fast. I was breathing just as hard. My adrenalin was probably at the same levels. What was different? Somehow I had side stepped from anxiety to excitement, from one emotion to another, and it was very adaptive. It helped me take another step in skiing.

So anxiety and excitement are sometimes just a step away from each other. Sometimes when we are anxious, it is possible to think of it as excitement, and excitement is a whole lot more fun than anxiety.

The physiological arousal symptoms of anxiety and excitement can be quite similar. Two psychologists, Schachter and Singer, injected college students with adrenalin (with their permission) and found that the adrenalin by itself did not produce reliable emotional effects. The emotions which the college students experienced depended on what they thought they should experience. This in turn was manipulated by the experimenters using two other students who were confederates of the researchers. They were able to show that the physiological state of sympathetic arousal on adrenalin can go along with anger, amusement, or euphoria. It greatly depends on the context.

So next time you are anxious and your heart is pumping, and your breathing is getting more rapid, try the following. Imagine that you are not anxious but excited. You are excited and eager to get on with whatever stress you are facing. It is making your blood pump and your heart race and your lungs breathe faster. But it is not a bad thing; it is good. It is exciting. See if you can do the sidestep, replacing one emotion for another--another emotion which is much more palatable.

Are there other emotions where this sidestep is possible? Probably. I will be giving this more thought.

Now I said that sometimes replacing one emotion with another is not healthy. When is it not? When it involves denial or reaction formation. When we are not aware of what we are doing. When we are being dishonest with ourselves somewhere deep within our mind, so that we don't even know that we are doing it. "I'm not angry!" would be denial if it were not true and if we were being dishonest with ourselves. And "I'm not sad, I'm actually very happy" would be reaction formation if it were not true. So adaptive coping mechanisms would differ from unadaptive defense mechanisms in that the person knows what he/she is doing; it is being done intentionally, and the person is being honest with themselves.

Now, for some theoretical comments from non-psychology fields. (Skip this if you like. It is just some theoretical stuff I have been thinking about.)

I came to understand this principle of side stepping is not limited to psychology when my jazz piano teacher and my painting teacher taught me the same lesson in the same week. In a general sense, this can be called chromatic substitution.

"Chroma" is the coloring of something. Two things can be similar but have a different coloring. Of course a "coloring" when listening to something means something different from the coloring in a painting. And both of those are different from the "color" of a feeling. But there is quite a bit of similarity, too.

In jazz piano, a tritone substitution can be used for a dominant seventh chord, or any diatonic chord. A tritone substitute chord shares the major 3rd and minor 7th of the original (usually dominant 7th) chord. They have just changed places. Now the fifth and ninth become something different, causing what is in essence the altered version of the original chord. Altered chords are very cool sounding in a jazzy sort of way. They sound good, and they are similar to the original chord, but they are also different. And to a jazz musician, they often sound better. So chromatic substitution here means using a tritone instead of the original dominant seventh, or using the altered chord instead of the original simple dominant chord. And the substitute can be used because it is different, but in some ways also the same.

In painting, it is possible (especially in impressionist painting), to add additional colors, replacing the original "realistic" colors. The new hues might be only hinted at, or even absent, in the original "realistic" image. These colors usually disappear entirely in photographs but can be glimpsed by an artistic eye in real life. In impressionistic painting, they have to be added at the same value level as the original colors. (The value level is the black/white darkness level. If you "desaturate

There is one other type of sidestep in therapy, and that is reframing. Family therapists discovered early on that it is often not clear exactly what motive a person has in a family interaction. When families become angry and deadlocked, they tend to "frame" the motivation of another family member in a very negative way. A reframing can be quite helpful in family counseling. For more on this, see http://en.wikipedia.org/wiki/Reframing .

How Do You Spoil a Child?

2012-01-22T08:53:00.000-06:00

I had an interesting conversation the other day with an acquaintance on the issue of spoiling children.  He was saying that we needed to watch out and not spoil our children--that it was important not to give them too many things.

I generally agree with that statement. However, he was using the word "spoil" in one way, and I use it in a slightly different way. I think we all need to keep clear on what it would mean to "spoil" a child.

In a larger sense, for something to spoil is for it to go bad. So the essential issue for me in whether children have been "spoiled" is not whether they have been given too much (although this is one way for them to become "spoiled") but whether they have been treated in such a way as to harm their psychological development.  In my way of thinking, if a child is deprived of everything, they can be "spoiled" or made bad in a totally different way. I know that this is not the way that "spoiled" is normally used, but it makes more sense to me. A spoiled child in the larger sense is one whose development has been seriously harmed.

So the issue in my mind is not simply one of whether a child gets a lot of things. For some children, that might not "spoil" them. I think that spoiling might or might not occur when children have a lot of possessions.    Now having said that, I would generally agree that children getting too much too quickly is a real hazard to them emotionally. Here is why.

1. I think it creates problems for children to give them everything they want so quickly that they do not have to work for anything.  Working for something builds skills and psychological strengths.

2. It may create problems for children to give them so much that they cannot really appreciate any one thing because it is just one thing in a mountain of things. If we do not appreciate what we have, we cannot appreciate the fact that we are blessed to have anything. We also are not likely to appreciate the fact that others may have very little.

3. I think that having too much too quickly also keeps us from learning patience. The desire to have it now, or the feeling that we need it right now, has to be tempered by the ability to be patient for what we want.

So I do not believe that the essence of spoiling a child is simply in having many things, although that creates a hazard. I think that the essential aspect of spoiling children (in this particular sense) is depriving them of the opportunities to learn to work for something, to learn patience, and to learn to appreciate each and every object they own.

So while I might quibble with my friend over some details, I do believe that if we do give our children too much, then it is hard, if not impossible, for them to appreciate each item. And if we give our children too much too quickly then the acquisitions will come so fast that they cannot learn patience. And if we give our children too much too quickly, then they will only have the opportunity to work for a small fraction of what they have.

But overall our emphasis in parenting needs to be helping our children grow up straight and healthy; it does not need to be keeping them in a state of semi-deprivation. We need to focus on giving them the real gifts of life: patience, a work ethic, and appreciation for what they have.

What Makes a Family Functional? Here's Two Thoughts

2012-01-17T20:03:00.000-06:00

First, let me say that don't really think of families in all or nothing terms, either as functional or dysfunctional. I don't think that I have ever known a fully functional family. Families exist on a continuum between the two.

Secondly, to write about what makes a family functional in general would be a whole blog in itself. Perhaps I will devote more space to this in the future. But here I just want to write about two processes or behaviors which I think are important for families as they struggle to be more fully functional.

1. First of all, let's start with a relatively easy behavior--getting through the holidays without arguing. It is my experience that when families cannot get through Thanksgiving or Christmas without arguing that it lowers the overall sense of family self-esteem. It tends to create a sense of "what's wrong with us that we can't even get through Christmas (or Thanksgiving)"?

There are also other events besides holidays which I think are equally important to get through without family meltdowns. Weddings would be one. People going into the hospital with a health crisis would be another. There are simply times that we have to put aside our desire to "stand our ground" or "be right" or "make a point," and we just need to "grin and bear it" in order not to detract from the well being and happiness of others.

If we are going to insist on making a point, winning an argument, or having a family showdown (and I am not sure that any of these are all that necessary), then at least they need to occur aside from one of these "exceptional" days.

Funerals pose a particular problem for this rule, because many families do seem to have meltdowns soon after a patriarch or matriarch has passed away. It is as if the "glue" of the family has been lost; at that point, the children's squabbles often break out in the open. But again, my rule of thumb would be that if it is absolutely necessary to have a squabble or showdown, the day of the funeral is inappropriate.

2. Shock absorbers versus shock amplifiers. When one family member begins creating tension in a family (and all of us have our little meltdowns from time to time), then there are basically two options that any other family member has. One is to react in a stronger fashion, adding negative energy to the family system, and the other option is to dampen down our reaction. Members of the family have the choice of giving out less negative energy than they receive, which would tend to calm the situation, or they can choose to amplify the first person's upsetting statements, adding to the family tension.  When the latter happens, then there is escalation, and sometimes an explosion. In chemical and nuclear explosions, energy is released from some trigger which then affects neighboring matter, releasing more energy than was received. This process is repeated over and over, microsecond by microsecond in an explosion.

In thinking about how family members can react to each other in a knee-jerk fashion, I often think of the analogy of a rack of pool balls. A little known fact about pool balls is that they are extremely elastic. That is, they tend to transmit energy very, very well rather than absorbing energy. Once the cue ball hits the rack, then there is an automatic, inevitable transmission of energy to the other balls. They all react. If we then imagine the balls to be family members and the cue ball as being one particular family member who stirs things up in the family system, then the cue ball hitting the rack is analogous to one person stirring things up in the family and everyone automatically reacting to that person.

Let's say a father walks in and says, "It's been a terrible day at work; and to top it off, somebody left their bicycle in the driveway, and I ran over it!" In the pool ball example, all of the family members would automatically react to his upset feelings and statements and start saying equally upsetting things, such as "Well, why don't you pay more attention to your driving!" or "You're going to have to buy me another bicycle!" and so on.

An alternative possibility to the cue ball example, however, is to imagine little shock absorbers between each ball in the rack. The cue ball hits it, and then the shock absorbers cause there to be a kind of thud, where some energy but not all energy is transmitted from one to another and to another. Then the balls move but not with a perfect transmission of energy. There is no automatic reaction carrying the energy around the family system. And there is certainly no amplification of the energy.

On the other hand, imagine little battery packs inside each pool ball, and when one one is hit, then it actually moves with greater energy than the one that hit it. Pretty soon all of the balls would be bumping into each other with greater and greater energy. That is how some other family systems operate. They amplify the negative energy coming in, and pretty soon everyone is in an uproar with very hurtful things being said or done.

I would want to live in a family with shock absorbers. I am not suggesting that we don't react to negative events.  We're just human. But if the family members tone down their reactions, then pretty soon all of the energy is dissipated, and life can return to normal. Maybe it would take a few seconds or several minutes. Or maybe a little longer. But it would not turn into a nuclear explosion. So my second choice of behaviors for a functional family (relatively speaking) would be for there to be the shock absorber effect.

How can this be put into action? Well, one way to absorb the negative energy is to delay. For example, if someone said, "Let's take a look at the bicycle and see if it can be fixed," then there is a delay. The reaction is put on hold until there is more information and a better understanding of the problem. Rather than jumping to conclusions, or imagining it being a mangled piece of irreparable steel, there could be time taken to simply take a look at it. It is possible that minor repairs rather than major repairs might suffice.

This leads to a third issue--not jumping to conclusions.  There are a variety of negative communication behaviors that can cause problems in families, and jumping to conclusions would be one. But then that would require a whole other blog post.

Increasing Your Self-Control

2012-01-11T08:22:00.000-06:00

There are always new concepts being explored by psychologists. And one fascinating one that I have just recently been reading about is the concept of willpower. It is the ability to restrain oneself from an activity, whether it is eating a dessert, or shoplifting, or sex that one might regret later. This blog post is based on an article in the Monitor on Psychology, a publication of the American Psychological Association. In a recent article, psychologist and researcher Roy F. Baumeister discussed his work regarding will power. He has written a book entitled Willpower: Rediscovering the Greatest Human Strength.

Here are some of the areas which Baumeister lists as being helped by self-control and willpower:
addiction
overeating
domestic violence
sexually transmitted diseases
prejudice
debt
unwanted pregnancy
educational failure
under performance in school and work
lack of savings
failure to exercise

Looking at the above list, it makes one realize just how important willpower is. With it, there is the capacity to form a civilization. Without it, there is chaos and no civilization.

Now we may think of willpower as only something we have to use now and then, as when there is chocolate cake on the kitchen counter.  But in fact research has shown that people use willpower many times a day. It is a capacity worth cultivating because we are going to use it over and over in life.

We all know that at certain times we have more or less will power than at other times. What people may not know, is that willpower can be temporarily "used up."'  Research shows that if people have to resist temptation in one situation, they are likely to have less power to resist in another situation which comes soon afterward. If you successfully resist temptation for an hour to eat chocolate chip cookies you just baked, and then you try to do homework, you are likely to be less able to resist temptations that would take you away from homework.

One might expect that resisting temptation in hour one would be good exercise to resist temptation in hour two. However, while it may help to exercise the self-control "muscle" for the future, it does not help immediately afterwards; instead it hurts or depletes one's immediate ability to exert self-control. In some way, it uses it up for the moment.

So, just as with exercising a muscle, using it helps strengthen it for the long run but may use up its energy and power immediately afterwards. Baumeister refers to this process as "ego depletion." Not only does resisting temptation use up this resource, even making decisions depletes it to some degree. And that makes total sense to me. There have been times that I had to make so many decisions that I was just tired and didn't want to make another decision. It also makes sense to me because I would view both activities as involving the prefrontal region of the brain, so what would affect one capacity could also affect the other.

The good news is that we can increase our willpower and self-control. It is not fixed and unchangeable.  Just like a muscle can be strengthened. Unfortunately, I believe that our society is not training children well in this area today. Moreover, I suspect that drug use works to undermine this ability in the brain.

Surprisingly, glucose (a form of sugar) aids in impulse control. A simple glass of lemonade can improve self-control.

The main point that Baumeister makes in the article is that we do not need to fatalistically accept the idea that self-control is a limited resource. It is not; it can be increased over time.  In the long run, practicing self-control leads to even more self-control.

The Vicious Cycles of Depression

2012-01-06T06:55:00.001-06:00

There are plenty of theories about what causes depression. And many of them overlap with each other in some of their concepts. But here is another theory, one that is often in my mind as I am treating patients. It is not necessarily different from other existing theories, but it has a somewhat different emphasis.

It seems to me that depression is an illness involving numerous vicious cycles. Event A leads to Event B, which leads back to more of Event A, which leads to more of Event B, and so on. There are a variety of these cycles in depression. If there was just one, it would be easier to treat. But there are several, and each keeps perpetuating itself.

The theory doesn't really address the issue of what starts depression in the first place. But it does help explain how a mild depression can turn into a severe one.

Here are some of the vicious cycles which I see in the depressions my patients struggle with:

Cycle #1--Withdrawing from the World. Depression increases passivity and decreases social interaction.   This in turn isolates the person and deprives them of interpersonal stimulation. They don't get the social support and distraction from negative thoughts which they would otherwise get from interpersonal relationships. They are increasingly left alone to deal with negative thought distortions on their own without any corrective input from non-depressed persons. This in turn increase depression. Which increases social isolation. And so on.

Cycle #2--Negative Thinking.  Depression increases negative thinking about self, world, and future. The increase in negative thinking increases the depression level. The more depression a person has, the more negative thoughts are generated in the brain.  This is the basis of cognitive therapy. The cycle of negative thinking to depression and back to negative thinking has to be interrupted.

Cycle # 3--Possible Negative Effects on Nutrition. Depression often decreases the appetite, which in turn may be depriving the person of important nutrients relevant to mood, well being, and health, thus increasing depression, and so on. The depressed person may opt for a high carbohydrate (high sugar), junk food diet because they don't want to eat, or don't feel up to cooking a more balanced diet. They seek out foods that will medicate their immediate feelings, not foods that will provide good nutrition for their brain. Lacking good nutrition, the brain may be more susceptible to depression.  The link between nutrition and depression has not been proven, but there are some studies suggesting that there may be a connection.

Cycle #4--Decreasing Assertiveness. Depression makes people less assertive and less likely to use good problem solving techniques. When people are less assertive, they don't get their needs met. Aggravations in their environment can continue unabated. Problems pile up. And depressed persons generally do not follow well thought out problem solving approaches that would be needed to deal with the stresses they face. The ongoing presence of stresses keeps them depressed. The lack of assertiveness and/or problem solving allows stresses to get worse (such as by building up finance charges on credit cards), which can make the person more depressed. And so on.

Cycle #5--Downward Spiral of Physical Activity. Depression makes people less active, which means that some of the benefits of exercise (e.g., brain derived neurogrowth hormone and so on) are not obtained. (Neurogrowth hormone is a naturally occurring substance in the brain which helps nerve cells grow.) Theoretically, nerve cell growth or regrowth in the brain may be necessary to recover from depression.

The lack of activity also means that the depressed person is deprived of positive environmental stimulation (lights, sounds, tastes, etc.) Even though these stimuli may be less interesting and less pleasurable than when the person was non-depressed, they may still give some pleasure, and these may be almost totally absent as the person withdraws into their house and/or room.

Cycle #6--The Cortisol Loop. Psychological stress causes increases in cortisol. Cortisol has a negative impact on brain function, although we are not sure all of the different ways this may affect it. The impact of cortisol on the brain (or of other stress related chemicals)  may then cause the brain to go into deeper depression. Which causes more negative thinking, less energy, and so on. And so on.

Cycle #7--A Lowering Availability of Mental and Physical Energy to Cope with Stressors. Let's say a person goes into a mild depression. This reduces their energy and likely increases their negative thinking about how much they have to do. A molehill starts to seem like a hill; a hill starts to seem like a mountain; a small mountain starts to seem like a big mountain. There is a perceived difference between what they have to do and overcome on the one hand, and how many resources they have for the task.  The person may get an overwhelming feeling of, "I just can't do it all." This is not just a thought process. It is visceral--felt in the gut. They see their tasks as overwhelming, but they also feel it to be overwhelming because they are so fatigued due to the depression.

These vicious cycles all have the capacity of deepening depression to moderate or even severe levels. For that reason, intervention can be needed to help someone recover.

In other cases, depressed persons may succeed in eliminating the external source of stress.  That is, if they are without a job, they may succeed in getting another suitable position.  In still other cases, time may cause the external stress to seem less important. If we lose a job today, it may feel overwhelming, but in two years, it may seem much less important.

Whatever the reason, the vicious cycles of depression fortunately do not go on forever for most people. If, on the other hand, a person's depression does seem to be going on and on without any let up, then it would be logical to bring in an outside influence such as a psychotherapist, to help break up the cycle.

What Does It Mean to Be Strong or to be Weak?

2012-01-02T08:31:00.000-06:00

One of the things I often hear from patients is that they is that they feel they are weak for having depression, or they feel they are weak because of coming to a counselor.

Because I have heard this so much from my clients, I have thought a lot about that term, "weak," and to tell you the truth I am confused about it. I am still not sure whether it has any place in psychology and in the way we think of ourselves and others.

One way of thinking about depression is that under the pressure of environmental stresses, the brain has quit working properly. (This is an oversimplification, but just stay with me for the moment on this.) Depression means that some pathway in the brain, or some segment of it, is not working correctly. That could be compared to the weak link in a chain. It could be compared with a bridge giving way under the strain of an excessive load. Some grouping of nerve cells has quit operating properly. We talk about a weak link in a chain, so why not talk about "weak" nerve cells?

If a bridge collapses, we would speak of it being weak, or would we? We might simply say that the bridge was put under an excessive load. We might blame the load as being too heavy rather than blaming the bridge for being too weak.

If we were going to talk about the brain being weak, wouldn't we need to talk about "weak" pancreases when people have diabetes or weak bones when there are broken bones? But we generally don't. If a bone is broken, we assume that it was under too much stress--the person fell or was in a car accident. We don't normally talk about weak bones unless the person is old.  We do talk about weak bones when there is osteoporosis. But with younger people, we don't say that they or their bones were weak when a break occurs. We assume that the load was just too much for the bone to bear, as when bones break in an automobile accident.

What do we really mean by saying that someone is weak? Are we referring to "weak" nerve cells?  Probably not. When a depressed person calls themselves weak, they are not referring to nerve cells; their are generally referring to their character.   I think when people use the term "weak," they are really making some kind of a moral judgment.  They are talking about something which is not physical but almost metaphysical--something invisible. If we call someone weak, we are in essence implying that they just shouldn't be that way. They should suck it up and be stronger, whatever that means.

But "strength" is after all only a metaphor. What does it really mean in human behavior? We can measure weakness in structural materials in an engineering sense when a component breaks under pressure. How many newtons or pounds of force are required before a physical object breaks? That is a clear statement about strength in physics. But surely the use of the term "strength" and "weakness" if someone develops a mental disorder is something quite different.

So it comes down to metaphors. Words like "strong" and "strength" and "weak" and "weakness" are metaphors.  The question is are they good and useful metaphors or not?

Actually, I think these terms are bad metaphors because they often make the problem (depression, anxiety, etc.) worse. The metaphor becomes an additional problem Once we refer to ourselves as weak, we then are likely to begin to feel more depressed. Which can cause more negative thinking. Which can make us more depressed. And so on. Moreover, to tell ourselves that we are weak is an attribution which is internal, stable, and generalized, which does not help our feelings of self-efficacy.

Would there be a better metaphor besides being "strong" and "weak"? Perhaps. Perhaps we could say that people are resilient or not resilient. That metaphor makes a certain amount of sense. We have all seen how a blade of grass can bounce back after it has been bent down. It can be resilient and bounce back after a stress.  I don't think any of us would feel nearly as bad about telling ourselves that we would like to be more resilient instead of telling ourselves that we are weak. However, even here we have to watch out for labeling ourselves in a generalized sort of way. For example, most of us are resilient in some situations but not others.  Rather than saying, "I am not resilient," the alternative would be to say, "I am having a hard time being resilient in this situation."

So maybe to say we are weak after becoming depressed makes a little bit of sense, but in the end, but the metaphor bs damaging in its own right because of what it implies. It may be true that some system in our brain was "weak" enough that under a heavy load of stress, it "broke" or quit operating in a satisfactory manner. We felt depressed, quit eating, couldn't sleep, and so on. But I say we let go of that term because for many of us what we really mean telling ourselves that we are weak is that we are flawed, no good, worn out, etc. And that would not be true. And it would bring on more depression.ecom

Here's another problem with the "weakness" metaphor. And this perhaps gets more to the heart of how illogical the metaphor really is. Let's say that a cell can malfunction in two ways. Let's say that it can fire too much or too little. Now let's say that if that nerve cell fires too much, the person becomes more manic. He or she has more energy. The person has more confidence. They take chances. In battle, maybe they get up out of the foxhole and charge at the other line. Now let's say that if the nerve cell fires too little, that the person holds back. They feel tired and unsure of themselves. In battle, maybe they would not charge at the other line. They might appear weak. It's all a matter of whether that nerve cell fires too much or too little. Either way, the nerve cell would be malfunctioning. And that might be a matter of genetics, or even a matter of what moment in time it is. Certainly, a bipolar person could appear super humanly strong one day and "weak" on another day. So if the nerve cell (purely theoretically for this example) malfunctioned by firing less, society would label the person as a coward, and if the nerve cell malfunctioned by firing more, society would laud the person as brave and give them a medal or promotion. The "coward" would be referred to as "weak" and the soldier charging the enemy line as "strong." Recall the scene in the movie Patton where the general was disgusted with the soldier with "battle fatigue" and berated him.

To put it another way, if the cell malfunctions and the person becomes manic, then there is a problem, but the term "weakness" would probably not be used. Other metaphors are used for mania, such as "He had a nervous breakdown."

But now let's complicate it even further. In the brain are excitatory neurons and inhibitory neurons. We would expect that depression would result from too little firing of excitatory neurons. But what if it actually results from too much firing of certain inhibitory neurons? Then the neurons being too active would end up causing behavior which appeared to be "weakness." That would seem somewhat contradictory. Or putting it another way, it's all a matter of which neurons are overly active. Certainly if certain neurons in the amygdala fire a lot then there is anger, perhaps causing bravery on the battlefield. But if other neurons in the amygdala fire too much, then there is anxiety, perhaps causing someone to pull back in battle. It might be just a matter of which set of neurons are firing the most, and they may not be far away from each other in the brain.

When all is said and done, I think it is better not to use the concept of "weakness" in talking about people and psychological problems. It confuses us. It can make us look down on ourselves or on others. It does not lead to solutions of problems. It makes it harder to solve the problem of our depression or the depression of those close to us. What is the alternative? I think there are a variety of ways of thinking about depression without ever referring to weakness. I think that the concept of resilience is a fairly good one. "In this situation I am having a hard time being resilient." That is likely to describe what is going on without adding to the problem.

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

2011-12-23T10:35:00.000-06:00

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.

On Forgiveness

2011-12-12T12:02:00.001-06:00

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.

How Do You Use Your Power?

2011-12-08T08:25:00.000-06:00

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.

A Theory of Life

2011-12-04T08:41:00.009-06:00

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.

A New Kind of Contest

2011-12-01T08:33:00.000-06:00

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.

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

2011-11-30T08:38:00.001-06:00

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?

Some Final Notes Regarding the Book Anatomy of an Epidemic

2011-11-19T07:51:00.000-06:00

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.

If Not Medications, Then What--Natural Healing?

2011-11-16T22:17:00.001-06:00

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.

If Not Medications, Then What? Psychotherapy.

2011-11-13T17:49:00.003-06:00

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, http://www.pubmed.com/. 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

ANXIETY AND STRESS:

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)

DEPRESSION:

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

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

HEALTH PROBLEMS:

*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)

PROBLEMS OF CHILDHOOD:

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

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

MARITAL DISCORD:

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

SEXUAL DYSFUNCTION:

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

OTHER:

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

ANXIETY:

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)

CHEMICAL ABUSE AND DEPENDENCE:

*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)

DEPRESSION:

*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)

HEALTH PROBLEMS:

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

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

MARITAL DISCORD:

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

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

PROBLEMS OF CHILDHOOD:

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

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

OTHER:

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.

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

2011-11-06T06:59:00.005-06:00

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.

Be Kind to Your Therapist and Say Goodbye

2011-10-30T08:56:00.000-05:00

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.

Dealing with Our Hidden Neuroses

2011-10-21T16:56:00.000-05:00

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.

Has the Narcissistic Generation Finally Arrived?

2011-10-14T20:52:00.007-05:00

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.

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

2011-10-11T21:10:00.000-05:00

(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.

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

2011-10-09T21:46:00.000-05:00

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.

What If There Is a Drive to Dis-Affiliate?

2011-09-26T07:55:00.000-05:00

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.

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

2011-09-23T16:23:00.001-05:00

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.

Keys to a Positive Marriage--Building a Positive Cycle in Marriage

2011-09-13T12:53:00.000-05:00

(This blog posting is an extension of my previous one on using positive reinforcement in marriage.)

How does one go about building a good marriage? There are a variety of answers to this. One concept I use in marriage counseling is the concept of positive reciprocity.

Reciprocity is the tendency that most of us have as humans to give back what we get. Most of us are not so saintly that we want to give positive things to people who treat us badly. We generally give back positives to people who treat us positively and negatives to people who treat us negatively. That may or may not be a good idea in real life. Religions have often emphasized the importance of not getting into negative reciprocity. The importance of forgiveness has been emphasized in religion and even in modern psychology. However, that is not the issue I want to get into right now. The fact is that people being people, we can get into a cycle of giving back to others some type of negative interaction when they do something negative to us. In life in general, this kind of negative reciprocity can lead to certain problems. In marriage, it can be disastrous.

When we are dating, positive reciprocity between a couple usually abounds. We are positive towards our partner, and they tend to be moe positive towards us. They say and do nice things towards us, making us feel more positively towards them, and we in turn do and say complimentary things back, etc..

Unfortunately, as marriages age, reciprocal interactions can slide towards the negative. Negative comments are made to us, and we feel inclined to dish it right back. How does that come aboout? How do we slide from positive to negative reciprocity?

First, we lose those incredibly positive feelings which were part of the initial bonding. In the beginning of the relationship, there is that very special feeling. Almost anything the other person does makes us feel special. Just looking at a sunset with them can make us feel that way. We can call it infatuation, falling in love, or whatever, but there is a distinctly chemical state in the brain which makes eveything about our partner more positive for us--at the beginning. It is easy to maintain positive reciprocity in this state.

I believe that many couples confuse this early state of attraction with love in its deeper form. It is easy to be positive towards someone who triggers such positive, biochemically inspired feelings. But the type of love that can sustain a marriage has to go far beyond that. It seeks the good of the other. It is generally forgiving. It values the other person for themselves and not just for what they can do for us; it does not always demand its own way. When that type of love is present, then the slide to negative reciprocity is much less likely to occur. But if we think that love is just the state of feeling good and being treated well by the other person, it is easy to start being negative and verbally aggressive.

If a cycle of negative interaction has begun, an intentional, deliberate focus on positive reinforcement may be able to lead back to that original “positive reciprocity.” It would be unreasonable to expect this type of positive reciprocity immediately. But in the long run, when we want positive behaviors from our spouse, we are most likely to get them for ourselves if we have been giving them out freely. By intentionally giving positive reinforcement to our partner, we can build a reservoir of good feeling. A sense of goodwill can carry a couple through problems.

Building positive reciprocity when there have been hurtful interactions may require you to reorient yourself to a new way of relating to the other person. This can require us focusing on what they do “right” rather than what they are do “wrong.” It focuses away from blame and onto what the other person is doing "right." (“Right” and “wrong” are put in quotes because these are usually defined in our own minds. We may have very distinct ideas of them and "know" that we are right about them, but often times they are more our ideas than they are some type of universal truth. But then, that's another blog.) Simply paying attention to our partner's positive, constructive behaviors can have a beneficial impact on how we feel about them and how they feel about us.

To re-establish positive reciprocity doesn't come easily. It can take time and determination. Most of all, I think, it requires a deep understanding of love and forgiveness. It requires us to be willing to look after the good of our partner and the good of the relationship, and not just what feels good to us in the moment.

Keys to a Positive Marriage--Playfulness and Sexuality

2011-09-05T05:51:00.001-05:00

Relationships often start out as playful, but all too often they end up being routine and too serious. As people age, they often become more serious. Joking and playfulness may stop.

People are living longer and longer, and there are things we need to do so that our relationships don't die from terminal dullness before our bodies give up the ghost. I think that being playful and having the capacity for spontaneity are important to keep our marriages and relationships viable.

First, let's think about what playfulness is.

What is the definition of play? I think any definition would have to include some element of spontaneity for the sheer fun of it. A trip across country can be done in a routine, serious manner or a playful manner. Driving down the road, if one spouse says to the other, "Let's try this restaurant, I've always wanted to try [such and such type of food]," it might be playful according to the above definition--spontaneity in the pursuit of having fun.

Here are some excerpts from Dictionary.com about the word "Play":

fun or jest, as opposed to seriousness
to exercise or employ oneself in diversion, amusement, or recreation.
to do something in sport that is not to be taken seriously.
to take part or engage in a game.
to pretend
to behave in a playful or frivolous manner; fool around
to do something without seriousness
diverting activity
any such form of activity, often undirected, spontaneous, or random
amuse oneself in (a game)
fun, jest, or joking: I only did it in play

One important aspect of play in marriage is sexuality. Hopefully, it remains playful rather than always being pursed according to a formula. I think that too often older married couples approach it with so many preconceived expectations that they are in a straight jacket. They are more likley to have a variety of ideas about what is going to be appropriate, what is going to be satisfying, what "needs to happen," and so on. To some degree this can be good and healthy because it means that they know their partner well and know what is satisfying to their partner. They also know their own bodies well and what gives them pleasure. But on the other hand, this can also make sex overly serious and overly routine. This has to be done, and this has to be done, and this has to be done. One, two, three.

But sex is not the only realm for playfulness. Travel can be play. Exercise can be play. Cooking together can be play. For example watch the portrayal of Julia Childs and her husband in the movie Julie and Julia. Whether accurate to their true lives or not, in the movie Julia and her husband knew how to be playful.

Perhaps one slight word of caution needs to be added. If you are in a relationship and haven't been playful for a long time, your partner could well take it the wrong way. If taken too literally, then certain types of playful statements might taken as being slightly offensive. You may need to help them understand in some way that you are not being serious when you do or say certain things. A wink or a certain look may help them to understand that you are being playful and that you are hoping that they will respond playfully rather than taking what you are saying seriously.

Keys to a Positive Marriage--Belief in the Other Person and Their Growth

2011-08-28T21:58:00.000-05:00

What is love? Is it a feeling of romance? Is it a bonding between two persons? Is it shared experience?

I think it is many things, but let me tell you one thing I believe it is. It is an awareness that the other person is important. They are important not only because you love them, not only because they make you feel good, not only because they are beautiful, not only because they are intelligent, not only because they are funny and sociable, but they are important because they exist. There is a reason for them to exist on this Earth.

Perhaps you don't see it that way, but stay with me for a moment. At least hopefully you believe that your partner has a potential to be something special. My belief is that each person has a capacity for growth for becoming a unique person. They have a capacity for self-directedness and self-actualization.

I sometimes think of life as a trajectory. It is as if we are fired from an artillery piece out into the sky and into the world. Under the best of circumstances, each person traces a very unique arc to their eventual landing place. This trajectory is theirs uniquely, and the quality of their life and the meaning of their life will depend on the success they have in this task.

As a spouse or partner, we can assist the other person in this. Or we can ignore it, or even fight against it. When we are in a relationship, it is likely that at different times, we will probably do all three. But love is helping our partner on their unique trajectory.

There may be times when what is good for the other will rub us the wrong way. Perhaps one partner has a desire to go back to college, and we are worried about what that will do to family finances. Perhaps one partner feels the need to be away from the house to do volunteer work, and we want their time for ourselves. Perhaps the highest grossing wage earner decides that they really need to do something different in life, but it will bring in less money. Things such as this may trouble us or frighten us. But one aspect of love is realizing that our partner needs support and help. They do not need to be encumbered by our selfishness.

This is essentially recognizing the other person as a person, and not as an object or possession. It takes joy in letting the other person be who they are while still staying in the committed bounds of the marriage relationship. While I am not Buddhist, let me use a concept from the Easter religions here. It is the concept of Mudita. (Pronounced moo-di-tah.) This is the idea of taking joy in the good fortune of others. We take joy and happiness in the other person discovering themselves, developing their talents, and being all that it is possible in their being to be. This is in many ways similar to the Christian concept of agape. It is love directed toward the best interests of the other person. It strives towards being selfless rather than just getting our own needs met.

This is not to say that we don't have the right to speak up when our partners do something which offends us. We do have the right. If my spouse wanted to take a trek by herself to the Himalayas, I would definitely speak up. But I need to be aware of her needs and the things which will lead to her self-actualization, even if they don't seem to meet my needs at the moment.

The opposite of this concept is narcissism. In narcissism, I want my spouse to be an extension of me. I want to pull their strings, like one would with a marionette. Or I expect them to behave as a puppet. I see them as an extension of me, and not truly as another person with their own wants, feelings, needs, and trajectory in life.

Now, of course, all of this is very idealistic. It is often beyond our ability to be this selfless. But then, to quote Robert Browning, "Man's reach must exceed his grasp, else what's a heaven for?"

Keys to a Positive Marriage--Using Positive Reinforcement

2011-08-19T08:11:00.006-05:00

It is tempting in marriage to think that our partner is the source of the marriage's problems and then to try to change our partner by making negative comments. Negative feedback is sometimes necessary. But oftentimes criticism changes little if anything. As I have said in one of my earlier blog postings, I'm not sure we can ever change our partner for the better. On the negative side, maybe some people batter their partner into submission with their words or actions, but that is not positive change.

So I don't recommend setting out trying to change your partner. But there is one fundamental principle of psychology which should not be overlooked. And that is the power of positive reinforcement.

Positive reinforcement is good for a marriage in several ways. It shows that you are paying attention not just when your partner is doing something wrong or something you don't like. It shows that you are aware of when they are doing positive, constructive behaviors.

Secondly, positive reinforcement enhances the self-esteem of your partner.

Thirdly, positive reinforcement keeps you positive. It keeps you looking for and being aware of the positives in the marriage. It can make you a better a person.

When it absolutely seems essential to you that your partner change their behavior, then even though I am not sure that it can be accomplished quickly, you can encourage behavior change slowly by using reinforcement. It takes time, and it needs to be consistent. By consistent, I don't mean that positive reinforcement needs to occur every day. But it can't stop for weeks or months at a time.

Start by carefully observing your partner's actions, then reinforcing them when they are acting more positively or doing something which approaches what you want. In other words, wait for them to make a positive change, even if it’s a small one and then reinforce them. Reinforcement increases the likelihood that they will come back at a later time and repeat the positive behavior. Note that I didn't say that it makes them do it again, and I didn't say that it guarantees that they would do it again. I said that it enhances the probability that they will do it again. Nothing is guaranteed here.

It accomplishes this by following their pleasing behaviors with something which is pleasant and rewarding, such as expressing appreciation or doing something nice for them. If the husband is working on something which the wife has been asking him to fix for awhile, she might bring him a sandwich and a soft drink while he is repairing it.

This method does not wait until a full and total change. It waits only for an approximate change before reinforcing the other person. Let’s say that the husband has been complaining to his wife that she isn’t keeping the house as neat as he wants it. One day he comes home and the kitchen is clean and straight, but the living room is still messy. If he comments to her on how disastrous the living room looks, then the wife will feel that her new attempts to change her behavior have been met with punishment. Is she likely to clean the living room the next day? It’s doubtful. She’s likely to think, “Well, if I clean the living room, he’ll just complain about the bedroom.” Even if the husband is totally upset with how the rest of the house looks, he needs to try to be patient, gradually encouraging the type of cleaning behavior that he wants from his wife through reinforcement. Similarly, if the wife is trying to get him to be more involved with the children, it is important that she not wait until he has become the perfect dad before starting to make positive comments.

Positive reinforcement can sometimes build a strong sense of goodwill between partners which carries far beyond the original problem. If the wife reinforces the husband for washing the outside of her car, she may find that he next cleans the inside of her car. And if she keeps reinforcing him, he may go on to do other car related or household chores as well.

One delightful advantage of reinforcement is that we never know where it will lead! It usually leads somewhere positive. One place where positive reinforcement can lead is “positive reciprocity.” This means that we tend to get back what we give. The wife brings a sandwich to her husband in the workshop, and he may give her back a hug. When we start giving out positively reinforcing behaviors to our spouse, we are likely to receive back other pleasant behaviors from them. Now, it would be unreasonable to expect this type of reciprocity immediately. But in the long run, when we want positive behaviors from our spouse, we are most likely to get them if we have been giving them out freely.

Reinforcing your partner may require you to reorient yourself to a new way of relating--focusing on what they are doing “right” rather than what they are doing “wrong.” (“Right” and “wrong” are put in quotes because I am defining them here only by what you want them to do or don’t want them to do.) Simply paying attention to their positive, constructive behaviors can have a beneficial impact on how you feel about them.

Another advantage of responding to your partner’s behavior in this way is that they tend to be more open to other feedback you may give them and less likely to be defensive. It is as if we are saying to them, “You are so wonderful, and all you have to do to keep being wonderful is just keep doing what you are already doing.” Who can resist that? Who doesn’t want to hear that?

What if reinforcement does not seem to be working? Or what if there seems to be little or no opportunity to provide reinforcement? There are times that we just can’t wait around for the other person to do something differently. In this type of situation, we have to be more assertive about expressing what our desires and needs are. By being direct and telling the other person what we need or want, we may be able to prompt them to try something new or different. But it is still important to be ready to reinforce them if they follow through.

When asking a partner to change their behavior, they may become defensive. In order to minimize this, it is helpful to follow a few guidelines:
--Provide the feedback about what you don’t like and the request for what you want from them in private.
--Make the request in a straightforward non-emotional tone of voice if possible.
--Don’t ask for more than one or two changes at a time. Don’t throw everything and the kitchen sink at them all at once.
--Make a positive request rather than a negative request (example: I would really appreciate it if you could speak to me in a calm tone when you are discussing a problem. Try to focus on what you want in a positive way rather than on what they are doing “wrong.”

Keys to a Positive Marriage--Weaving Your Lives Together

2011-07-29T08:06:00.000-05:00

Let me begin with what may seem to be an outrageous statement and then try to explain myself.

There is nothing more natural than two people, married or otherwise, growing apart. The goal of marriage is to prevent that from happening.

Why do I believe this? I believe it is true because in the past, in a more rural society, people shared common goals and interests. Both often worked on a farm or similar setting. Meals were shared in common. Topics of conversation were the crops, the animals, the children, and so on. (Please understand that I have never lived on a farm, but I think the logic still holds.)

Now consider a modern urbanized family. In many cases, both partners have jobs. It is highly unlikely that they work at the same place. They do not know the same people. They have somewhat different stresses and somewhat different focuses to their lives. Each person is brought into contact with other people. These are people who have a similar interest and focus to them individually (banking, law, sports, etc.) but not necessarily for them as a couple. This may make them feel closer to co-workers than to their spouse or partner. I am quite fortunate in that my spouse is also a counselor. So our outlooks are quite similar. Our values are. Our intellectual interests are. But this would make us somewhat of an exception.

When two people originally bond through marriage or long term commitment, there is usually some degree of commonality of interest. But whatever the original common interest, it can change over time. It might be their university, a sport, or the social circle they are in.

As we mature and grow older, we change. Our brains change in ways that science has not yet fully figured out. And our environment (read, job) changes us.

But we can take the time to continue to weave our lives together. If we put the time and energy into it, we can keep things in common. Here are some things which couples might have in common:

a circle of friends
going to university events such as football games
going to church together
having a hobby together (sailing, bowling, etc.)
going to children's sporting events together
participating in extended family get togethers
traveling together to see and share experiences in common
discussing events in the news and sharing ideas
tackling home improvement together (although this can also be stressful on a marriage)
making plans for the future together

You may have your own ways of weaving your lives togehter. The how is not so important here. What is important is to realize that it takes effort to stay within each other's worlds.

Be a part of who the other person is and what they are interested in. You can still have your own interests and individuality. You can still have spaces in your togetherness, as Kahlil Gibran put it. But find ways of weaving your lives togehter. Don't assume that the initial good feelings of love and romance will link the two of you together forever without any further work on your part.

Keys to a Positive Marriage--Understanding and Preventing Escalation

2011-07-29T08:01:00.001-05:00

I am fascinated by how arguments escalate in marriages--both in my own and in others. Being married allows me to study this first hand, and I think I understand a few things about it.

First, I understand how easily it can happen. It can happen more quickly than either partner expects and sometimes out of the clear blue sky.

Secondly, I understand that often feelings and arguments can escalate inside our own heads before we ever say anything out loud to our partner. We can talk ourselves into an emotionally upset state to the point that we are unlikely to be able speak calmly and rationally. This makes it easy for the external escalation (i.e., what we actually say out loud to our partner) to occur. It can occur quite rapidly because we have been thinking things in our head that we haven't yet said; but with a slight provocation, these things then spill right out.

Thirdly, I understand that most of the time escalation can be prevented. It can be stopped early in the process. I believe that for most couples, escalation can be a decision rather than an uncontrollable chain reaction, if we have an awareness of ourselves, what we are doing, and why we are doing it. We can decide whether we are going to escalate a discussion into an argument or not.

Fourth, I understand that many couples practically lose their heads in arguing. (Translation: by "lose their heads" I mean give themselves over to emotional thinking rather than using the rational and logical thinking that their brains are capable of.) They often end up arguing over something very unrelated to the original issue. In marital counseling sessions following a major argument or fight, they often can't tell me how the argument started or how it transformed from the original discussion topic to what they were fighting about at the end. They don't remember.

Now, before going further, I need to clarify my terms. I will talk more about this later, but in a nutshell are some words and phrases about marital communication and what I mean by them:
     talking--logical sharing of information
     arguing--heated sharing of thoughts and feelings; a debate; defensiveness; not really interested in hearing what the other person has to say, wanting to vent to the other person and to defend oneself against what they are saying. Arguing is not helpful but is inevitable at times in any marrige.
     fighting--Fighting means that we want to hurt the other person with our words or hurt them physically. We don't just want to win an argument, we want to batter them into submission and hurt them.

Talking can escalate into arguing, and arguing can escalate into fighting. The arguing is inevitable, I think. Every couple will argue at some point in their marriage, but I don't believe that it accomplishes anything. Fighting is not inevitable. It might be possible for a couple to go through 20 years of marriage and never intentionally hurt the other person just to hurt them. (We might need to elevate them to sainthood, but I think it is possible.) It is different to hurt someone accidentally because you are arguing and to hurt them on purpose.

Here is my suggestion, based on 35 years of my own marriage. Don't escalate.  It can be hard, but it can be done. How?

1. Be determined not to escalate. First you have to have a reason in our own minds not to pursue escalation. We have to decide as individuals and as couples that escalation is not what we want and that it will not help us achieve our goals. That there is no reason to escalate things 99% of the time. (Maybe 0.1% of the time there is such an important principle at stake that you need to be willing to go "all the way" with the argument--arguments over child abuse, spousal abuse, illegal behavior, etc. come to mind)   We cannot ultimately win anything important through argument. We can maybe win the argument about what type of car to buy. But if winning causes resentment in the other person, then we haven't really won anything important. My philosophy in my marriage is that I can't change my spouse through arguing. And rarely, if ever, have I felt that I saw examples of one spouse change another.  That doesn't mean that people don't change; it just means that one person cannot directly change another through arguing and escalation. I believe that I can suggest change. I can give positive reinforcement for change. But if I try to coerce change through escalation, nothing good comes of it. And I believe most marriages are this way.

So, if we can't change our spouse for the better, then why escalate? Probably most of us at one time or another just feel the need to vent our emotions. And that is not all bad. We are human beings after all; we are not saints. Some emotional venting is necessary.

But escalation often brings with it damaging statements that we weren't planning on saying, things which can never be taken back.

Secondly, realize that one partner cannot escalate an argument all by themselves.  They can explode or become abusive, but an escalation of an argument requires two people. Just like a comedian "funny guy" needs a straight man, and vice versa, for the act to work, true escalation needs both people to cooperate. So either person has the power to stop it. Keep that in mind.

Thirdly, if you are in a situation which can escalation, keep track of the back and forth comments. I suggest using the "rule of two." First, state your beef, what's bothering you. Now, let's assume that your spouse becomes defensive. They argue with what you said. Perhaps they didn't understand what you said. Perhaps it has become distorted in their minds. Restate your point more clearly.
And then,
And then,
shut up.

If they are starting to argue or escalate, don't follow up right then. You have said what you have to say. If they are upset, escalation can occur at this point. If they are not upset, let the information roll around in their head for awhile. Or if they are in a reasonable mood, then a good discussion can occur. But if they wanting make it into an argument that would escalate, there is really no need to say anything else. If there is going to be an argument, then they are not really likely to hear what you are going to say next, so why say it right then? Say it at another time when they are calmer.

There are some interesting findings in learning research that suggest that if you want to learn something and want to transfer it from short term memory to long term memory, close your eyes after you read it or see it. This prevents new information from crowding into working memory and competing with the first information. the first information can be better consolidated and stored for the long term.

Similarly, if you follow up an initial important point with an escalating argument, the important intiial information can be crowded out by the subsequent arguing so that they other person does not end up remembering what you first said, which was what you really wanted them to hear.

But what if your spouse wants to argue and wants to escalate? That doesn't mean that you have to participate. You can say that you have really already made your point. You can clarify it as long as the discussion stays on topic and as long as you feel that you are staying in the talking stage, not proceeding to the arguing/debate/defensiveness stage.

Rember that you don't need to have the last word. This may seem to contradict what I just said about the last thing seen or heard is what is remembered. But in learning theory, people remember is most likely to be the first thing in a series or the last in a series. While it was be advantageous for us to have the last word, that doesn't work in most arguments, because each person is struggling to have that last final comment. That is what leads to escalation and even to getting sidetracked.  If we insist on having the last word, we are more likely to have escalation. Both persons want the last word, and because each may be talking over the other, neither may really get that clear opportunity. Moreover, since walls of defensiveness go up during arguments, getting the last word in a marital argument may not have that same advantage of being the last thing learned in a calm college list learning experiment. So instead, settle on having the first word. Bring up the issue calmly. Then don't escalate. It's easier when you have already decided that you are not going to try to have the last word.

Making Marriages Work--Things I Don't Really Need to Say

2011-07-29T08:01:00.000-05:00

In my next few blogs, I am going to be writing about what I think makes a marriage work. I am not going to bother to state the obvious. I won't be writing about not abusing your wife, not coming home drunk, and not having affairs. If you need to be told not to do these things, then consider yourself told. But maybe some of my upcoming blogs on marriage will touch on things that you haven't thought of.

Here are some things which I won't be touching on though. I hope they are obvious enough.

Do not select a spouse on the basis that they have a "kick ass" tatoo.
Do not select a spouse because they are a great drinking buddy and can drink everyone else under the table.
Do not select a spouse because they are a good "fixer upper."
Do not select a spouse on the basis that they are in prison for multiple felonies but deep down really "have a good heart."
Do not select a spouse on the basis that they have been married five times to "no good bums," but now you will have the opportunity to rescue them and show them what a real man or woman is like.

All tongue in cheek comments aside, maybe someone needs to write a list of statements like the above for people who need it. But I think that has already been covered by Jerry Springer and Dr. Phil.

So it is time to move on to more serious blog postings on marriage.

Understanding Psychotherapy Research and Evidence Based Practice

2011-07-09T21:08:00.000-05:00

A recent trend in psychotherapy due to the abundance of psychotherapy research has been a call for "evidence based practice."

Let's take a look at what that means and what may be in store for us in the future.

First of all, this movement means that there is a desire to protect the public from quackery. If, as a psychotherapist, I am constrained or compelled to only use empircally validated techniques, I cannot just use whatever comes to mind at that moment. I cannot tell my patients to wear copper bracelets to get better. I cannot simply smile and be pleasant.

Secondly, it means that some traditionally accepted treatments may not make the cut either. For some disorders, psychoanalysis may not have been shown to work. Hypnotherapy may not have been shown to work. Transactional Analysis or Gestalt Therapy may not have, either.

Thirdly, it means that patients have a fighting chance of getting better. No therapy is perfect. No therapy has been shown to work 100% of the time. And even when therapy works, it often does not work 100% effectively for an individual. But the patient has a fighting chance because people have been shown to get better with that therapy.

Now let's look at some drawbacks to movement. First, just because a treatment has been shown to be effective doesn't mean that my patient may be ready to accept it. Exposure to a feared stimulus (phobia) has been shown to be an effective treatment for that type of anxiety disorder. However, patients may not want to use that treatment because it means that they have to confront the feared stimulus first.

Secondly, while research has shown certain treatments to be effective for certain disorders, it is important to understand what that means. It means that there is a statistically significant difference between the beginning and end of treatment or between two groups--a treatment group and a control group. It does not mean that people receiving that treatment get "well."

Thirdly, just because a treatment has not been shown to be effective does not mean that it isn't. It may only mean that no research group has devoted the time and monetary resources to test the treatment. A treatment rejected today because of lack of evidence could well be supported by research next year.

Fourthly, when a patient walks into my office, they often do not want to be treated as a disorder. They often do not want to be known as a case of "agoraphobia." And so they may not want a packaged treatment for that disorder. They may want more than anything for someone to just listen to them. What if the empirically verfied treatment does not call for "listening" as a primary therapeutic ingredient?

Fifth, the patient may not tell me why they are there at first. Shame may keep them from revealing the true nature of their issues until they get to know me better. What if I start treating them for the symptom picture they present with, but then six sessions later they tell me a rather different issue that really what is bothering them the most?

Sixth, patients are complex. They are rarely just a single symptom picture. They often have several different symptom issues, such as ADHD, mild depression, and anger issues. Which of the three guides me in determining the empirically verfied treatment?

The above problems are not to say that we cannot or should not use empircally verfiied treatments. We need to. The history of psychotherapy research (only about fifty years) has been productive in testing out some treatments and helping us understand what works. It also has pointed to the importance of the therapeutic alliance in therapy outcome. Psychotherapy has to be scientific to the extent that it is possible. It is not mumbo jumbo. Or if it is, then it needs to be taken out of the field of medicine.

But psychotherapy is somewhat unique in the field of medicine. If a person needs a shot, or an MRI, or an antibiotic, then the doctor's pleasant demeanor is a nice bonus. But it is not totally necessary. The relationship is of utmost importance in psychotherapy. The patient is not an object. They are a person. And that is why the who issue of evidence based practice has to be approached very carefully.

Three Ways of Thiinking about Self-Esteem

2011-01-26T12:24:00.000-06:00

I believe that there are three ways that people attempt to establish feelings of self-esteem. Self-esteem has to be based on something. We may base it on our achievements, our relationships, our intelligence, but it has to be based on something. Let's look at three ways that people try to develop feelings of significance:

1. Spiritual/humanitarian ways of thinking about self-esteem.
2. "Normal", everyday ways of thinking about it.
3. "Neurotic" ways of thinking.

First of all, what do I mean by "Spiritual/humanitarian"? This could include Judaeo-Christian beliefs, such as the idea that we are all created by God. It could be the idea that we have value because we are human beings. It could be based on values, such as the importance of honesty and integrity in living one's life. It could be based on the idea that all human beings have innate worth no matter who they are or what their situation.

Then there is the "normal" or "everyday" ways that people base self-esteem. We feel good about ourselves when people like us, when we do well on a test, or when we achieve something. We feel good when we are attractive and people seem to want to be around us or to date us. We feel good when we are sought out for our skills. There is nothing wrong with these, and they can be healthy. But these ideas sometimes let us down. That is, sometimes people don't like us. Sometimes we don't do well on tests. And sometimes we lose a job. Moreover, many of these things don't really change anything inside of us. That is, if somebody likes me, it doesn't reach inside of me and make me a better person. And the same person who likes me today may disapprove of me tomorrow. I can't have changed over night. So some of these are more externally based than internal to us. And if they are external, then they can't really have that much to do with us and our significance. It's okay to feel good about these things, but they can let us down.

Thirdly, there are the "neurotic" ways of basing self-esteem. The word neurotic is a somewhat dangerous word. It has no clear meaning, and people can use it against themselves as another negative thought. In cognitive therapy, we might call these "dysfunctional assumptions," or "irrational beliefs." Call them what you will, they can cause self-esteem problems. Some of these I have already written about:

I must be approved of by everyone to be worthwhile;
I must be loved by the person that I loved to be worthwhile;
I must be in control at all times to be worthwhile;
I must achieve great things to be worthwhile;
I must be perfect to be worthwhile.

There is nothing wrong with wanting people to like us. There is nothing wrong with wanting to be loved. And so on. But the neurotic beliefs are inflexible. They do not allow for our humanity and for the ebb and flow of human experience. We will not always be perfect, and we will not always be liked. We will not always achieve. We will not always be loved by the people that we want to be loved by.

It is sometimes possible to meet the neurotic beliefs for awhile. We may be the smartest in our school--for awhile. We may be the most popular--for awhile. We may be the most beautiful--for awhile. But these canl not always be true for all times and all situations. And when the neurotic need or belief is not met, we will feel a tremendous sense of let down, and maybe even depression.

So in my way of thinking, it is good to start with a religious or philosophical base for our self-esteem. Then we can build on top of that with the things which will sometimes work for us and sometimes won't--the success, approval, and love that most of us want. And we need to stay away from the inflexible and problematic neurotic beliefs which can really hurt our self-esteem. If we set up overly stringent standards for ourselves, we will fall short at some time. It is inevitable that at some point we will not meet the standard. And to be frustrated by the inevitable is to be inevitably frustrated.

Spirituality and Psychology

2011-01-17T08:08:00.003-06:00

Increasingly, psychologists are recognizing the importance of spirituality. In a recent article published in the American Psychological Association magazine for psychologists, "A Reason to Believe," Beth Azar looked at some of the psychological benefits of spirituality.

She noted that since Sigmund Freud, some psychologists have seen religion as unhealthy. However, research is now showing that it is in many ways just the opposite--a very important part of human existence. Despite the 20th century movements of communism and atheism, 85% of the world still has some type of religious belief.

One important role of religion is to create "increasingly larger social groups, held together by common beliefs."

Religion provides a sense of certainty during times of angst and uncertainty. People search for meaning and order and find comfort when they find it.

To some degree, the tendency to believe may be innate, and it may have to be "taught out of us." One psychologist found that "children as young as age 3 naturally attribute supernatural abilities and immortality to “God,” even if they’ve never been taught about God, and they tell elaborate stories about their lives before they were born, what Barrett calls “pre-life.” "

Some areas of the brain have been found to be more active during religious contemplation. Buddhist monks who were meditating used the attentional areas of the frontal lobes more intensely.

Spirituality seems to lead to people having longer lives. Religious persons live longer, have less depression, abuse substances less, and may take care of their health better.

Religion also leads people to be more prosocial. They are more cooperative and more fair with strangers.

There is much more that could be said here. The field of the psychology of religion keeps growing. Some researchers are believers and some are not. Either way, we've come a long way since Sigmund Freud and the knee jerk reaction that says that religion is pathological.

Captain Kirk and Mr. Spock

2011-01-16T22:28:00.001-06:00

Why are the Star Trek movies and TV series with Captain Kirk and Mr. Spock so popular? And what have they to do with psychology? After watching the new Star Trek sequel for the umpteenth time, I have realized that the Kirk/Spock duo represents many of the dualities that all of us experience in our own brains. Kirk is more intuitive (right side of the brain), and Spock is more linear in his logic (left sided). Kirk is more impulsive (limbic system), and Spock more restrained (frontal lobe executive functioning). Kirk is more emotional (again limbic system), and Spock is again more restrained.

Of course, Kirk would make a lousy starship captain if he were only a limbic system with a little bit of right sided neocortex. But still, he and Spock clearly embody the conflict(s) that occur between different parts of the brain. Perhaps one of the reasons why we enjoy watching them so much is that we experience these conflicts every day of our lives. In each situation, we have to decide whether to respond out of logic or out of emotion.

From a neuroscience point of view, the question is whether we only get to use one part of our brain at a time, or whether we get to "have it all"? That is, does one part of brain have to win out over the other part in each situation? Or do we get to integrate the different parts so that "all of us" gets to participate in different situations? Ideally, we get to integrate the different parts so that "all of us" gets to participate in any situation.

It is interesting that in the sequel, Kirk lands at the top of the hierarchy once again. We wouldn't have it any other way would we? We don't want to lose our humanity--our emotions and the ability to act slightly impulsively at times. But the whole sequel movie is a conflict. It is not resolved quickly and easily. And maybe our brains are relishing every moment of the conflict, then getting to observe a nice neat resolution at the end. We, however, don't have a nice neat resolution. We continue to struggle every day of our lives trying to figure out just how we are going to resolve the conflicts inherent in our own brains.

Rewiring Our Memories, Removing Fears, and Treating PTSD

2011-01-14T07:55:00.000-06:00

The future of the treatment of PTSD (Post Traumatic Stress Disorder) may lie in a unique combination of psychological and pharmacological intervention. In the past, these two have been used separately, or side by side, but not actually in an interactive way.

Memories, it turns out, are not as permanent as we once thought. Once a memory is activated, the brain then turns around and reconsolidates it. However, if this process is interfered with, then the reconsolidation process doesn't work quite right. If there is an emotional memory (such as a car accident, or a battle), the fear can be stripped away from the objective memory by interfering with the reconsolidatoin of the fear memory.

In the original research on this issue, researchers made rats fearful of a situation. Then they found a way to make the rat recall the situation. But they also gave the rat a protein synthesis inhibitor (with the theory that memory formation involves protein formation in the brain). The rats no longer attached fear to the situation as they did before.

This could ultimately be one of the biggest breatkthroughs in all of psychotherapy, finding a way to detach painful, overwhelming feelings from past memories.

Currently, the protein synthesis inhibitors are not available for clinical use. Beta-blockers (heart medications) are being used instead, which may or may not prove satisfactory.

Testing For Attention Deficit Hyperactivity Disorder

2011-01-13T08:14:00.000-06:00

How does one go about testing for ADHD? Ideally, there will be multiple viewpoints and data sources. The major data viewpoints are:

clinical interview with patient and parents, if the patient is a minor
some basic measures of depression and anxiety (these have to be ruled out as causes of ADHD)
some rating scales to be completed by the patient
rating scales to be completed by the parent or spouse
rating scales to be completed by teachers
a computerized test of attention (vigilance)
sometimes, an IQ test (more about this below)

Let's take these one at a time.

The clinical interview is absolutely necessary. It is important to hear what a patient has to say, and it is also important to observe their behavior. I usually conduct a full clinical interview. That is, I don't just assume that the problem is ADHD. I ask about all typical areas of childhood problems, including depression, anxiety, psychosis, and even eating disorders.

When it comes to the ADHD symptoms specifically, I ask the child first what their thoughts are about a symptom (e.g., "Do you have a problem keeping your attention going in class?") and then ask the parent for their opinion, so that I have both perspectives.

I use a self report depression inventory and a children's anxiety inventory, which I read to them. Depression and anxiety can cause attention problems. I also want to know if their ADHD is causing them to have low self-esteem or depression.

If the child is a teenager or older, I use a self-report ADD questionnaire. There are ADD questionaires for children, but generally I only use self-report questionaires for teenagers and adults. I use the Brown ADD Self Rating Scale for ADD.

I also use the Behavior Rating Inventory for Executive Functioning. This measures executive functions, which I have written about elsewhere. It measures nine different types of executive functions.

Problems with self-monitoring (being aware of how one is acting and how it is affecting others)
Problems with initiating tasks
Problems with working memory (being able to keep things in short term memory to perform actions on them, such as remembering a phone number from the time of reading it in a directory to the time of dialing)
Problems with planning and organizing time
Problems with task monitoring (being aware of whether a strategy on a task is working)
Problems with organization of materials
Problems with inhibiting impulses–causing acting out and impulsivity
Problems with shifting from one task to another when needed or shifting from one problem solving strategy to another when one is not working
Problems with controlling and modulating (smoothing out) emotions

I use the Conner's Continuous Performance Test-II to measure vigilance over a 15 minute period of time. The Conner’s Continuous Performance Test-II is a computerized test of attention which lasts approximately 15 minutes. It does not measure brief bursts of attention (as measured by some of other types of tests); rather it measures the ability to continue to attend to a simple vigilance task over a period of time.
I use the WISC-IV or WAIS-IV to measure IQ. I am not really all that interested in IQ. IQ is in my opinion an oversold concept. The full scale IQ of someone is not nearly as interesting as understanding what their strengths and weaknesses are. The Wechsler scales have four major indexes and a minimum of ten subscales. I want to know if the child's IQ accounts for their problems in school. I also want to know if they are showing any problems with working memory. Other items of interest on the WISC or WAIS are the comprehension subtest, measuring social comprehension and the processing speed subtests.

Sometimes, a measure of intelligence is needed, particularly if there has been poor school performance. However, the IQ measure does not really tell us much about whether ADHD is present. Instead, it helps us to know whether the child is underperforming in school, or whether poor grades are perhaps due to something else. Sometimes, a learning disorder is thought to be present, and an achievement test may be needed. Usually, learning disorders are diagnosed by comparing achievement testing with IQ tests. Learning disorders are often present in ADHD. However, ADHD proper does not need IQ tests or achievement testing for diagnosis.

The Problem with Being Nice

2011-01-12T15:33:00.001-06:00

In our culture, we often teach girls (and sometimes boys) to be "nice." Nice people are easy to get along with. And they probably serve an important function in our society, helping everyone to get along. They are conciliators. I enjoy being around nice people.

However, "nice" people are often not assertive. They have been taught to sacrifice themselves and their own feelings for the sake of pleasing others.

In fact, one of the dictionary meanings of the word "nice," is "pleasing." To be always pleasing to others can mean sacrificing ourselves and our own needs. It can also cause anger to build up inside of us, so that it may eventually come out in a blow up.

There is nothing wrong with being "loving." I would view being "loving" as an active emotion. It can be very benevolent. But it is not always "nice." If a child is acting up and needs to learn better, prosocial behavior, they may need to have firm limits set on them. And the same is often true for adults. If we really care about someone else, we sometimes need to speak up to give them feedback about how they are behaving. But this may not be perceived as "nice."

However, I am not advocating the opposite. I am not advocating being grouchy, rude, unconsiderate, or aggressive. Those attributes carry with them their own problems, both for oneself and for others.

Being "nice" can take its toll on a person. It encourages passivity rather than activity and assertiveness. Be benevolent. Be loving. Be active. Be creative. But watch out about being too "nice."

Teaching Children How to Do the Hard Thing

2011-01-11T12:40:00.000-06:00

There are many theories about how to raise children, and many have a great deal of truth to them. For example, I like the ideas emphasized by concepts such as nurturing, using positive reinforcement, modeling positive behavior, and so on.

I want to write today about one part that may be overlooked--the development of good frontal lobe functioning by teaching children to do the "hard" thing.

I remember one child saying to me in therapy, "I know how to do the (math homework) questions, so why do I have to keep doing more and more math problems?" There are probably a variety of good reasons for this. But here is one: Life often requires us to do the hard thing, to persevere, and to "hang in there" when we would just like to give up.

The act of persevering is stimulating to the brain. We are learning how to do the hard thing. We are learning how to motivate ourselves, to organize activities, and to find ways of staying with them until completion. All of this builds better neural systems in the brain. Learning how to do anything builds neural networks. Doing 20 math problems instead of two is building at least two different sets of neural networks--one for math, and one for perseverance.

If I could give my children just two sets of cognitive abilities, one would be to have a good sense of values, and the second thing, right behind it, would then be a good set of frontal lobe executive abilities.

The term "executive function" is not widely used in our culture--yet. It refers to the function of the prefrontal lobes. Other lobes of the brain may have primary sensory (e.g., visual or auditory) functions or primary motor function areas. There are no such primary sensory or motor areas in the prefrontal lobes. That is the area which ties everything together and makes things happen. Hence it is termed the executive function area. Think of a manufacturing business. One part of it takes in raw materials. Another arm of the business transforms raw materials into a product. Another arm of the business ships out product. Another arm of the business collects money. But the executive administrative offices may not appear to be doing anything at first glance. Yet they tie everything together and make things happen. The same is true of the prefrontal region of the brain. They tie everything together and make things happen.

My chance to teach executive functioning to my children is over. And fortunately, my grown children seem to have excellent executive functions. Maybe I will have a chance to do that next with grandchildren, although it won't be up to me how to structure my grandchildren's lives.

But I hope that in the midst of a loving, tender, caring home with good role models, that they will also have to learn to do the hard things in life. (I am not saying to do the hardest things, but hard enough to develop those prefrontal neural networks.) I hope that when they reach adulthood, their prefrontal regions have been well developed and well established. Then, when combined with a good set of values, they will be in a good position to reach their goals.

Reasons Not to Commit Suicide

2011-01-10T07:25:00.004-06:00

One of the issues that all mental health professionals have to deal with is helping people past suicidal thoughts at times. Life can become so painful that suicide may seem like the way out for some people. Here are some of the things which I tell my own clients when this issue comes up.

Suicide is closely related to hopelessness and to negative thoughts about the future. Persons who commit suicide are generally convinced that there is no other way out for them. This is not true. There are better solutions to problems than suicide. If you are concerned that your depression will always be with you, then keep in mind the fact is that even severely and chronically depressed individuals can have long periods of time in which they are not bothered by depression or mood swings. Most depressions come to an end and do not go on forever.

Since hopelessness is so closely associated with suicide, it is vitally important to find a reason for hope. In this regard, it is important to avoid catastrophizing and fortune telling. The suicidal person believes that the future will be bleak and full of despair. Some examples of typical fortune telling thoughts are:
“I’ll never get over this depression.”
“I’ll never be happy again.”
“Now that I’m divorced, I’ll always be alone.”
“I’ll never find someone else that I can love or who will love me as much.”
“I’ll never find another good job. I’ll always be scraping by from now on.”

The suicidal person often anticipates that something dreadful and intolerable is about to occur. However, the future is almost never a sure thing. There is no way of knowing with certainty what is going to happen. Even if it appears fairly definite that something bad will occur, it may be that you are not just afraid of the event itself but of something which you think will follow it. For example, if you are sure that your spouse is going to get a separation, maybe what you fear most is the idea that she will take the children away and that you will never see them again. The likelihood of a separation may be almost certain; the probability of divorce may be somewhat less sure; and the chances of her taking the children away where you could never see again them are even less likely. The farther into the future a person is predicting, the more doubtful it is that their fears will actually come true.

Suicidal individuals often have the thought that others will be better off without them. “No one would miss me if I’m gone.” “I’m worth more to them dead than alive.” These are examples of the extremely distorted thinking that can occur in depression. The grief, pain, and suffering of family members after a suicide is often overlooked or discounted by the depressed person. Suicide is not a noble act. It is does not take a burden off the family--just the opposite. It is a desperately self-centered act which can burden survivors with feelings of guilt, anger, and depression for years to come. It is important to realize that underneath the selfless sounding words of “taking a burden away from the family” through suicide, the depressed person is sometimes actually very angry.

HOWEVER MUCH SUFFERING SUICIDE SAVES THE DEPRESSED PERSON, IT PUTS MUCH MORE ON THE FAMILY OF THE PERSON TO DEAL WITH.

Suicide is often more of an expression of anger than selflessness. When this is realized, then the suicidal person can find more appropriate ways of dealing with their anger.

Suicide can be thought of as a last ditch, desperate means of solving a problem. The problem usually consists of an external component (such as a legal problem or a relationship disappointment) and an internal feeling of pain. The person usually feels that all possible means of dealing with the problem have been exhausted and that there are no good alternatives left. Usually, this is not true, although it may be necessary to get help from a friend or therapist to see the alternatives which have been missed. Get someone to help you see some new solutions to problems that you have not yet been able to see. Get away from any rigid, all or nothing thinking. When persons are stuck in trying to solve a problem, they often feel that there are only one or two ways to solve it. When they feel that neither of them is working, then they tend to feel helpless and hopeless. In reality, there are often a variety of solutions to a problem. None of them may be perfect, but almost every one of them is likely to be better than suicide. Oftentimes, there may be multiple problems, which is particularly confusing to a person who is already depressed, tired, and having difficulty concentrating. A therapist can be very helpful in pulling apart the different problems and helping to find solutions for each.

Distracting Yourself Until Suicidal Thoughts Pass

Usually, suicidal thoughts don’t last for more than a few hours at a time. By remembering that such impulses usually pass, it is easier to find ways to distract yourself temporarily. If you can get past the moment, then you may change your mind about wanting to kill yourself. The first step is just to get through the night or the next few hours. Contact a friend. Then reconsider your situation. Delay acting on your suicidal thoughts. Keep your choices open. As long as you are living, you have the choice to stay alive or not to. But once you are dead, you have no choices. Give yourself the chance to change your mind. Once the crisis passes, develop a plan for how you will deal with the thoughts and impulses if they occur again.

AS LONG AS YOU ARE ALIVE, YOU HAVE OPTIONS. ONCE YOU COMMIT SUICIDE, ALL OPTIONS ARE GONE.

Obtaining Help and Social Support

Don’t isolate yourself. It is vital to garner social support. It’s time to call in your favors from people. This is no time to be independent and strong and to try to go it alone. Suicidal thoughts and actions are often triggered by the loss of a relationship. If you have lost a person through divorce or death, then your needs for companionship are likely to be greater. You may be feeling intense loneliness. Ask for help. Set up a support network of individuals who understand your feelings and who agree ahead of time to be supportive.

If there is a family crisis behind your urges to kill yourself, it may be helpful to turn to the member of the family who is most stable, supportive, and calm for help. Let that relative know that you have a problem and what it is. See if there is something they can do tho help you through the crisis.

If you feel that you are facing overwhelming demands that you cannot possibly fulfill or carry out by yourself, ask for help from others. If your family is not willing to provide the support that you need, there are people who will be glad to help you, such as local telephone hot lines, depression support groups, church groups, friends, a therapist, a minister, and others.

Form a strong relationship with your therapist. They are there to help you. If you feel that you need more frequent sessions with your therapist, ask for them. If your therapist does not seem to give you the amount or kind of support that you need, discuss that issue in your therapy session. Find out what the rules are about contacting them in a crisis. However, don’t stop at finding out what the therapist’s guidelines are.

Making a Contract

Make a contract with a friend or family member to stay alive. Have a firm agreement to call them and to see them before hurting yourself. Some persons are leery of making such a contract. They feel that they are giving away their freedom to someone else. Two things need to be said about this. First, you are not giving away your freedom. You are preserving it. As already mentioned, dead people are not free; only living people are free. Secondly, if you cannot make an indefinite contract, make a contract for a limited period of time--a month, two weeks, or even one week. That way you are not committing yourself “forever.”

Create a contract between you and your therapist that you will not harm yourself before coming in for another session. (It is not enough only to contract that you will wait until talking with them on the phone).

Avoiding Alcohol and Drugs

Avoid substance use because it increases the chances of following through on suicidal thoughts. Drugs and alcohol impair judgement and lower a person’s inhibitions. Moreover, alcohol and many drugs are depressants. If you need a medication to help you feel better, get a prescription for an antidepressant or anti-anxiety medication from a physician. However, make sure that the doctor knows that you are suicidal so that she can prescribe one which cannot be used to harm yourself.

Give Away Any Means of Suicide

Make it harder for you to kill yourself on a whim or an impulse. Give any lethal medications or weapons that might be used to hurt yourself to someone else. Get rid of all guns in the house. Don’t leave temptation lying around. You may even need to avoid driving at times if you find yourself having the impulse to wreck your car.

The Two “Yous”

There are in reality two ”you’s”. There is the suicidal you in the present, and then there is the you in the future that will be glad to be alive. Your therapist and friends are trying to keep you alive because they know the future “you” will be happy to still be living. Not all of your personality wants to commit suicide. The fact that you are still alive to read this means that a part of you has not wanted to die and has kept you alive up to this point. Remember that suicide is a permanent solution to a temporary problem.

What Is the Difference Between a Psychologist and a Psychiatrist?

2011-01-09T08:09:00.001-06:00

This is a confusing question for many people, but also a very important one, as people seek out help with mental health issues. Do they need a psychiatrist, or a psychologist, or a social worker, or a licensed professional counselor? Some states have other licenses and certifications as well (such as marriage and family counselor). I'm just going to deal here with the distinction between a psychiatrist and psychologist.

There is a basic difference in training and in method. In the beginning of psychiatry (early 20th century or late 19th century), there was a beginning in medical research, neurology, and Freudian theories. In the beginning of psychology, there were laboratory studies of animal behavior, study of child development, and school psychology. These two different beginnings led to two somewhat different perspectives on human behavior, each valid and useful.

In addition to there being differences in perspective, there are differences in training. A psychologist gets a four year bachelors degree, then four to six more years for a Ph.D. and a year for internship. Sometimes there is an additional year or two of a postdoctoral fellowship.

A psychiatrist gets the four year college degree, then four years of medical school, and then four years of residency. If they are a child psychiatrist, there are two more years of residency for that specialization.

Then in addition to differences in training, there are differences in treatment methods. Both psychologists and psychiatrists can do psychotherapy. However, in the United States, psychiatrists often see patients for 10-20 minutes for medication treatment, leaving the psychotherapy for non-MDs. Psychologists, on the other hand, spend most of their time doing psychotherapy, usually 45-55 minutes at a time. Psychiatrists can prescribe medication and order laboratory tests and interpret them. Psychologists cannot. And while theoretically psychiatrists can do some basic psychological testing, it is not really part of their training, and they usually do not attempt it beyond short questionnaires. Psychological testing is often a major part of a psychologist's training.

Oftentimes, a psychiatrist and a psychologist will refer patients to each other and have a close working relationship. For some professionals, however, there is more of an antagonistic relationship, which is unfortunate for patients. Much of the research literature suggests that combined psychotherapy and pharmacotherapy is a superior treatment to either alone. So it is usually in the patient's best interest to have the option of seeing both a psychiatrist and a psychologist.

If you are seeking out treatment, you may want to consider seeing both a psychiatrist (or some other physician) and a psychologist (or some other non-MD psychotherapist). But which one do you go to first? The answer is generally that the more severe the symptoms are, the more logical it would be to start with a psychiatrist. If there are hallucinations, delusions, or an inability to go to work, then medication is generally necessary. However, if the issues are milder, or if there are family or relationship problems, then starting with a psychotherapist is generally a good idea.

Don't Let Your Grief or Loss Turn into Depression

2011-01-08T06:26:00.004-06:00

Very often, I work with people who have recently suffered some type of important loss in their life, usually a spouse or significant other. The loss can be through death, divorce, or the break up of a relationship.

This process is almost always painful, but it is important in these situations to separate out the necessary pain from the unnecessary pain. The necessary pain is the grieving. Grieiving is the way that the mind detaches from someone with whom the grieving person has bonded. Grieving hurts badly, and I wish that it was not necessary, but it is.

On the other hand, depression is not necessary. Depression is more severe, more pervasive, more disabling, and to some degree has a different symptom picture. "Uncomplicated grief" is different from grief that develops into depression:

In grief, the negative thoughts tend to be more realistic, such as "I will miss them terribly," or "they were unique," rather than "I will always be alone" or "There is no one else that I can be happy with."
Similarly, feelings of worthlessness are not part of grieiving. To the degree that guilt is present, in grieving the feelings are limited to specific incidents regarding the deceased; in depression, it may be more pervasive or illogical.
In grief, suicidal thoughts are usually not present.
In grief, there is usually not the intense psychomotor slowing (slowed thoughts and movements).
In grief, there is usually not too much work impairment.
Depression tends to be more pervasive, and nothing may lead the person to feel much better, whereas in grieving, the support of friends and family is more likely to help the person.

There are probably at least four pathways by which grieving becomes depression.

Pathway #1. Negative thinking. In this pathway, the person doesn't simply miss the person that has died or left them; they attach very severe negative interpretations to it. "I'm a loser; I will never find anyone else; I'm ugly; it is my fault that he left me; I'm being punished by God by Him taking my husband away."

Pathway #2. Excessive withdrawal from life. Many of us have a tendency to withdraw and "lick our wounds." To some degree this is normal. However, it is quite possible to withdraw so much that we interrupt the flow of our daily lives. We pull back from life so far that we cannot recieve any social support. We may pull back from pleasurable experiences in general.

Pathway #3. Triggering an underlying genetic tendency towards depression. For some people, the depression is not due to what they are doing or thinking but to the way their brain responds to stress. They may have already experienced major depression in their life. In this case both medication and therapy may be needed.

Pathway #4. The triggering of old memories. The loss of someone in adulthood may trigger painful, unresolved feelings from some event very early in life, such as the death of a parent. Again, therapy might be helpful in this situation.

In general, when I am helping someone who is going through this process, I try to allow them to grieve in whatever way is comfortable to them, but within limits. I try to keep them from falling into the trap of excessive negative thinking, or from pulling back so much from life that they have no enjoyable experiences.

Can Bipolar Disorder Cause Dementia?

2011-01-07T08:18:00.001-06:00

We normally think of bipolar disorder as a treatable for most patients. My experience is that if the patient is compliant with treatment (and that is a big "if"), then symptoms can be mostly controlled.

Unfortunately, there is some evidence that some persons with bipolar disorder may eventually develop more enduring memory problems and other cognitive deficits. I frequently have bipolar patients referred to me for assessment of memory problems or evaluation for possible dementia, and usually I do find mild to moderate problems.

Most of the patients referred to me in this situation are in their fifties, not in their sixties, seventies, and eighties, as usually occurs when I am testing patients for dementia. This suggests to me that there is something very different about this process than Alzheimers. It seems to develop earlier in life, causing problems in one's job. In addition, the patient seems to have more insight that they are having problems, whereas many of the patients with Alzheimers are brought by their family members and do not have insight that they are having cognitive problems. However, if there is such a thing as a bipolar dementia, we do not as yet have a clear picture of what t would look like in terms of specific symptoms like to differentiate it from Alzheimers, ischemic dementia, and so on.

In a situation of testing a person with bipolar disorder, it is always possible that their memory problems are actually due to their depression. Depression causes a generalized decrease in brain function and interferes with memory. And so, part of the evaluation always has to be looking at the current severity of depression. But the cognitive deficits associated with bipolar disorder do not appear to be linked to whether the person is currently depressed or not. There seems to be something else going on. It is possible for example that the excessive cortisol release caused by depression and mania over the lifespan have damaged the hippocampus, so that even after depression improves, there is a memory problem.

Three factors tend to make the problem worse: older age, having an onset at a younger age, and having a more severe illness overall. There is some evidence that the more episodes of depression and mania, the greater the cognitive deficits may be. Thus, the cognitive deficits in later life may be preventable if persons take management of their illness seriously and treat it conscientiously.

Problems occur in other aspects of brain functioning besides just memory. These include problems with executive functioning, concentration, and visuospatial skills.

The cognitive problems appear to be persistent and sometimes severe, so that sometimes a diagnosis of dementia may be appropriate. Usually, I do not diagnose dementia with these patients because the symptoms are not quite severe enough. I use the milder DSM-IV diagnosis of Cognitive Disorder Not Otherwise Specified. Until we have more information about the reversible or irreversible nature of this illnes and how it responds to treatment, I prefer to use the less serious diagnosis.

Psychological Testing for Dementia and Alzheimers

2011-01-05T22:08:00.000-06:00

I have written a little already about psychological testing in general. One of the types of testing which I mentioned is testing for dementia.

People often confuse dementia and Alzheimers. Alzheimers disease if a form of dementia. Often, it is difficult to tell the difference between Alzheimers and other forms of dementia. What are the other types? Ischemic dementia involves disease of the small blood vessels of the brain, with occlusions (or blockages) starving brain cells and causing small areas of death. The areas may be small, but the process is occurring over and over. Ischemic dementia is also called white matter disease (because the small strokes are occurring in the deep whtie matter) or multi-infarct dementia (because of the repeated small infarcts, or strokes). Sometimes multi-infarct dementia can be detected by the "spotty" pattern of results. That is, a patient does well in some areas and poorly in others, rather than doing poorly across the board on cognitive tests. There are other dementias as well. Frontotemporal dementia is somewhat different from the other dementias because its meain features are problems with impulsivity and executive functions.

Here is a basic dementia battery that I generally use:

Clinical interview--There always has to be a clinical interview. And there generally needs to be collaborative information from family, radiological results, nursing staff, etc. The clinical interview needs to rule out other possible causes of memory loss and cognitive dysfunction besides dementia, such as severe depression, anxiety, medication effects, and so. The interview also looks at current medications, history of head trauma, alcohol and drug abuse, and so on.

My own habit is to look next at the Geriatric Depression Scale. I always want to know next how depressed the person is, mainly because severe depression can cause memory problems. On the other hand, cognitive problems can cause people to become depressed, either psychologically depressed, or through more direct biochemical pathways.

For a cognitive screening, I use the Dementia Rating Scale. Many people use the Mini Mental Status Exam (MMSE). I find that the DRS gives a better screening. It looks at attention, initiation of tasks, graphomotor functioning, abstract thinking, and memory. By the time the DRS is over, I have a rough idea of whether the person is actually having any significant cognitive problems or not. If so, I don't know what is causing them; I just know whether there are any gross problems.

I look at spatial functioning using a simple clock drawing test, and I look at ability to find words using the Boston Naming Test. A straightforward verbal list learning test is also part of my screening batter. If the dementia is severe, sometimes this simple battery is all that I need to answer a referral question. If the cognitive impairment is less severe or uncertain, or if very specific information is wanted, I use a longer battery of tests.

For example, I use the Wide Range Assessment of Memory and Learning-2 to assess verbal memory, visual memory, attention, delayed recall, and recognition memory.

The Wechsler Adult Intelligence Scale-IV is an IQ test, but IQ is not really what we are looking for here. We are looking at the pattern of results. There are some patterns more suggestive of dementia than others. Verbal abilities such as vocabulary tend to remain at the same level during cognitive decline compared to the loss of perceptual organizational abilities. The IQ test allows us to look at such patterns.

If I suspect a frontal lobe problem, then there is a test which includes several tasks measuring frontal lobe functioning.

What else could be done? Well, there are other tests, but in my experience the above tests usually provide the information which is needed for diagnosis.

Followup to the testing involves a feedback session with the patient and their family. The main question which they usually have is whether the memory loss is permanent and whether there is any treatment for it. I usually tell them to talk with the psychiatrist, but I tell them that most dementias do not get better. (Some insults to the brain, on the other hand, do heal.) I talk with them about medication being available for some dementias. I also talk with them about maybe seeing a rehabilitation psychologist to help them learn ways of improving memory, or if not improving it, at least compensating for memory problems.

Five Neurotic Beliefs

2011-01-05T01:00:00.003-06:00

The word "neurotic" has been used in so many different ways that it hardly means anything anymore. So, first let me explain what I mean by neurotic in this context:
These are general ideas which a person may have. They are not just specific negative thoughts, such as, "I'll make a bad grade on this test." They are more general, such as "I have to be perfect in everything I do--all times, and all places, and all circumstances.

Secondly, these thoughts often make people feel bad much of the time, because they are so hard to live up to.

Thirdly, they generally do not help us to live more productive lives.

Fourth, they are inflexible and rigid.

Here are some of the dysfunctional attitudes about self-worth which are common:

I must achieve in everything I undertake or I am not worthwhile.
I must be approved of by everyone. If someone dislikes me or disapproves of me, there must be something wrong with me.
If I am not always in control of my feelings and actions, then I am weak. And if I am weak, I am worthless.
I must be loved to know that I am valuable.
I must do everything I do in the best possible way (that is, perfectly) or I'm not worthwhile.

This last one, perfectionism, is particulary important with regard to depression. Perfectionistic attitudes have been found to be particularly prone to cause depression. In one study of persons in treatment for depression, the higher the levels of perfectionism, the less likely it was for the person to improve. It didn’t matter whether they were in cognitive therapy working on negative thoughts, receiving medication, or in some other form of treatment. Perfectionism was a roadblock to significant improvement in all the forms of therapy offered. The implications of this are very clear. Although some depressed persons see perfectionism as a very logical approach to life, it is actually a landmine in the road to success and happiness.

It is not always necessary to deal with underlying negative attitudes to get out of depression. Clearly, there are times when circumstances improve or when the passage of time helps the person to feel better. However, when negative assumptions are not dealt with, then the person is likely to be just as vulnerable to future depression if stresses occur again. It is not easy for people to change these attitudes by themselves, and discussions with a therapist are often helpful and sometimes necessary.

Here are some questions to think about:

1. What kinds of stresses have caused you to be depressed in the past? Does this tell you anything about your depressive attitudes? For example, have you tended to become depressed following relationship breakups? Being disapproved of by someone important to you? Experiencing school failure or a job setback? How about after making a mistake?

2. What kinds of stresses have not depressed you in the past?

3. As you consider your answers to questions 1 and 2, does it appear that there are particular kinds of stresses to which you are most vulnerable?

4. Rate yourself on the following underlying attitudes.

Attitude Strongly Disagree Disagree Not Sure Agree Strongly Agree

If I fail at something, it means that I am inadequate or worthless.
If I do not accomplish something which is very important to me, then I am a failure.
If someone that I love does not love me, then it means that I am unlovable and worthless.
I must be approved of by everyone. If someone dislikes me or disapproves of me, there must be something wrong with me.
If I am not always in control of my feelings and actions, then I am defective and/or weak.
If I do not strive for perfection, I am likely to turn out to be mediocre and worthless.

Depressive Attitudes and Stress Are an Explosive Combination

Depressive assumptions and stressful life events can team up to cause low self-esteem and depression. For example, consider what happens with the following combination of a depressive attitude and a corresponding event:

Attitude "I am worthwhile only if I am loved." + Event "My husband left me." =False conclusion "I am worthless."

In this case, the attitude and the event go together to create feelings of worthlessness and depression. The particular attitude and the particular event fit together hand in glove. Making a “D” in a course or even an “F” might be less likely to trigger depression in the above person, given their basic attitudes about what makes them valuable. The person is basing their self esteem on love, not on success. (The exception to this would be if they thought that people would love them less for making poor grades.)

Each of the depressive attitudes can lead to low self-esteem or feelings of worthlessness if the right stress occurs. Think of it as a jigsaw puzzle in which certain pieces fit together. If a person believes they must succeed and do well in everything they attempt, then not getting an expected raise or promotion can be a severe blow to their self-esteem. It may even lead to clinical depression. On the other hand, if members of his family are upset with him and avoiding him, it may cause upset, but still not result in depression because his underlying attitudes regarding self-worth are not based on love and approval.

Here are some of the logical problems with each of the dysfunctional attitudes.
1. "I must do everything perfectly":

Problems with This Way of Thinking:
--Trying to do everything perfectly may so overwhelm a person that they may never get started. They may then get less done than if they tried to do a good or adequate job.
--A person may spend so much time on details that little work gets done overall.
--Doing things perfectly is not really possible. Thus, it is inevitable that the person will feel inadequate at some point.

2. "I must succeed in everything I undertake. I must never fail or else I am worthless."
Problems with This Way of Thinking:
--It is not possible to always avoid failure.
--If an individual fails at one thing, is she supposed to ignore and overlook all of the things that she does right?
--This way of thinking can cause such a fear of failure that a person will not take even minor risks. This can cause them to be immobilized.
--Some of the people who have accomplished the most in history have had significant failures as well as successes.

3. "It is terrible to be disapproved of. If someone disapproves of me, I must have done something wrong."
Problems with This Way of Thinking:
--It is not possible to please everyone.
--If it appears that we are pleasing everyone, we are probably only succeeding in being wishy-washy and having few if any real principles.
--This would mean that other people’s opinions are automatically more valid than my own.
--Since someone will always disapprove of us, we are doomed to always feel inadequate and unhappy.

4. "I must be loved to know that I am valuable."
Problems with This Way of Thinking:
--Whether we are loved does not change our intrinsic self-worth. It is very important to be loved, but it does not reach into the core of our being and change who we are.
--If we must be loved to feel worthwhile, we are likely to be a doormat in a relationship for fear of losing it.
--A person's value to society comes more from the love and concern they give than from the love they receive.

5. "I must be in control of my emotions and actions at all times or I am weak and worthless."
Problems with This Way of Thinking:
--No one can be in control at all times. This is a myth perpetuated by Hollywood heroes in action movies. We cannot live our lives according to a Hollywood script.
--Emotions cannot always be controlled. Furthermore, a person who attempts to have tight control over their feelings has difficulty being spontaneous and having fun. They may also tend to try to control others and so are not much fun to be around.
--A person who has this idea and gets depressed is then likely to get even more depressed because they will tend to blame themselves for not being in control of their situation and feelings.
--Part of the fun of life is being spontaneous and seeing what will happen next in life.

The One and Only One Good Thing about Divorce

2011-01-04T01:00:00.001-06:00

Therapists generally do not recommend that people divorce. This is for a variety of reasons. For one thing, most of us do not consider it our role to make such a recommendation. In addition, have seen how difficult separation and divorce can be on people. There are high rates of depression in separation. Then there are the effects on childen. And we have seen times where divorce may have seemed to be the solution for a patient's depression or problems, but it wasn't really.  Divorce is not a simple solution for problems.

But what if, despite all that, you are getting a divorce? What if you didn't choose it, and it was forced upon you? Or what if you began the divorce process but felt you had no choice?

What is that one thing which is good about divorce?

I believe that it provides a chance for re-inventing oneself.  We have all gone through our lives trying to make the puzzle pieces fit as best we could. But it is a little like a 12 year trying to build a house or car. They reach their 20's and would like to make some changes to their house or car, but they would practically have to level the house or take the car totally apart to do it.

Divorce is like a card table with a jigsaw puzzle with a bomb underneath it. The bomb goes off, and the puzzle is once again thrown into pieces.  Not everything has to be put back together. But quite a bit has to be reassembled. And this time there is the opportunity to reassemble one's life in a better way than it was put together before.

Of course, I am speaking somewhat optimistically, pointing out the opportunities for growth. I often see my patients going through a growth process like this. Unfortunately, it can also be true that people may simply put the puzzle back together just as it was before. Maybe a woman keeps looking for her worth in sexual encounters with men. Or a man continues drinking and looking for his worth in money and status. But there is the opportunity when relationships break up to stand back and do something new with one's life. Whether remaining single or getting back into a relationship, routines will be disrupted, and new routines have to be created. There is a chance also for taking a new look at one's religious and philosophical beliefs. There is a chance to make new friends. It can be an opportunity for learning new leisure interests. Perhaps a new dating partner likes skiing, or opera, and you learn to like them too, even though you thought that you would be interested in them.

As painful as divorce can be, if you find yourself going through it, this one good thing about it needs to be understood and taken advantage of. Take the chance to do something new and better with your life. Seek out a therapist if you need to in order to use it as a growth process. Use your adult perspective to redo old decisions from childhood which were not working for you. There may never be an opportunity like this again in your life.

What Does Psychological Testing Have to Offer Me?

2011-01-03T01:22:00.001-06:00

Most people never need psychological testing. But since I do a lot of it, I am very aware of what it can offer to people.

Most of the time it is a psychiatrist who is requesting the testing. They are wanting more information about diagnosis. People are in psychiatric hospitals for only a very short time these days, so the psychiatrist is in a hurry to understand as much as possible as quickly as possible--"Is the person depressed;" "Are they in touch with reality;" "what is is their IQ?" and so on.

Sometimes it is the client that needs information. Perhaps they need to document their symptoms for one reason or another, such as applying for disability. While psychological testing is not necessarily the same thing as documenting a disability, testing reports do provide useful information about symptoms, and they also help to pull together a lot of relevant information about a client's history (symptoms, hospitalizations, effects of symptoms on work, and so on). Creating a total clinical picture and history to present in applying for disability is difficult for many patients, because of their psychiatric problems.

Another leading reason for testing these days is establishing the diagnosis of ADHD. Family doctors may be reluctant to prescribe ADHD medicines without a full evaluation.

Diagnosing the onset of dementia, or Alzheimers (Alzheimers is a subset of the dementias) often necessitates testing. People may think that they have memory problems but really don't. Or people may not believe that they have cognitive problems, but their family members do. Psychological testing is an objective way of answering that question. When a person is in the early stages of Alzheimers, there are medications which can help, and so it is important to know when the onset of dementia is occurring.

Neuropsychological testing is aimed at establishing how well the brain is functioning. It is used with dementia, but it may also be called for after motor vehicle accidents, strokes, and diseases of the brain.
Oftentimes, children are having academic problems, and it is not clear if the problem is intelligence, ADHD, learning disability or some emotional issue. Testing is often helpful in this situation.
Sometimes children are having behavioral problems and it is not clear if there is a serious disorder present, or whether they are just "going through a phase," or simply responding to stress within the family system.

These are some of the typical reasons that I receive requests for psychological testing. I enjoy testing because it allows me the opportunity to interact with almost every conceivable type of patient. Moreover, it allows me to provide a little bit of consultation as well as helping to establish the diagnosis. In other words, I don't just test the person and write a report. I like to interact with them and help them develop strategies for dealing with their problems.

More On Aspergers

2011-01-02T08:52:00.000-06:00

Since the Asperger's article was one of my more popular postings, I am saying more about that here.

Let's look at each of the DSM-IV criteria and try to understand them the best we can.

DIAGNOSTIC CRITERIA FOR ASPERGER'S DISORDER (DSM IV)

A. Qualitative impairment in social interaction, as manifested by at least two of the following:

1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction;

The issue here is whether the child can participate in social communication, not just using words but using the eyes, hands, and whole body. Poor eye contact can be a tipoff to a problem in this area, but the criterion says that there has to be a deficit in multiple nonverbal behaviors, so poor eye contact alone would not be sufficient to meet this criterion.

2) failure to develop peer relationships appropriate to developmental level;

Aspergers children seem to prefer the company of adults or younger children. Adults may be preferred because the language used among them is more "objective" and intellectual. Children of a younger age may be preferred because the Aspergers child has not progressed developmentally as much as their age mates. Communicating with age appropriate peers requires a high level of social skills. Moreover, with one's peers there is always a type of competition for social status, or at least for inclusion, and the Aspergers child is not able to keep up in that competition. They don't have to compete with adults, and they can compete more easily with younger children.

3) a lack of spontaneous seeking to share enjoyment, interests or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people);

The Aspergers child lives in their own world to some degree. They do not necessarily want to bring things of interest to them and show them to other people. They are happy with discovering things or playing with things on their own.

4) lack of social or emotional reciprocity.

What does this mean? Well, I can tell you what I take it to mean. Social reciprocity would mean being able to give help and receive help. It could also mean playing a game with give and take rather than just playing with toys and games on one's own, or playing side by side with someone. Emotional reciprocity would involve being caring and empathic for others. If another person is hurt or feels sad, then most children have some sense of sadness. If another person has something really good happen, then most children have some good feelings, too. Again, it's all about whether they are in their "own world" socially and emotionally.

B . Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus;

An Aspergers child may be very focused on a normal activity but to an unsual degree, such as knowing more about insects than most adults, or knowing a great deal about racing cars, or video games. One child was very interested in Pokemon--not unusual in itself. But he had drawn every single Pokemon character and made two elaborate and well organized notebooks with all of the characters--an extreme investment of time.

Or the Aspergers child may have an interest in something very much outside the realm of most children's interests, such as learning the Russian language.

2) apparently inflexible adherence to specific, nonfunctional routines or rituals;

Sometimes these routines can look like Obsessive Compulsive Disorder. For example, it might involve needing to have all of one's army soldiers standing up in a row before going to sleep. Sometimes, this symptoms just looks like an overly strong insistence on routine. E.g, the child has to put the shirt on, put their pants on, brush their teeth, pick up their books, pick up their lunch, in that order before going out the door.

3) stereotyped and repetitive motor mannerisms (eg: hand or finger flapping or twisting, or complex whole-body movements);

The extreme forms of this are unmistakable, such as hand flapping. Other times, the child is doing something in a more subtle manner and hiding it from others.

4) persistent preoccupation with parts of objects

It's not the whole object and its associated purpose which may interest the child but some small part. One child in my office was intrigued by the bottom of a brass lamp, which was convex and had a funhouse mirror effect. Another child played with toy cars by turning them upside down and spinning one of the wheels. Many Aspergers children like to take things apart.

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

In other words, there has to be some impairment in functioning for the disorder to be diagnosed. If they meet the above criteria, they are very likely to have some impairment in functioning.

D. There is no clinically significant general delay in language (eg: single words used by age 2 years, communicative phrases used by age 3 years).

If there is, then a different pervasive developmental disorder may need to be diagnosed, possibly austism.

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood.

If there is, then a different pervasive developmental disorder may need to be diagnosed, possibly austism.

F. Criteria are not met for another specific Pervasive Developmental Disorder, or Schizophrenia.

Other Pervasive Developmental Disorders would take precedence in the diagnostic decision making chart. And if a full symptom picture of Schizophrenia is present, then Schizophrenia is diagnosed instead of Aspergers.

These criteria are being revised for DSM-5. At that point, autism and aspergers will probably be subsumed under the diagnosis of Autism Spectrum Disorder. I think this makes sense. However, it will make my job a little more difficult--telling a parent that their child has Austism Spectrum Disorder. The word autism carries a lot of emotional baggage with it that the term Aspergers does not.

A Note About Emails to Me

2011-01-01T08:24:00.001-06:00

Until recently I have not included my email address. There are some very good reasons for this. Most of all, I do not want to be giving therapy advice by email. There are many ethical and legal problems with this.

But on the other hand, I am glad to provide educational information.

So I cannot offer therapy or advice. (It may be presumptuous of me even to think that people might ask for that; but just in case...)

If you have theoretical or factual information that you want to share with me or questions that you want to ask me, I will be glad to hear from you.

Ed Beckham

Navigating the Maze of Psychotherapy--And Choosing a Therapist

2011-01-01T08:05:00.002-06:00

It can be quite a daunting experience to try to choose a therapist. It would be kind of like me going to Manhattan to choose an investment banker for a company (if I owned such a company). I wouldn't be able to tell one investment bank from another. The bankers would all come with impressive offices and impressive titles, and they would have all graduated from impressive institutions. I would be out of my league.

I'm sure that it must be much the same for individuals trying to find a therapist. Where to start?

Let's take a look at some of the obvious practical issues which I think influence people choosing a therapist:

Are they on my insurance plan?
What type of therapy do they do?
How much do they charge?
How close is their office?
How often will they be able to see me? Want to see me?
How often can I afford to go see them?

These are the practical issues which I suppose influence people in their decision making. (I don't know if there has every been a study on what really guides people's decision making. It would be an interesting study for some aspiring graduate student out there.)
Now, here are the issues which I think are most important

What is the conceptual framework of the therapist?
Will you be able to build a therapeutic alliance with them? (Or perhaps the question is will the two of you be able to built a therapeutic alliance together?)
Will you feel accepted by them and be able to tell them about the parts of yourself that you hide from others?
How much experience has the therapist had?
What is their reputation in town?
How "professional" are they? Do they have good ethics and good boundaries?
Are they burned out and tired, or do they still have an energy and zest for what they do?
Are they able to see problems in only one way? Or can they work out of multiple frameworks?

These latter questions are very difficult to answer. Even colleagues that I have known over the years are still a little bit of a mystery to me because I have never had the opportunity to listen in to one of their sessions. I know how they come across to me, and I have an idea of their conceptual framework, but I have not actually seen them do therapy. So if someone came to me asking for a referral, it would still not be a slam dunk process for me to decide whom I would recommend.

But nevertheless, in case you are one of those individuals who has made the decision to seek therapy, here are some ways you might go about it.

Many people start by checking the list of providers in network on their insurance list. That is not a bad place to start, but it is not the sole consideration. Insurance companies are getting more picky. If there have been ethical complaints and lawsuits, a therapist may be taken off their list So being on an insurance list is one consideration, both ethically and financially.

Check with your family doctor. They may have had experience with referring to a specific therapist, and they know whom their clients have liked and who they haven't liked. Similarly, ask a pastor, or ask friends.

Place a call to the therapist's office, saying you would like to talk to them and ask questions. Notice how long it takes to get a call back. In some instances, you might not ever receive a call back. If you receive a returned call the same day, that is a good sign that if you had an emergency they would get back to you. Now some doctors are really, really busy. And I am not criticizing a doctor who would not return a phone call to a stranger within 24 hours. But it could still be useful information for you to have.

Ask questions (maybe some of the ones above). You're not exactly looking for an exact set of answers. You want some idea to the above questions, but you are also listening to the tone of the person and asking yourself whether you might be comfortable with them.

Are they defensive about you asking questions? Or do they take it in stride? Do they seem sure of themselves? Unsure? Cocky? Dogmatic?

You might also ask if the doctor would be okay with you seeing them a few sessions and then deciding whether to stay in therapy with them. Again, it's not their exact answer which matters. It's the way they handle the question that gives you the most information.

So, good luck. Remember, you know more than the therapist about some things (such as what is going on in your life), and they know more than you do about some things. So don't be afraid to dialogue with them and ask how it is that they can go about helping you. Have confidence when you talk to the therapist, and if they make you feel intimidated, well, maybe you need to keep looking.

The Problem with Shoulds--New Years Resolutions Revisited

2010-12-31T12:36:00.004-06:00

I have written before about New Years Resolutions and why I don't particularly have any confidence in them. And I have also written about the problems with "should" thoughts. Today, I would like to talk about both of these together and how they relate to each other.

People often tell themselves what they should do or should have done (e.g., "I should have known that was going to happen," "I should study harder," "I should exercise," and so on.) These types of shoulds often cause feelings of shame, guilt, and inadequacy. They are probably best used only when there is a moral issue at stake, e.g., "I shouldn't be lying," or "I shouldn't be stealing from this person," etc.

But there is another problem with shoulds. We use them as if we believe that they will motivate us. We say, "It's a new year, and I should be exercising." Or something like that. We use "should" thoughts to try to motivate ourselves and get us going. But my experience is that this tactic rarely works. Much has been written about what can bring about true behavior change, but to my knowledge focusing on the fact that I "should" diet in the coming year has not been found to lead to reliable weight loss.

The reasons why "shoulds" do not work are unclear, but I can think of several possibilities.

1. They involve rather shallow neural processing. They are not focused on the reasons why change needs to occur, the benefits of changing, the problems if we don't change, the methods that can be used to bring about change, analyzing the obstacles which will get in the way of change. They simply assert that "I should change and will change." Thus, there is relatively simplistic cognitive activity involved in the brain. My guess is that it taps into more primitive brain regions which are not well equipped to accomplish complex behaviors.

2. They often evoke feelings of shame. The thought that I "should" exercise is not far away from a shame based feeling that I am bad for not exercising. Shame generally makes us feel bad about ourselves and seems to evoke negative behaviors rather than positive behaviors.

3. They are often based on what others think we need to be doing rather than what we want. We may not really want to exercise but only believe that it is the right thing to do because others tell us it is.

As an alternative to prodding ourselves with shoulds, I would recommend that we focus on the "I want" aspect of change. "I want to exercise because I will feel better" or "I want to diet because I will look better." A variety of different brain circuits will be used if we imagine how much better we will feel after behavior change, and if we connect the behavior with wanting rather than shame or guilt. Other brain circuits will be involved if we analyze the obstacles which have kept us from the behavior, discuss our plan to change with a friend, and so on.

There are a variety of strategies which can be used to assist in behavior change, but "should" thoughts are at the bottom of the list in my opinion.

There are a variety of good web sites on changing behavior. Here's one from the University of Arizona that I found:

http://ag.arizona.edu/maricopa/fcs/Documents/SSHW-FS_6-25_Behavior_Chang.pdf

Are Near Death Experiences Scientific?

2010-12-30T11:35:00.001-06:00

I have a strong interest in near death experiences. One issue which I often grapple with is whether they are scientific.

In a sense, this is the wrong question. Every phenomenon is worthy of study. What is scientific or unscientific is the way that it is studied.

Can NDE's be studied scientifically? One element of science is reproduceability, and that is probably the Achilles heel of NDE research. It is very difficult to reproduce them. In fact, we don't really want to reproduce them. We don't want to cause people to be near death.

On the other hand, they are reproduceable in the sense that they are occurring over and over.

There have been other situations in science where a phenomenon could not be reproduced at will. We had to wait to study it. The fall of meteorites was one example. The use of solar eclipses to study the bending of space and light wave paths due to solar gravitation would be another example. So reproduceability does not mean that something has to be reproduceable upon demand. It simply has to occur again repeatedly in the future so that new observations can be made and replicated.

Another aspect of scientific method is the ability to objectively measure something. In NDE's, objective measurements are difficult. However, science does not totally require objective measurement. For example, if I am studying depression, it might be quite useful for me to be able to measure monoamine activity in the brain. But I can also do research which asks the person what their mood is, what their appetite is like, how much support they feel they are receiving from their spouse, what their view of the future is, and so on. This is subjective, and it is still legitimate scientific research.

The problem is that NDE's appear to be outside of the current scientific frame of reference. Thus, the methodology used in their study requires even greater scrutiny than other areas of research.

There are a few lines of evidence suggesting the objective reality of NDEs.

1. They are generally similar to each other--not always, but usually. If I interview two patients with major depression, I will find that they are generally similar. But they will not be similar in every way. One may have appetite problems and no sleep problems. Another patient may have that reversed. But they may both experience fatigue, loss of interest, pessimism, and social withdrawal. The overall cluster of signs and symptoms is generally constant from depressed patient to depressed patient, but usually not two depressed persons are exactly alike.

2. NDEs have occurred in history prior to the publication of popular books on the subect. This is not a phenomenon that began in the 20th century.

3. NDEs occur at times in young children who have never heard of NDEs. There are numerous child expeiences of this sort; and yet many of these children have never heard of the concept of a NDE.

4. NDEs often have a strong impact on the beliefs, behavior, and feelings of people. This is a kind of evidence for its reality, although by itself, it is not enough. But when we see how people often change their lifestyles because of the near death experience, that is a fact not to be overlooked.

5. Sometimes people experiencing NDEs, as in surgery, may be able to report objective events which occurred while they were anesthetized, and when their heart had stopped beating. This is truly objective data. It is sometimes reported as true; it is hard to fully document that it actually happened.

Much more could be said about NDEs, but this one article certainly can't address all of the issues.

Why is this important psychologically? One reason is that NDEs can have a destabilizing effect on people. It can make them much happier, more productive people. On the other hand, they can temporarily have a depressing effect, too. While people usually experience feelings of elation, freedom, meaning, joy, and knowledge during them, they often don't want to come back. They often say that they were compelled to return. This can be depressing and confusing to them.

Secondly, sometimes health professionals dismiss their experience as the effect of anesthesia, or offer some other explanation which readily falls in their scientific frame of reference. This does not help people to integrate their experience into their lives. It causes them to feel discounted, and this can cause them to be depressed or confused.

As mental health professionals, we need to be open to our patients' experiences without discounting them or explaining them away.

Is It ADHD--Or Is It Anxiety--Or Is Depression?

2010-12-30T11:11:00.001-06:00

In psychology and psychiatry, we are almost always presented with the issue referred to as differential diagnosis. There is often more than one diagnosis which can explain a set of symptoms.

For example, with ADHD, there are deficits in attention and other aspects of executive functioning. However, these deficits can be caused by many reasons. Some of the most typical causes (besides ADHD) are depression and anxiety.

In depression, if it is severe enough, the brain is not working at maximum efficiency. In fact, it is like a car trying to go up a hill when three out of six spark plugs are not working. There just isn't the power to do what it needs to do. Concentration and memory consolidation are affected.

For an example of a pet scan in depression, go to http://www.mayoclinic.com/health/medical/IM00356
(Pet scans are like an xray of the brain. However, instead of revealing structure, they reveal activity levels. They show the level of glucose utilization. Red and orange areas show high levels of glucose utilization, hence indicating higher levels of brain activity. Purples and blues indicate lower levels of brain activity.) In the petscan at the Mayo Clinic link, you can see how the brain which has recovered from depression is more active than the brain in a state of depression.)

In anxiety, the person has a hard time concentrating. They may feel fuzzy headed, or they may be distracted by their worries. This interferes with attention, and when there is impaired attention, it is hard to learn.

Of course, it is quite possible that a person will have both depression and ADHD, or anxiety and ADHD. Depression, at least in a mild form, is often a result of ADHD in children and teenagers because they are not doing well in school and perhaps not being accepted by their peers. On the other hand, the more severe that the depression is, the less likely it is to be explained by depression, and the more we have to start looking at other causes.

Two Opposite Trends in Psychology

2010-12-29T08:40:00.001-06:00

I find it interesting that there are currently two very opposite trends in psychology--both of which are critically important. I have already commented on the different levels which human psychology can be viewed. The two extreme polar opposites are neuropsychology and human potential awareness. The latter term is not a current term; it is from the '60s. But I use it to make my point. The current term is actually "positive psychology" or "the psychology of happiness." The main difference between the two is that there is much more of an empirical (experimental) base to positive psychology. (Human potential psychology was often referred to disparagingly as "armchair psychological theorizing").

But both of these trends are absolutely useful and important. They describe the human experience at different levels, using different metaphors. And they are both true, if by "true", we mean that there is experimental evidence collected to verify their theories.

The studies on happiness have immediate relevance to all of us. But the the neuroscience studies have relevance too, in a different way. The happiness studies let us know that certain behaviors, such as altruism, can bring positive effects in our lives. They are not just something taught by religious texts. The neuroscience studies lead to new medications, but they also suggest new psychotherapy techniques. And perhaps most importantly for the layman, they give us that humility that I have spoken of in other postings--the humility of understanding the complexity of motivation and that there are often fundamental physiological reasons that we and those we know act in certain ways.

Unfortunately, at times in the past each of these perspectives tried to invade and take over the doman rightfully occupied by the other. For example, it used to be taught that autism was caused by cold, rejecting mothers. And it was also taught by some that altruism did not really exist; it was just a conditioned behavior, or the result purely of our evolutionary past and survival mechanisms. The micro and deterministic trues to subsume the macro and holistic and vice versa. But they are both important, separate ways of viewing the world which are both important.

It's a wonderful age that we live in that it is scientifically acceptable to converse and conceptualize human behavior in so many different ways and at so many different levels. It is intellectually freeing, and it frees each of us to explore our own psychology in ways that our ancestors never could.

Why Did I Do That?

2010-12-28T20:22:00.001-06:00

Few things are as certain as human motivation. When people do things we don't like, we often want to know why they did them. But that is a very slippery path.

Let me explain.

Take for example, the sixth grader who is bugging the person ahead of him in class. The teacher gets on to him. He stops--for a few moments. And then twenty minutes later, he is doing it again. The teacher asks him why--why are you doing this after I got onto you for it only 20 minutes ago? He sits there sheepishly. She asks him again. He shakes his head. He doesn't know. But she doesn't settle for that answer. She wants to know why. She might even say something like, "If you don't know why you are doing it then who does?"

But the actual answer is complex, difficult, and even profound. Because even if he were to tell the teacher something that sounded contrite and convincing, it might well be wrong. Let's start with what he might say. He might say, "I'm sorry; I'm not trying hard enough. I will do better." Here the explanation is something like he isn't trying hard enough. The teacher might accept that, but she might have her own explanation--he is a bad kid. Or she might have a more sophisticated explanation--he comes from a troubled home. Or she might even think that he has ADHD.

A neuropsychologist might trace his impulsive and restlessness to the prefrontal region of the brain and to the child's father and grandfather who had similar problems. One thing is for certain, the child is not likely to say:

"The reason I did it is that I am impulsive. That is a symptom of my Attention Deficit Hyperactivity Disorder, Predominantly Hyperactive/Impulsive Type. I inherited that from my father and grandfather. As a result, my prefrontal region of my brain does not inhibit impulses well and does not screen out irrelevant stimuli well."

In some classes, such an explanation might get the child a smack for being "sassy." But not to worry, it won't happen, because a child cannot articulate such a sophisticated explanation.

A family therapist might even look at other explanations. They might point to the turmoil in the family at home and how the child's symptom of acting out at school is a predictable result of that turmoil.

A behavioral psychologist might point toward the system of rewards and consequences. He/she might point out that the substitute teacher last week imposed no consequences on this behavior. Or perhaps they would point out that the child being tormented inadvertently gave positive reinforcement for the behavior by what they said.

And we could go on looking at a variety of other explanations. Why is the child doing what they are doing? The "Why?" question is always very slippery. Sometimes a behavior is determined by multiple causes, and the one we choose as the REAL reason may not be the real reason, or it may be only one of several reasons which accumulate to produce the final behavior.

Similarly, in marriage and in the family setting, we are tempted to ask the why question. And when marriages are young and new, we are kind and assume the best of the other person. But when relationships deteriorate, we often choose the most unkind explanation for what the other person did, which accentuates our anger. Even adults do not always know why they are doing certain things. They may not know why they are in a bad mood, or snappy.

When we are tempted to ask the why question, we need to be aware that we are in dangerous territory. We all want to know why things happen. We want to know why our husband chose to be late getting home, why our wife chose not to do what she said she was going to do. And the answers to those questions may be very important and very relevant to our lives. But we also need to keep a level of humiility about our ability to discern the real causes and reasons behind behavior. Even if the other person tells us the answer, we may still not know. Keeping a level of humility about our explanations for Johnny acting up in class, or our husband taking the long way home, and so on, may keep us from overreacting to situations with excessive anger, disgust, or punishing responses.

One Way of Understanding How Psychotherapy Works--Achieving Higher Levels of Integration in Our Neural Processing

2010-12-28T08:27:00.004-06:00

One of the basic concepts in the book that I have already referred to--the Neuroscience of Psychotherapy--is that therapy helps people to achieve a higher level of neural integration. What does that mean exactly? Well imagine a house with several computers in it, and each computer is linked by a single line to one central router. Actually, that is not too different from what most of us have. Now, imagine in the future that each computer is linked directly to every other computer, and every router is linked directly to every other router. A new level of functionality could be be achieved by that integration.

The theory is that many people lack neural integration because of a variety of factors, mostly environmental. These could include neglect of the individual by their parents when they were growing up. They could include defense mechanisms such as repression, denial, reaction formation, and so on. When we have a feeling (such as anger or lust) and our response is "that's not me!" then we are preventing integration. (A different response might be "Wow, some part of me feels that!?") Integration can be vertical (neocortex down to limbic system) and lateral (right to left brain, etc.) The technicalities are not important here. What is important is that in psychotherapy, people have the opportunity to grow new dendritic branches to make more connections. This in turn increases their level of self awareness of the problem and increases their flexibility in problem solving.

Imagine the following. You are in a bad part of town. It is dark. You want to get to the freeway, but you keep hitting "dead end" and "detour" signs. Now imagine a totally different scenario--no matter which way you go, the streets lead to more streets, and all of them give you routes to the freeway. This can be seen as the role of therapy, opening up new routes to flexible action through the growth of dendritic branching and the increased integration of the brain. This helps to overcome old defense mechanisms and can lead to totally new ways of behaving.

The idea that our brains can continue to change and grow is an exciting one. It means that we don't have to be stuck with the attitudes of our childhood. We don't have to continue in old, well-trodden, but self-defeating ways. It is the goal, and the job, of a good therapist to help make that happen. Sometimes we succeed, and sometimes we don't, but that it is the goal. And when it happens--it's exciting!

Aspergers--The Most Underdiagnosed Disorder?

2010-12-22T08:27:00.002-06:00

What is the most underdiagnosed psychological disorder? Twenty years ago, I would have said that it was Attention Deficit Hyperactivity Disorder. However, public awareness of that problem has grown. And I wouldn't say it is depression. Both ADHD and depression can respond somewhat to medication, which has been an incentive for drug companies to spend considerable resources on public education through the TV and other means.

Right now, I would say that the most underdiagnosed disorder is Asperger's Disorder. Considered by many to be a high functioning type of autism, it can cause major problems in a person's life. But most of the time, the problems are simply attributed to being an odd personality. Or the person gets a diagnosis, but it only captures part of the person's problem, such as the ADHD component, the anger, the depression, etc.

Asperger's Disorder is mostly a problem with social communication. It inhibits the persons ability to communicate with others of their age group. They usually lack the social skills to easily interact. If they are told to "just be themselves," they don't know what that means. Social skills have to be learned step by step with someone to instruct them.

Persons with AD often have some unusual sensory integration problems, what I refer to as "sensory hypersensitivities." They may have difficulty with certain foods, certain sounds, loud noises, strong light, and so on. Aspergers children often avoid certain foods, not because they taste bad, but because the texture of them looks "yucky" or "nasty", or because the texture of the food feels bad in their mouth.

Often AD children have a particular area of interest which is unusual in either its focus or the amount of time they spend on it. They may focus on a typical area of childhood interest, such as cars, but be more knowledgeable than most adults about the area. Or they may focus on an area which is not typical for children, such as learning a certain foreign language.

Persons with AD are often withdrawn, preferring their own company to being in a group. They can do quite well at tasks which involve taking things apart and putting things together, but they do not do well with interpersonal tasks. Children with AD generally prefer the company of adults, where more objective, less emotional communication is the norm, or the company of younger children. They generally do not make friends easily with children of the same age.

Sometimes, but not always, they have an aversion to being touched. This can cause great distress to their parents, who may wonder if they did something wrong to cause this.

There is much more that could be said about Asperger's than I can put in this one single column. And there are many good resources on the web. The best place to start, if you suspect that you have if or a family member has it, would be looking at the DSM-IV criteria for it. DSM-5 criteria will take effect in a couple of years. Asperger's Disorder will probably be renamed Autism Spectrum Disorder at that time, and it will be somewhat more difficult to be diagnosed, based on those criteria.

Finding Your Passion

2010-12-19T12:53:00.002-06:00

Who are the luckiest people in the world? I'm sure there are many answers to this, some psychological, some spiritual, and some material.

Let me make one suggestion. They are the people who have found a passion in life. They have found a source of energy that comes from deep within. Their work is not just a job. It is a calling.

Or it may not be their work. It may be their hobby that is their passion.

What is a passion? It is something which energizes us as we think about it and pursue it. It feels like more than passing time. It provides pleasure, but it is more than pleasure.

It can perhaps be thought of as something which produces a feeling of flow. (See Wikipedia article http://en.wikipedia.org/wiki/Flow_(psychology)

We need to help our children find their passion in life. One way we can do this is to find our own passion. We can show them by our actions that there is something to be enthused about in life.

Of course, there are many things which can get in the way of this, such as stress, depression, severe life disappointments, and so on. And I don't want to disparage anyone who doesn't have this feeling. There may be very good reasons that they don't have it.

But I encourage all of my patients to look for what is most important and most exciting to them and follow that vision. I believe that we are all here for a reason. We need to discover what that is, and if we do, then we are likely to find that it is not just a job but a passion.

Varnish It and Frame It--Loving Life's Little Moments

2010-12-19T09:09:00.002-06:00

When painting, there may be times when for one reason or another, artists don't paint large, grand canvases. Sometimes, they paint very small pictures, or vignettes. These may only be 4x6 inches, or something like that.

The large, grand canvases are wonderful, but it is not always possible to paint them. They may require more time, money, skill, or resources than the artist has at that moment.

In the same way, we often want the larger picture of our lives to be grand and wonderful. But circumstances may not allow that. Sometimes, the larger picture is painful to look at.

In my painting class, my teacher made a small vignette example picture for me, to give me some instruction on how to paint. I like the little picture. When I varnish it (it takes 3-6 months before a painting can be varnished), it will bring out the color and luster even more. And if I put a little frame of some sort around it, it will highlight it even better.

Life has little moments like that. They need to be varnished and framed. If we can't enjoy the larger picture of our lives, we need to be aware of the small moments that are beautiful and focus on them. At least we can zero in on the delightful and the positive, even if the larger picture is not going well

So--if something good happens in your life, even if it is small--varnish it and frame it!

To Accept Limitations or Not?

2010-12-19T09:03:00.002-06:00

One of Freud's basic ideas was that the pleasure principle had to be replaced by the reality principle. The baby's belief that it could have whatever it wanted (fantasy) had to be replaced by the reality that it has to do things to get what it wants, and that some goals and objects are simply not obtainable.

Manic persons can be delusional and lose sight of the reality of their limitations when they are manic, particularly in a psychotic mania.

But here is the problem. When we accept our limitations, we automatically close off certain possibilities because we know that they will never occur. It automatically becomes a self-fulfilling prophecy. We know we cannot accomplish something so we don't try.

Thus, as a psychotherapist, I have to struggle to walk the line between not giving patients false hope (e.g., becoming a nationally known singer) and not giving them the encouragement to reach their true potential.

Last night I had the opportunity to listen to and talk to a jazz pianist who has only been playing five years. He was going to be an military policeman when an accident injured him and caused a dramatic change in his life. He has only been playing five years but is polished, professional, and a delight to listen to. He takes lessons from a teacher in New York City and has performed in a jazz festival outside of Rome, Italy. He has to struggle right now to feed his family (he still works as an Oklahoma City policeman) and practice and perform. But he is almost there--almost to the point of being a full time jazz pianist. He has a gift, and he will undoubtedly reach his goal.

Another person I know has built a multi-million dollar company in the space of a year's time. At this point, it is not clear if there will really be a limit to what he can accomplish financially.

So the question is, how are we to view the reality principle? Are we to believe that we have limitations, or not?

One clue to answering this question is to look at the fact that one of the above persons is in his young 30's and the other in his late 20's. So perhaps one way of answering the question would be to look at the age of a person. I am in my sixties. I have less energy than I used to. And I have less time on Earth left. So it would be best if I was realistic about what I could and could not accomplish. Another clue to answering the queston is that both of the above men made some tangible progress towards their goals within a few years. Other people may fantasize more than actually doing something. Both of the above men are full of energy and work hard at accomplishing their goals.

But I am left wondering, is it better to accept limitations or not? Right now, I guess I just don't have the answer.

In Love and Out Again--The Dilemma of Many of My Patients

2010-12-16T10:04:00.001-06:00

Why do people fall out of love? I have asked myself this many times as I have worked with clients. What went wrong that these two people have come to this point of distance, or indifference, or anger, or even hate? It is often hard for me to imagine what has caused such a wrenching change in a couple's relationship.

Most of us understand that love cannot continue in its white hot state forever. But still, why does it go away entirely?

There are both active reasons and passive reasons.

The passive reason is that we ignore it. It is a plant starved at the roots because it is not fed. It is taken for granted. And many times, the energy given to the children is one reason that it is not nourished. That energy is needed elsewhere. Or we funnel the energy to our jobs.

On the other hand, there is an active reason as well. We kill it. We kill it when we allow discussions to become arguments, and arguments to become fights. Arguments are inevitable, but they can be limited in their scope and time duration to do less harm. We kill it when we threaten divorce over and over. Long, ongoing arguments, or arguments where divorce is mentioned, are destructive. And then sometimes arguments beomce fights. In fights, people try to hurt each other.

So my recommendation to couples is to nourish the relationship. Give it time and energy. And limit arguing. Limit its scope and its length. And never, ever, fight. That is, never, ever try to hurt the other person.

Try to remember what made you fall in love with the other person to begin with. Try to bring back those feelings by remembering how wonderful it was and all the things which initially attracted you to them.

The Myth of Christmas Depression?

2010-12-11T17:12:00.005-06:00

Through my career, I have often been asked to speak on the topic of holiday depression. The problem is that research indicates that it may not exist--at least for our country as a whole.

There is no evidence that there is more depression around Christmas than at other times of the year. In fact, the suicide rate is highest in the spring, not at Christmas. There is no apparent in suicide around Christmastime.

Most clinicians do find a rise in depression in late fall, for persons who are normally prone to depression. While this could be due to the approaching holidays, there is more evidence to support the idea that it is due to Seasonal Affective Disorder and the lessening sunlight of fall.

There is no doubt that Christmas is depressing for some people. We are bombarded by happy images on the TV, and if our family isn't/wasn't like that, then we may indeed feel down. However, for other people, Christmas is a time that lifts their spirits, and so there is an offsetting effect for people in general.

I don't want to make light of the problems that some people have with Christmas and Thanksgiving. For some, it may be really difficult. But the idea that there is more depression at Christmas is essentially an urban myth. There can be depression at any time of the year, and like any depression, if it goes on long enough, it might be wise to seek treatment.

Getting "Over the Hump"

2010-12-10T08:24:00.004-06:00

Many times my depressed patients find themselves stuck. They are at home, fatigued, sad, and filled with negative thoughts. What is often needed at times like that is to get out of the house and get some new experiences. Staying at home and watching TV is not sufficient stimulation to distract them from their internal negative thoughts. However, getting out can be difficult. It requires energy, and that is something they often don't have.

But once they are out, they usually feel better than if they had stayed at home. It would seem like a paradox. Why don't we do what is good for us?

I think that one answer is to use the example of a lawnmower. It takes initial energy to get the process started. Then once it is started, it runs on its own. A scientist patient of mine compared it to the energy of activation of a chemical reaction. It takes an external input of energy to get the reaction started; after that it is self-sustaining.

So the depressed individual needs something to get them "over the hump," to get them going. Then once they are out of the house, they often feel better than they would have felt if they just stayed at home watching TV or sleeping.

What is the solution? In therapy, I find that it works best if there is a plan. Once the patient has a plan, they are more likely to follow through. One plan is to make a commitment to get together with other people. Another type of plan is to buy tickets. People often will follow through with a concert or event because they have already put money down on the tickets. Another type of plan is to have someone come by to pick up the person and go out. It is hard to turn someone down who has made the trip over. There are probably many other types of solutions to this, but these are a few.

I think that another important type of plan is to look objectively at the consequences of staying home. Does it make the person feel better? If not, then the next time they have a chance to get out, they need to remember that staying home may be the easiest thing to do for a few minutes or an hour, but it may lead to more depression over the next several hours than getting out would.

Stress, Cortisol, and Depression

2010-12-09T15:41:00.001-06:00

What’s the evidence to think there’s a link between stress and depression?

There are 23,000 references in PubMed if you type in stress and depression.

The first type of evidence is epidemiological: People who have just had major stressful events are statistically more likely to fall into a depression.

Stressors are 2.5 times more likely in depressed patients compared to controls.

In community samples, 80% of depressed cases were preceded by major life events

Most episodes of major depression are preceded by stressful life events (although
most people do not become depressed even if they experience a negative life event).

It all seems so obvious that stress could lead people to be depressed. But actually it’s not.

For example, why doesn’t excessive stress cause something else? Why doesn’t it cause us to run amok, doing all sorts of wild and crazy things? Why depression?

Why doesn’t stress cause us to work harder? That would be logical–for our bodies to pump out more adrenalin and make us work harder to fix the problems we face.

The answer is we don’t know.

But to have any chance of understanding the human stress response and depression, we have to start with the basic nature of the human stress response.

We have a generalized response to a variety of stresses. Psychological stress and physical stress on the body generally lead to the same set of hormonal responses within the body, which is in itself unusual, or at least, counterintuitive.

We have one main stress response syndrome in our body:
Perception of threat
Hypothalamus activation
Pituitary activation
Adrenal gland activation
Adrenalin+Noradrenalin+Cortisol

During stress, a chain reaction of physical and chemical processes prepares the body for a fight or flight situation. After the logical, thinking part of the brain recognizes that danger is present, another part of the brain, the hypothalamus releases Corticotropin Hormone Releasing Factor (CRF). This in turn stimulates the pituitary (the “master gland”) to release Adrenocorticotrophic Hormone (ACTH). The release of ACTH triggers the secretion of cortisol from the adrenal cortex (the adrenals are located on the kidneys) to provide energy and to help suppress inflammation. Through a neural pathway (that is, via a nerve rather than chemical release in the blood stream), the adrenals are also stimulated to produce more chemicals called adrenaline and noradrenaline. These in turn serve to accelerate the pulse rate, elevate blood pressure, and stimulate the central nervous system.

The fight or flight response is a good thing. It has saved many of our forbears from saber tooth tigers and other dangers. But what is good for us in the short run is not necessarily good for us in the long run.

And cortisol is one of those things. I believe that our best bet at the current time to understand why stress would lead to depression is cortisol.

We do have some evidence that that may be true.

Cortisol like drugs, i.e., steroids, can cause depression as one of their side effects.
People who are given high levels of synthetic glucocorticoids for autoimmune disorders or inflammatory issues have greatly increased risk of going into a depression.

Secondly, we know that long term exposure to cortisol results in some really nasty effects on the brain, particularly the hippocampus. The hippocampus is the memory center of the brain. It also does something else. It modulates the release of cortisol. Long term exposure of the hippocampus to stress leads to loss of neural branches called dendrites. And it leads to problems with memory loss.

If cortisol has a damaging effect on the hippocampus, then it also might have a damaging effect on other parts of the brain. There is only one article I found on this , but it could be true. The negative effects of prolonged cortisol exposure occur throughout the body, so it is not a far stretch to believe that we have only begun to understand the negative effects of it on the brain.

Thirdly, about 50% of people with depression hypersecrete cortisol. Of course, by itself this proves nothing. But it would be consistent with the hypothesis that too much cortisol leads to – too much cortisol. In other words, stress leads to too much cortisol, which can lead to damage of the hippocampus, which unleashes more cortisol.

By the way, elevated cortisol levels occur in mania as well as depression.

Now, let’s transition from looking at depression as a biological disorder to looking at the psychological aspects of depression.

It is certainly possible that once we become depressed, the depression itself stresses us. It enhances our negative thoughts, which increase our perception of threat and stress, which increases our cortisol output, which in turn would further cause disorder of brain functioning.

There is some evidence that the anterior cingulate, a curved bundle of nerves around the corpus callosum between the limbic system and the prefrontal cortex is affected by or is causing depression. And there is a small amount of evidence that high cortisol levels can cause atrophy or smaller volume in the anterior cingulate.

And there, the physiological trail runs cold. We just don’t know the rest. But sometimes a bad theory is better than no theory at all.

So here is the theory in my head when I am working with patients.

Stress begins for most people as a psychological process, although there are also physical components. If my wife is in the hospital, I may sleep different hours, eat different meals, and so on. But also there is mainly psychological stress.

Then the HPA axis causes the release of cortisol. If this is on a sustained basis, the long term effects of cortisol affect the hippocampus and perhaps the anterior cingulate.

Since the hippocampus is supposed to help regulate the HPA axis, if it is impaired, then the HPA axis may get further out of control leading to more cortisol.

Ultimately, the anterior cingulate and the serotonin pathways are affected, leading the person to become depressed if this goes on for too long, and the person has certain genetics.

But even if the trail runs cold, we may know enough to inform our decision making. Stress, particularly prolonged and severe stress is not our friend. Combatting stress takes time and energy, and in some ways it is simply easier to let ourselves be stressed out, even if that is more painful. But it is not good for our brains and it is not good for us. And depending on our genetics, it is often a luxury that we just can’t afford.

Thinking about stress psychologically.

Stress is not just the result of a situation. It is the combination of the situation and our way of perceiving the situation.

We used to think of, or I used to think of, stress as something which could go away. And once it went away, then everything would return back to normal. This way of thinking clearly has gone out the window. Memory will sometimes return back to normal after exposure to chronic stress is over, but not always.

And multiple depressions leave us even more vulnerable to further depressions. Thus, we cannot conclude that we simply return back to normal.

I sometimes say to my patients that stress is a luxury that we can’t afford. What do I mean by that? Because oftentimes, there is little that we can do about stress. Either we are stressed or we aren’t.

But that’s not quite true. There are things we can do about stress.

Cognitive therapy, for example, is aimed at helping people to be less stressed by situations than they otherwise would be.

So there is some sense in saying that stress is a luxury that we can’t afford. To the degree that we do have any control at all over our stress, we cannot afford to let ourselves sink to the bottom of the pit, with the idea that we will eventually bounce out. For some of us, this undoubtedly triggers a genetic response of biological depression. For others of us, it may impair our hippocampus if this goes on for months or years. And for others of us, it may do both.

So if stress is a luxury that we cannot afford, what can we do about it?

This is where the panoply of typical depressive therapies comes in.

Cognitive therapy works to reduce irrational negative thoughts. Why is this important? Because without excessive negative thinking, our body just might turn off the stress response. Which could turn off the cortisol. Which would give our brains a chance to heal.

Behavior therapy sometimes works on assertiveness training. Why is this important? Because assertiveness often fixes situations that we perceive as threatening, which means we don’t have to be stressed, which means that our bodies can turn off the cortisol, which lets our brains heal.

Interpersonal therapy works on improving interpersonal relationships. Which again often fixes situations that we perceive as threatening, which means we don’t have to be stressed, which means that our bodies can turn off the cortisol, which lets our brains heal.

Therapy sometimes helps the person to gain control, or at least enhance their feeling of control, which etc etc.

Get the picture? We cannot afford the luxury of stress. If there is anything that we can do which can turn off the stress response, then we need to do it. If we can divert our attention for a few hours, so much the better. If we can fix the situation, so much the better. If we can find more adaptive ways of thinking about the problem so much the better.

A Very Sophisticated Book

2010-12-09T08:16:00.004-06:00

One of the most sophisticated books I have read in a long time is The Neuroscience of Psychotherapy: Healing the Social Brain. Psychotherapy books in the 1970's (a long time ago when I was in graduate school) were often criticized as being "pop psychology." This is anything but. It is not easy reading for the layman. But for the sophisticated reader, it can't be beat as a way of understanding how psychotherapy relates to brain functioning. The book tackles the problem of integrating two very different paradigms, or heuristics--psychotherapy metaphors and neuroscience concepts. Both are important.

There is at least one more paradigm which has to be integrated with these two, which is the spiritual paradigm.

I once had a patient, a computer programmer, tell me that he had been reading about how computers can be described as operating at seven different levels. I'm no computer wizard, but I can imagine what he means: the atomic level, the circuit board level, the basic machine language level, the macro language level such as A++, the final interface level with the human operator, etc. The same is true of humans. Their functioning can be described at many different levels, and it is hard to integrate all of these together. It will be a long time before we can integrate all of them. But in the meantime, Louis Cozolino has made a really great start in this book.

Settling on a Parenting Philosophy

2010-12-07T10:28:00.007-06:00

Many times parents are overwhelmed by the task of parenting. And too often they have never settled on a parenting philosophy. They are just "flying by the seat of their pants," reacting to each situation in turn.

What is a parenting philosophy? It is a guiding set of principles. It is essentially the answer to the question, "What is the most loving thing we can do for our child?"

Here are some questions to consider. Most or all of these do not have a "right" answer. Parents can discuss these without having to always agree. However, I do think that it is important for parents to know where they disagree, and I do think that it is important for parents to agree more than they disagree.

Questions to consider:

Are rewards or punishments more important in raising a child?

Pro Reward View: Punishments tend to have temporary effects. They may cause resentment, anger, and further rebellion. They do not model the positive behavior parents are generally trying to teach.
Pro Punishment View: Sometimes it is necessary to get the attention of the child. Rewards do not necessarily do that. Moreover, setting limits is important, and it is hard to set limits sometimes without there being a punishment included.

Do children do best when left to grow up "naturally," or do they need to have enriched environments and experiences to grow up best?

Pro "Natural" Viewpoint: Many children do grow up well without fancy education or extra experiences. My parents and parents-in-law did quite well with this viewpoint. Children have a natural tendency to explore their environment and learn.

Pro "Enrichment" Viewpoint: Studies have shown that highly stimulating and enriched environments lead to greater proliferation of nerve cell connections in the brain. Additionally, there is just too much to be learned in the modern world without children receiving assistance. Public schools cannot provide this for a variety of reasons, including financial costs. While children may have a natural tendency to explore their environment, they can also get sidetracked into computer games and the internet. They are not necessarily exploring the world in the way our parents did.

Do children need limits more, or praise and warmth more?

This is probably a false choice. They need both. But parents often choose to focus on one or the other more. You probably have a preference and parents will have less conflict over parenting if they are generally on the same side of this issue.

Is it okay to be inconsistent with a child, or is consistency extremely important?

Pro-Consistency Viewpoint: Without consistency, children can be confused. They can pit parents against each other. Children may learn to manipulate. Moreover, they need to learn to deal with real life, and real life has many instances of consistency. When we do certain things, there are negative consequences--touching a hot stove, overspending our credit card limit, and so on. If parents are inconsistent, then children may be surprised and angered when they grow up and these life consistencies fail to budge to their manipulation and complaining.

Pro-Flexibility: Life is too complicated for total consistency. Often there are extenuating circumstances. Often children have learned their lesson without the full punishment being meted out. Setting a good example might not always mean showing total consistency. Setting a good example might mean showing good parental judgement when there are extenuating circumstances.

Is it better to correct children and point out what they have done wrong, or to empathize with their feelings and try to understand why they did what they did?

Should consequences and punishments be mutually agreed upon by parents? Or is it okay for one parent to act unilaterally?

How long should punishments last for? Is it okay to to rescind a punishment once it is stated, or not?

How involved should parents be in helping a child to do their tasks, such as clean their room, etc.? Is it okay to help them, as a way of modeling behavior and making it fun, or is this coddling or enabling?

How important is it for a parent to set a good example and to lead by positive role modeling? Is it okay for the parent to do one thing but then tell the child to do something else?

When children misbehave, is the behavior to be seen as a result of being bad, making bad choices, or as a result of dysfunction (such as brain dysfunction, immaturity, or family dysfunction)?

Some of these are very hard questions. And you may not come up with answers to all of them. But it is better to consider them now, when your children are growing up, than later when they are adults.

It's Been a Long Time Since My Last Post

2010-06-08T22:31:00.003-05:00

And I think that it's about time that I shared some more of my thoughts here. One of the main things that I have been struck by in this last year is the importance of taking personal responsibility. Therapists don't cure patients. We are more like teachers and guides than we are like shamans or even medical doctors. We guide, we encourage, we even correct people when they are about to walk off of a cliff. But ultimately, we don't heal or cure. We each have to take the curative steps for ourselves. One of the problems, however, is that oftentimes, patients are so lost, they don't know what those steps are. And that's where the therapist comes in. So step one is that the therapist clarifies what steps need to be taken.

The therapist also clarifies and simplifies. I have often mused about how confused I would be if I was not a psychologist and had a mental health problem. I could imagine myself in front of a row of books at Barnes and Noble wondering which one to read. Or I could see myself looking through the Yellow Pages wondering which therapist to call. And even if I did buy an appropriate book, it would be doubtful that I would be able to stay with what it was recommending. So the therapist clarifies what is important. He/she does this partly by simplifying and leaving out the least important theoretical understandings.

And the therapist encourages. That's how people stay with things. Encouragement from a teacher. It is very difficult for any of us to teach ourselves. I have a jazz piano teacher. And I have an oil painting teacher. For all of the above reasons--to clarify, to simply, and to encourage. But ultimately, I have to practice and practice and practice. I would never expect that they could just magically make me into a good artist or jazz pianist just because I show up and pay them money. But I think that sometimes clients think that will happen. Effort, practice, thought, mistakes, persistence, and so on, are all part of the process.

The Death of the Frontal Lobes

2009-06-20T21:06:00.009-05:00

Our frontal lobes are dying.

Well, maybe not really. But they may be suffering. The old quote "rumors of my demise are greatly exaggerated" comes to mind here. But if our frontal lobes have not died they are perhaps in peril.

The prefrontal lobes of our brains contain much, if not most, of what makes us human. Our ability to plan and solve problems. Our ability to initiate a course of action and persevere. Our ability to hold back our emotions when necessary. Our ability to do the hard thing rather than the easy thing. Our ability to notice when we are missing the mark and need to change our course of action to be more effective.

But these are not the types of abilities which are now reinforced in our everyday lives. We often do not read books so much as skim across web pages. We do not make conscious decisions about what will enter our brains so much as clicking the most interesting web page link in front of us.

I know of what I speak, for I too seem to at times become one of the emerging prefrontal lobe brain dead. I can sit down at the computer and encounter lines of email "famspam" (my term for the unending funny pictures, interesting Youtube videos, patriotic Powerpoints, and so on, sent by well meaning family members and friends). Once I have sat in front of the computer, my clicking on links sometimes leads me to forget what I originally intended to do at the computer.

This is a passive approach to the world and to information, and, I am afraid it is leading to a passive approach to life in general. We do not do the hard thing. We seek the easy or the most interesting thing to do with the click of a button. Check our email. Check Twitter. Respond to email. Respond to Twitter. Watch TV, surf the channels.

It is the adult version of what happens when children play video games. We become passive responders. We are responding, but without clear intent, planning, or moral effort. (There is effort in playing a video game, but only of a type.)

Human life needs to be more than passive responding, whether it is to a video game or to Twitter. But it is not just a matter of whether we will seek to do the hard thing. It is also a matter of whether we will be able to do it. Will our prefrontal lobes be there for us and have the necessary complexity and ability to do what does not come easily?

I believe that the proper functioning of the frontal lobes depends on the building up of the neural substrate, that branching of nerve endings which is so marvelously complex in our brains. And I believe that the branching of the nerve cells ("dendrite arbors") can only occur when we use our prefrontal lobes.

Why are we in this position? Were our forebears morally superior "Giant Brains" and we are only "Tiny Brains?" (I am alluding here to the movie "Defending Your Life." If you haven't seen it yet, put it on your list to see.) I don't think that our forebears had better brains. They made many stupid mistakes, of which racial prejudice was just one. But we have so many interesting things to look at. We do not need to invent anything of interest because 10 things of interest have already been shoved at us in one way or another, constantly vying for our attention.

What happens when we don't exercise our frontal lobes? When writing a term paper becomes a simple exercise in cutting and pasting on the computer? My speculation is that we are not developing our frontal lobes and that as a result we will lose some of our self-directedness. We may also lose some our ability to do the hard things in life.

The most important "hard thing" is to set our own goals and then to pursue them. It is so much easier to fall in line behind people who will show us what to do, tempt us with something to do, and so on.

Time, as an empty, cavernous structure yawning before us does not comfort us. It seems to create anxiety in many. Visit a casino with the banks of slot machines. These slot machines can help us to "pass the time," "kill time," and "fill" our time. (I am not being a prude here; I like a little slot machine action once in a great while.) Killing time may also be a way of letting our frontal lobes atrophy.

What the world needs are people who can do that most difficult of all things, set meaningful goals, plan to complete those goals, and then make meaningful efforts to reach them.

The Triple Layer Cake

2009-05-06T22:30:00.005-05:00

There is nothing like cake to get my attention. So maybe I have your attention, too.

This is the way I explain depression to my clients. It's like a triple layer cake.

Layer one is the original depression. Let's call it biological depression. Something has happened in the brain in response to stress. As a result, mild to moderate depression has set in. The person is having difficulty concentrating, less enthusiasm for doing things (anhedonia), and some fatigue. As a result, they aren't getting as much done. Their grades are going down in school. They are snapping at their children.

Now here is the kicker. Now they start to criticize themselves: "I am lazy." Or, they may think or say, "I am stupid." And so on. They are not able to deal with their decreased efficiency. They think that they "should" be totally in control of themselves, their symptoms, their behaviors, their lives, and if they are not, then they are defective. Now we have the second layer of the cake--being depressed about being depressed. This drives the person down deeper into depression--perhaps from being mildly to moderatly depressed all the way down to severely depressed.

Now for the third layer. The person stops doing the positive behaviors they used to do. They quit socializing. They quit doing their hobbies. They start developing the habit of thinking negatively. Old, good habits start to extinguish. New, bad habits are taking their place.

If the person is treated with an antidepressant, they may recover their appetite, their energy, their sex drive, etc. And this may well help layer two--their self blame, since they have less to blame themselves for.

However, the habits of negative thinking, avoidance, and withdrawal may remain even though many of their depressive symptoms are in remission. This is one of the tasks of psychotherapy--to make sure that the person fully returns back to their normal self.

Many of my clients find that this simple little model helps them understand how their depression became severe in the first place and also focuses them on what they need to be doing to recover. Namely, they need to quit blaming themselves for any remaining depression. They need to overcome their acquired habit of negative thinking (e.g., as in cognitive therapy), and they need to get back to their old positive habits of socializing and having pleasurable experiences.

The Therapeutic Alliance

2009-05-03T07:47:00.004-05:00

In my testing and therapy, I am constantly struck by how much we don't know. How different is Bipolar II from Bipolar I? How different is Aspergers from Autism? Does depression permanently damage the brain, or are brain cells regenerated (as they are sometimes in the hippocampus)? And on and on. We know so much and so little. There is so much depression research appearing that a person could spend all of their time just reading it. But the big questions often elude us. And our patients must patiently suffer through our lack of awareness. It is as if we are always in the dark ages. Future generations will look back and marvel at how little we know, just as we look back and marvel at the treatments used in Freud's Vienna (and those were better than what was being used in the rest of the world!). It is my goal to use the best of current knowledge. What isn't known has to be imagined. We have to connect the dots and extrapolate in between for the benefit of our patients. And we have to learn from our patients. They teach us. The most exciting situation is when the partnership (AKA "therapeutic alliance") actually forms, and the patient and I go on a voyage of discovery together. We put together what we know, and something very important happens. It is an exciting experience.

The Soap Opera Rule

2007-07-13T16:29:00.002-05:00

Sometimes in therapy, when my clients are trying to figure out what decision to make about a personal problem, I invoke the Soap Opera Rule. The SOR is very simple. Figure out what they would do in a soap opera if this situation were to arise--and then do the opposite!

What is the reasoning behind the SOR? Soap operas make money by never resolving problems. The scripts stir up problems with games, self-defeating decisions, addictions, and dramatic interpersonal moves which only serve to complicate situations further. Soap operas do not try to calm situations and resolve them. In real life, dramatic moves interpersonally very often create more tension and problems than they solve. When things are going poorly in our lives, we may long for that major, dramatic action which will cure everything in one fell swoop. But it usually doesn't happen that way.

What generally does work well in real life is calm, deliberate action which is above board and straightforward. It may not be the material for a great novel, but in the end it often accomplishes what we want most--strong interpersonal relationships and success in other areas of our lives.

What Does Therapy Have to Do with Jazz Piano Lessons?

2007-05-15T12:30:00.001-05:00

My hobby, my main hobby, is jazz piano. I love jazz, and I enjoy expressing myself through jazz piano. Unfortunately, my musical IQ is not at the genius level. In fact, it is far below it. And at times, I find the lessons I am learning to be difficult, tedious, or even confusing. During some lessons, my teacher will demonstrate a chord voicing. I see her fingers on the keys, but I don't really comprehend what chord structure she is demonstrating. To her it is simple. For me, it sometimes makes me feel that I need to be in a remedial piano class.

So what has that to do with therapy? Everything. Learning something which is complex and complicated is difficult. It takes energy. It takes perserverence. There are times when we feel we are just not capable of learning it, and other times when we are sure that "other people" could learn it much more quickly. There are times when we are tempted to think that the way we used to do things was good enough, and we wonder why we are going through this grief of learning something a new way when it is so frustrating.

The answer is that there are points, when after considerable mountain climbing, we are able to look back over the terrain that we have covered, and we see just how far we have come. It is then that we realize that it has been worth it. But during the climb, we often wonder why we are doing it--why we are putting ourselves through it.

Taking lessons is in itself a lesson in humility. One of my graduate professors called the rejections he received on articles submitted for publication his way of learning humility. Taking flying lessons, and now taking the jazz piano lessons, is my way of learning and/or remembering what it must be like for my patients at times. I am presenting to them ideas and concepts as if they are simple and can be comprehended quickly. However, sometimes the brain goes into a "fog," and the concepts which seem simple to the teacher can be incomprehensible at the moment for the student. Perhaps all teachers need to be students at times, and need to try learning something really difficult. I know that every time I leave one of my jazz piano lessons, I have greater respect and empathy for what my patients are going through--not just in their daily lives but in undergoing the process of therapy itself.

Down with Laziness

2007-05-02T06:58:00.001-05:00

It is not uncommon in my counseling sessions for people to blame themselves or others for being "lazy." I have a major problem with that, because frankly, I don't know what it means. Nothing in my years of training or continuing education has ever prepared me to understand laziness. I understand something about depression, which can rob people of their motivation. I understand something about ADD, which can make people tend to wander around in life or in their everyday activities. I understand something about frontal lobe brain damage, which can rob people of motivation. I also have some general understanding of passive aggressive behavior, which in my experience is usually a reaction to punitive parenting in childhood. But I'm just not sure what laziness it.

I'm not saying that it doesn't exist. But it's one of those words and concepts that is really good for beating ourselves up without having a clear meaning. That makes it rather dangerous. We can call ourselves lazy and feel inadequate and depressed. We can call others lazy and feel angry at them. So we had better know what we mean by it. It's a powerful word.

"Lazy" is a moral judgement. We apparently are saying something more than "I feel unmotivated," or "he is relatively unmotivated."

There's another problem with the word. Lack of motivation is a relative thing. Even persons that we might be tempted to think of as lazy are often in fact motivated to do some things, maybe even things we ourselves wouldn't do.

In almost every situation that I encounter where a patient calls themselves lazy, they are in fact, either depressed, ADD, or experiencing a psychological reaction against a very dominant person (parent or spouse). The word lazy obscures rather than clarifies, creates obstacles rather than solutions. We have to know what the real problem is before we can fix it. So whenever one of my clients uses that word, you can be sure I point it out to them.

Usually, the client is depressed, and calling themselves lazy only compounds their depression. It is not usually accurate for a client to call themselves lazy because that (if it exists) is a character issue, a lifelong quality rather than being part of a temporary episode of depression.

It may be possible that people are born with a lethargic temperament for some reason, and may naturally not be very motivated. If so, that would not be a moral issue; it would be a psychological or biological issue.

So down with the word "lazy." When we encounter problems with lack of motivation, we need to figure out what is really going on and address the real issue.

The Hidden People

2006-06-28T16:09:00.002-05:00

Who are the hidden people? They are all around us. But in one way or another we do not see them.

They are the elderly and impaired people in nursing homes that no one visits.

They are the mentally retarded who are boarded in schools.

They are the people in prison.

There are visible people and invisible people in our society. Visible people are the ones with their pictures in the paper and on the TV. In a more mundane sense, they are the people you see in the malls and at the restaurants. They have the money, the mobility, the psychological and financial resources to take charge of their own lives and to be involved in life.

But there are all kinds of hidden people.

There are the people who hide themselves. They are depressed or have other emotional problems. They are not able to stand the glare of being around other people. They fear rejection or harm.

There are people who are hidden in plain sight. They are the people we would rather not look at, and generally we turn out heads because we do not wish to see them--the homeless, the addicted, the streetwalkers.

How is this a psychological issue? Many of the hidden people are there because of psychological reasons--dementia, retardation, schizophrenia, and so on. This is a psychological issue, but it is also a social issue and a spiritual issue. For those of us in plain sight, we need to be become aware of the hidden people of the world.

The Importance of Regular Body Rhythms

2006-06-06T14:07:00.001-05:00

Recent research has shown that in Bipolar patients, but also perhaps with Unipolar depressed patients, the 24-hour sleep/awake cycle is very important in establishing a normal mood condition. People with Bipolar Disorder are very susceptible to disruption of their moods when their 24-hour sleep/awake cycles are disrupted. Bipolar Disorder, for example, is the only psychiatric disorder which can be triggered by something positive happening in the person’s life. When a person has positive events occur it may lead to changes in their routine and in their sleep/awake cycle. When people stay up later and later, it can trigger the onset of a bipolar episode. In working with bipolar patients, we emphasize the importance of getting regular sleep, and regular waking periods. That is easier said than done, but it is important.

Research has also shown that in addition to having regular sleep/awake periods that it is important to have regular social interaction. The body sets its 24-hour cycle not just on the basis of sunlight, sleeping and waking, but also on the basis of regular social interaction. This could include something such as going to work, going to church, going at a regular time for doughnuts with a social circle, and so on. For that reason, the therapy based on this principle is called "Social Rhythm Therapy” because it involves both biological rhythms and using social events to set those biological rhythms.

For many individuals, the seasons of the year are important, and getting enough sunlight is important in stabilizing their moods. For that reason, one option is for people to stabilize their moods by walking every day at noontime for an hour. This ensures that they will get enough sunlight, and it also establishes a particular time by which the body can set its internal clock.

Persons living with Bipolar Disorder often seek out excitement and stimulation. They like change. However, too much change and too much stimulation will often trigger episodes of mania or depression.

The Dead End of Perfectionism

2006-04-28T22:48:00.001-05:00

Many of the people consulting with psychologists have a problem with perfectionism. Some of them understand the problem and burden imposed by their own perfectionism. They are tired to having to do everything just right; they are worn out. Or they are depressed and they realize where the depression is coming from.

For others, doing things perfectly is a lifelong value, even a cherished value. They do not realize the full downside to the perfectionistic way of doing things. They may be depressed or anxious, and they may want to feel better, but they may want to feel better without giving up their quest for perfection.

There are multiple problems with perfectionism. These are discussed more fully in the chapter available on my website under "handouts."

Here are a few of the problems with perfection as a goal

It leads to depression in some people
It can alienate other people from us
It leads to procrastination in some people
It is ambiguous, that is it has unclear and confusing goals
It can lead to focusing on minor details rather than the larger issues of life
It is impossible to be perfect

Perfection may be a halfway possible goal for the child or teenager. Consider the sixth grader. What do they need to do to be perfect? Make straight A's, keep their room straight, and obey their parents. (Having "perfect" thoughts is more difficult, since sixth graders can have a lot of aggressive thoughts.) But with the coming of high school, it is much harder to make straight A's. And in the college years, almost impossible. Then, the person enters adulthood. They are a worker. What does it mean to be a perfect worker? If the job is straightforward enough, again it might be possible. But then they become a homeowner, and they have a house to keep up. And then they become a spouse. And then they become a parent. Now they have to be a perfect person, perfect worker, perfect homeowner, perfect spouse and perfect parent. Are there really enough hours in the day? No, there aren't. And something will suffer if they try to achieve perfection in one of these areas at the expense of another area.
Being perfect is ambiguous. As we have seen, it is relatively straightforward for a person to know what being perfect is in the sixth grade. But what does it mean at age 65 when we are retired? Does it mean keeping our lawn trimmed everyday and keeping the weeds out? Does it mean that we are volunteering? Does it mean that we are obeying all the rules? Or does it mean that we are learning which rules to break (as for example during the civil rights disobedience of the sixties). Does it mean that our house looks perfect to visitors or that we are being creative with our time? Does it mean that we keep outward appearances just right so that others will approve of us, or that we will use our time wisely so that we will approve of ourselves?
There are large issues in life, and these can rarely if ever be accomplished perfectly. Perfection is something we can accomplish when we vacuum the house. It is not likely to be accomplished in poetry, painting, volunteering, or even just helping out a friend. It is unlikely that we can write the perfect poem or be the perfect volunteer. The temptation for the perfectionist can be to do the smaller things which can be done more or less perfectly.
Perfectionism can alienate the people around us. When they do not live up to our perfectionistic standards, we may be magnanimous and forgiving--or we may be critical. And even when we attempt to be forgiving and "overlook" any mistake, our impatience with their lack of perfection may show through. This can put people off.
Perfectionism can lead to procrastination. We know that once we take on a project, we will have to do it pefectly. This can make it a daunting task, and we may find it easier to keep putting it off rather than doing it "just right."
Finally, studies have shown that perfectionism tends to lead to depression in many people. When the perfectionist falls short of their perfect goal, they may berate themselves, causing low self esteem and this may in turn lead to depression.
As an alternative to perfection, we can aim at doing things well. We can realize that it is better to be fully engaged in life and trying a lot of things rather than just doing a narrow range of activities where we can be assured of the outcome. There are times to be perfectionistic. Pilots are taught to be extremely thorough in checking over their airplane before taking off, for example. And if I ever have brain surgery, I would prefer my surgeon to be a perfectionist. However, in everyday life, perfectionism tends to detract from our productivity and feelings of well being.

Can People Keep Up Psychologically in a Flat World?

2006-04-26T21:02:00.001-05:00

The recent book, The World is Flat, offers many stimulating ideas about how the world has evolved in recent years to the poker game it now is--the U.S., China, India, and the other players at the table. It gives a synopsis of the recent past but also a glimpse of the future. For people who have not yet read it, it summarizes the how the computer age has led us into a new economic age in human history.

For the first time, a person in India without an education in a first world country, can compete on almost a level playing field with people in first world countries. In the past, it might be necessary for a person from China who wanted to be successful in business, to train at Harvard or UCLA, and then to remain in the United States or Europe to establish a business. As new businesses become more computerized and more dependent on the internet, the actual geographic location of the business and entrepreneur becomes less and less important. It is becoming less important to do business physically in a first world country. Moreover, there can be a benefit to establishing the location of a business in a third world country if that is where the cheap labor is and if that's where the resources are. Sales and marketing can to a great degree be done over the internet while the physical plant is almost anywhere in the world.

The pace of change is staggering. China is turning out 65,000 engineers a year. In the United States, we are no longer just competing with others in the U.S. We are competing with China, and India, and soon others as well. We have been setting the pace for them to keep up with; soon they may be setting the pace. We have been content (many of us) to work 8 hour days. They are willing to work 12 hour days to be in the game. Can we keep up with them? Do we even want to keep up with them? Can we afford not to keep up with them? And if we do, can we deal psychologically with the continuing changes which will be at our doorstep. For persons in the computer industry, skills start to become obsolete after a year or so of not keeping up. But in the future, it could be six months, and then even less time.

In the past, individuals in the U.S. could decide whether they wanted to be ambitious or not. Whether to work hard or not. Whether to strive for more money, possessions, etc.--or not. And we can still make that choice. However, individual choices now have national implications and repurcussions, perhaps in the same way that they did during World War II. During that war, individual productivity was tied to the survival of the nation. The United States could not thrive and perhaps not even survive if people were to choose the easy life.

But whereas that war was limited to a particular period of time, there is no end in sight to the international competition which is only now gearing up to a full degree. Countries who fall behind, may stay behind for a long time. Countries who choose a life of leisure may end up being the servants of the trendsetters, that is, economically doing the bidding of those with the patents, the copyrights, and the industries.

In a worst case scenario there might be a frenetic pace of competition in which there was no pause. This is the most troubling aspect of the coming situation psychologically. People need balance in their lives. They need some leisure. They need time to reflect. A state of urgency (if not emergency) could be imposed theoretically, not this time by a dictator or the need to respond to a dictator as in World War II, but by the simple need not to be left behind, not to become a satellite nation to other more industrious nations which were willing to do whatever it took to be the inventors, the producers, and hence the dominators of the world economy.

This is reminiscent of the Charlie Chaplin movie, Modern Times, in which the machine conveyor belt gets the best of him . He cannot stop it. Once the machine is started, it seems unstoppable. In contrast to his movie The Great Dictator, it is now the machines (and those who run it) which are in control. Is it possible that the nations of the world could, in their competition to survive and flourish, get onto a treadmill in the world where no nation can afford to pause or get off? Is it possible that no one would dare to get off? And how might this translate down to the level of the individual? Could individuals get caught up in this same frenetic pace? What of the people who cannot deal with that new pace? It is not only cultures but also individuals which must adapt to it.

But perhaps this is looking at the situation somewhat pessimistically, from the vantage point of one living in America, where comfortable living is now rather taken for granted. It can be daunting facing the new crop of 65,000 engineers a year coming from China. But for one of those graduating students, the internet revolution flattening the Earth is indeed an opportunity to break free of poverty and isolation.

The long term consequences cannot be foreseen. But we can keep our eyes open to both the potential rewards and the dangers of the new and accelerating pace of global competition.

Supporting the Depressed Person

2006-02-22T22:30:00.001-06:00

Yesterday, I said that I would write something about how to best support the depressed person. I basically said what not to do. It can be difficult to be supportive when one sees the depression going on and on. But there are some things which I believe to be helpful.

First of all, there are different levels of depression. Even within the diagnosis of major depression, there are mild, moderate, and severe levels. A person with severe major depression will need more support than a person with mild major depression. And a person with milder forms of depression (dysthymic disorder, adjustment disorder, etc.) will not need the same kind of support. Persons with more severe depressions need practical as well as emotional support (such as filling out forms to be absent from work, setting up therapy sessions, making sure that the person takes their medication accurately, or driving them to therapy). Persons with milder levels of depression need more emotional support. For them, the practical support may be helpful, but it may have more of a symbolic helpfulness (showing that you care).

So, keeping in mind that it is difficult to give guidelines that would apply to all depressed persons, here are some suggestions:

First of all, support the person being in treatment. Don't criticize them being in treatment. If they are still depressed after being in treatment, that doesn't mean that they need to stop it and "buck up." It may mean, however, that some type of change is needed in their treatment strategy.

If you don't think that their current psychiatrist or therapist is helping, you can suggest that they seek a second opinion without criticizing their current doctor. Or alternatively, you could even ask if it would be okay for you to speak to their doctor and give feedback about your concern that they are not improving.

Realize that they don't want to be depressed. They most likely want desperately to feel good. They are trapped in a maze. They don't know how to get out. Communicate to them that you understand that they want to feel better and that you are there to help.

If they talk negatively, give them gentle feedback. For example, if they said "I'm just stupid," you could reply that you don't believe that and that there is no evidence for it. They may not accept your reassurance or believe you, but it is probably better to provide a gentle confrontation than to say nothing.

Help them to get out of the house. Staying at home allows them to ruminate over their negative thoughts more. They may not want to get out, but give them encouragement to do so. Make it easy. You do the footwork. Buy the tickets to the movie or make the babysitter arrangements.

Don't take their depression personally. It can be helpful to look to see if you are doing anything that is contributing to their depression. By all means. But oftentimes, you will have nothing to do with their depression. If you don't take it personally, you can be of more help because you won't be defensive. Support the person, but don't take responsibility for them getting well.

If on the other hand, your self-examination leads you to believe that you are part of the problem, then try some marital therapy sessions to work on those issues.

If the depressed person is also abusing substances of some sort, don't assume that this is their only problem. Oftentimes, there is depression behind their alcoholism or drug abuse. AA can be helpful for alcohol abuse, but it is not likely to be an effective treatment for depression.

Give the other person positive reinforcements. These can be in the form of positive verbal statements ("You did a good job cleaning house today," or "You look nice") or taking them out. Don't be surprised if they disqualify your positive statements (finding ways of saying that they are not true or don't deserve compliments).

Look for a local depression support group. Take them and or attend with them, if they wish it.

Educate yourself about depression. Very thick books have been written about depression. You don't need to know everything that is in them. But it is helpful for you to realize that depression is sometimes a severe, complex illness. It is not just a feeling. Educate yourself about some of the complexities of depression.

Help them manage their medications if necessary. Depressed people may not take their medications correctly because of a variety of reasons. They may forget to take them. They may become pessimistic about the medication helping and stop taking it. They may not believe that they can afford the medicine.

Take care of yourself. Make sure that you have a social support network, too. That way, you don't burn out, and you have something to give.

Be ready to deal with your own feelings of resentment. It can be difficult being the spouse of a depressed person. Don't feel guilty about feeling that way, but don't just stew in your resentment either. Find someone with whom you can talk through your feelings.

Don't Blame the Victim

2006-02-22T11:16:00.001-06:00

Psychological research has documented that there is an unfortunate tendency in people to blame victims. Part of the reason for this appears to be the need to reassure ourselves that bad things are not going to happen to us. When we see someone who suffers misfortune, we may feel anxiety and want to believe that it could not happen to us. Or we may feel a twinge of guilt that our lives are so good. For example if we hear of someone being robbed or attacked at night, we might think that they shouldn't have been out at night by themselves--they should have known better.

Some of my patients experience the same type of blaming. Depressed persons often report to me that their families do not understand their depression and tell them to snap out of it. People imply that they could be well if they wanted to be, that they simply want to be sick. Or there may be the implication that the person is morally weak and bad for not choosing to be well. This is also blaming the victim.

There may be some people out there who want to use their psychiatric symptoms for some reason (disability, etc.). I rarely encounter them. In my practice, I find people want to get well. If they could get better on their own, they would. One of the ways they work on getting better is by coming to see me. It does no good to tell them to snap out of it. It does no good to blame them and imply they are weak. Even worse is when people imply that their depression or anxiety is because they are out of right relationship with God.

There are ways of encouraging a depressed person to get better, but blaming them is not one of those ways. In my next piece, I will talk about some positive ways of encouraging persons who are suffering through psychological symptoms.

The Anxiety Spasm

2006-02-10T18:06:00.001-06:00

I have sometimes referred to anxiety as a spasm. I believe that this is an excellent metaphor. As a spasm grows, it only makes itself worse. The muscle can't pull out of it. The more it spasms, well, the more it spasms. Usually, there has to be some sort of intervention to make it stop, such as pulling the muscle.

My patients often find themselves in just the same situation. Anxiety focuses their attention on the problem, and the problem increases their anxiety, and the increased anxiety focuses their attention even more on the problem. They want the anxiety to go away. But strangely, they are often reluctant to go do something else which might distract them and make them less anxious. It is not clear why this is. Perhaps, they already feel at their limit, and they just want to rest somewhere away from any demands. However, physical rest does not bring mental rest when there is an anxiety spasm. It generally gives their brain the freedom to keep focusing on the problem, obsessing, and worrying.

The cure for many spasms is to pull the muscle so that the spasm gradually subsides. The cure for the anxiety spasm is often to pull away from the worry and get into another situation until the anxiety gradually subsides. This may involve an uncomfortable feeling at first, focusing the mind on something else when the mind seems keenly bent on dealing with the problem and only the problem. However, after pulling away and focusing on something else, many people start to feel better.

I sometimes suggest to my clients that they keep a chart of their anxiety, rating it from 1 to 100 over time. It can be useful to do this when they just stay home and don't do anything special, letting their mind think and feel what it will. And then other times, the chart can be done when they get out and do something else which pulls their attention away from the anxiety. This gives the client concrete data to work from. What is going to make me feel better? How long will it take for me to feel better? How much better will I feel?

Some clients have had antianxiety medication prescribed for them. Such medication can be useful, especially when it is combined with learning psychological ways of coping with anxiety. I do not believe in any client being tortured by anxiety, and severe anxiety is a type of torture. But I also believe that it is always important to combine anti-anxiety agents with psychological coping techniques so that in the long run, persons do not become dependent on the medication.

The Problem with New Years Resolutions

2005-12-23T20:03:00.001-06:00

This is the time of year that people often decide upon New Years resolutions. While there is nothing wrong with making a resolution, my clients often tell me that they often don't follow through with them. What are some things that you can do to make changes in your behavior and make them stick?

First of all, while New Years Day may be a convenient time to decide to make behavior changes, realize that there is nothing magical about it. Treating New Years Day as some kind of magical point in time could make you discouraged and wanting to quit altogether if you relapse. If your behavior change relapses to your old behaviors on January 26, then January 27 is just as good to begin all over again. There is nothing magical about January 1.

Similarly, don't let setbacks ruin your determination. Setbacks are normal. Relapses happen. It's only human. Sometimes a relapse makes people feel hopeless and helpless. While some people can stop drinking or smoking or some other bad habit all at once and forever, that is not the most typical pattern of change.

Thirdly, make a list of all the reasons why you really want to change. What are all the advantages of changing and all the disadvantages of not changing?

Fourth, if there are circumstances which act as trigger events for you negative behavior, remove them. For example, if you are trying to diet, and you are snacking too much, remove the snacks from view. In fact, remove them from the house altogether. If you are trying to stop smoking, remove not only cigarettes, but also the lighters, ashtrays and anything which would remind you of smoking.

Fifth, create a setting which encourages healthy behavior. Again, using the dieting example, tempt yourself with healthy foods. If you are reaching for healthy foods, then you are not reaching for unhealthy foods. If you are satisfied with healthy foods, then you will not crave unhealthy foods as much.

Sixth, reinforce yourself for behavior change. Treat yourself to something positive in a healthy way as a reward for positive behavior change.

Seventh, watch out for negative thinking and don't allow negative thoughts to undermine your behavior change. Some typical sabotaging thoughts might be, "I can't do this," "I don't deserve to have things go well in my life," and "one relapse means that I have failed altogether."

Eighth, take it one step at a time. Work from one success to another. Don't make it into an all or nothing proposition ("Either I lose a hundred pounds or I haven't lost anything.")

Ninth, focus on the process of healthy behavior and not simply eliminating negative behavior. For example, instead of thinking that one will NOT eat, focus on eating in a healthy manner. Every meal that you eat that is healthy is a success. This is a different way of thinking from focusing on what you are not going to do. Eat healthy three meals a day, and you are having three successes a day. One failure is only one failure among many successes. Life itself is a process. The process can be healthy or not. It can be positive or not. Don't just focus on the end goal. Also focus on daily process of living your life in a healthy way.

Tenth, realize that when you decrease a negative behavior, you are essentially creating a type of vacuum. There is a saying that "Nature abhors a vacuum." That is, a vacuum tends to suck things into it. If a person has been smoking, they have been lighting up, smoking cigarettes, emptying ashtrays, going to the store for more cigarettes, and so on. These are behaviors that fill time. If they give up smoking, there is now extra time, and there is a vacuum of sorts. They need to fill the time with something positive and constructive or the extra time on their hands will "suck" the old behaviors right back. If a child is writing on a wall with crayon, you can punish them and they will stop. But if you don't give them constructive alternatives, they may go right back to doing it. On the other hand, if you go to the toy store and bring back a white board with markers or a large paper tablet with markers and encourage them to mark on it, then they are much less likely to go back to drawing on the wall. This is because you have filled the vacuum. So if you give up on one behavior, look for positive behaviors which will give you something to do with your hands, or your mouth, or your time.

Investing in Your Life

2005-11-30T20:21:00.001-06:00

What would you do if you were given $100,000? Well, you might have some special circumstances that would determine it for you--kids needing to go to college, a family member with high medical bills, and so on. But imagine that you didn't need the money--what would you do with it?

I would hope that you might do several things with it, such as enjoying some if it, investing some of it, and sharing some of it. For example, you might want to buy a new car. Then you might take some of the money and put in a bank account. Some more of it might go into long term savings, and some might be shared with those you love or those in need.

Emotionally, all of us go through times when we have enough or more than enough emotional energy, and other times when we are pretty much running on empty. During the times when we are full of energy, it can be like we have just been given a lot of money. It's like we have been given a "present." If we don't pay attention to what we are doing with our energy and positive feelings, we may "spend" it all on the moment, preventing it from having any long lasting consequences. Even when we are depressed, we will often have brief periods of feeling better. At those times, extra energy can feel like an unexpected gift.

Here are some suggestions to consider the next time that you have the present of extra energy.

Spend some of it. That's not so hard is it? Although for some of my clients, it actually is. They have a hard time having fun. For others, however, that is the easy part. Spending it can mean simply doing whatever strikes you as enjoyable--something you want to do or accomplish.

Secondly, invest some of that energy. Invest it in building a social support network for yourself. That will pay dividends for you the next time you are down. Research has shown that high quality social support is the best thing since sliced bread. It helps buffer us against stress and strengthens our immune systems against physical infection. A short term investment (one that will yield relatively quick rewards) is to reach out to friends that we have neglected recently. We can reestablish friendships that we have not let slip away totally. That doesn't take as much energy as forming new relationships. (For a good online article on developing social support and relationships, see the Mayo Clinic web site--http://www.mayoclinic.com/health/support-groups/MH00041/si=2765 ).

A long term investment of the extra energy might go into starting brand new relationships. They take longer to form. But they too yield rewards in the long run in the form of emotional support. A long term investment might also be starting up a new sport or starting to play an instrument.

And then there is the issue of giving some of it away. Research has shown that altruism has positive effects. Volunteer and use some of that energy to help others. It will have a positive effect on you in return.

So, remember the next time that you have some extra energy--enjoy it!! But also invest some of it in your future. And give some of it away, too.

The Problem with Anger

2005-11-08T08:22:00.001-06:00

First of all, I want to make it clear that anger is a normal feeling. There's nothing unhealthy about feeling angry now and then. In fact, it would be abnormal and unhealthy not to feel angry now and then. The problem with anger comes when it loses its rightful proportion in our life.

First of all, let's take a relatively common situation. You are driving in traffic, and another driver cuts you off. He is driving recklessly, perhaps speeding. The typical response of most persons is anger, and that would be normal and natural. The anger comes--it peaks--and it goes away. We forget about it.

However, for some people, the anger comes, and then it gets stronger and stronger. The reasons for this are not fully understood. But one reason it can happen is that persons are using negative self talk to build up their anger. "That stupid person. How dare he do that? Somebody ought to teach him a lesson!." This type of thinking increases the anger.

Another approach to the same situation would be to acknowledge one's anger and then steer a wide berth around such a person. That is, to let the anger come--and then to go, without the negative self talk strengthening the anger.

Some persons are chronically angry. They keep resentments alive on, and on, and on. This is not the same as anger. It is very unhealthy psychologically and physically. It has negative effects in every area of one's life.

I have been asked by some patients, and indeed I have asked myself at times, if this approach to anger isn't really just suppressing it. And suppression and repression can have negative consequences, too. The answer is no. First of all, I am recommending that you be fully aware of your anger at first. There is no suppression here. Secondly, I am recommending that you don't rehearse negative thoughts. In other words, there is a difference between smothering a fire and not putting more wood on a fire. Thirdly, I am recommending that after having an awareness of the feelings and thoughts, that you simply let go. You therefore maintain an awareness of all the thoughts and feelings that you did have, but you are choosing to let go. The choosing is an important part of the process. When you choose to do something, it is conscious and deliberate. This has no negative psychological effects as far as I know. In fact, it has positive effects because it frees you up to go on with your day in a positive constructive way. It also frees you from some of the negative physical effects of chronic anger. Some of these are explained in my handout on coping with anger at www.DrBeckham.com/CopingHandouts.htm .

Stress and Anger as Psychological "Luxuries" We Can't Afford

2005-10-29T11:00:00.001-05:00

Most people think of stress and anger as simply part of life. We have to put up with them because they come with the territory of living. However, research increasingly indicates that both of these take a negative toll on our minds, bodies, and relationships.

Certainly, they are not totally avoidable. Some degree of stress is healthy for the body and mind. It actually strengthens us. But the old saying of Nietzche is not true--"Whatever does not kill me makes me stronger." In fact, what does not kill us may kill off brain cells and add fat to our waist. Excessive stress has been shown to harm cells in the hippocampus, which is a part of the brain central to storing memories. It has also been shown to lower the immune system's ability to fight off infection. Depression and anxiety can be triggered by stress in some individuals. For others, stress may lead to unhealthy use of alcohol and other substances.

The goal of the healthy individual need not be to eliminate stress altogether but to avoid very high, unusual levels of stress if possible. How can this be done? Many people believe that the stress they experience is totally beyond their control. But it is not. Here are some things which can be done to diminish stress.

First, live a healthy lifestyle. Do the obvious. That is, don't take excessive risks financially. Nurture and nourish relationships. Build for the future in both finances and social support.

Secondly, work on any excessive negative thinking. My web site has several handouts on how to do this (http://www.drbeckham.com/). Very often 50% or more of the stress we experience is of our own making from excessive negative thinking.

Deal with problems slowly, methodically, one at a time. Don't avoid problems. They will just pile up. And don't try to take on all problems at once. That will just overwhelm you.
Most of my clients have one of two different problems: either excessive negative thinking or avoiding problems. Working these two areas can do wonders for a person's stress level.

Next week: the "luxury" of anger.

Is There a Type D Personality and Does it Matter?

2005-10-19T12:16:00.001-05:00

In the past, it was thought that the hard driving, time pressed Type A personality led to more heart attacks than the easy going Type B personality. Unfortunately, that research lead did not prove to be true. But wait, now there is research on a Type D personality, and it remains to be seen whether the Type D personality predicts heart problems any better than the old theories. However, some research suggests that it does.

Johan Denollet, a psychologist in the Netherlands at Tilburg University found a personality type likely to build up chronic stress. They have both negative emotions and an inability to talk with others about those emotions. They tend to overreact to situations with negative emotions but then can't express these emotions and get them out of their systems, so to speak.

Persons high in Type D characteristics tend to have more heart disease, hypertension. They also tend to respond less well to treatment, have a poorer quality of life and to die prematurely. Among heart patients, they are four times as likely of getting another heart attack or dying too soon.

If you are interested in looking at the Type D questionnaire, you can go to
http://www.health.harvard.edu/newsweek/Type_D_for_distressed.htm

Sometimes the Closet Overflows

2005-10-18T21:22:00.001-05:00

One of the analogies I use with my clients is that of the stuffed closet.

Imagine that as a child, a person learns to clean up the items in their room by throwing them in their closet. And then, as they grow older, everytime they need to clean their room, they simply open the door and throw more things in. This works for years, say, and then there is just too much in the closet. Nothing else can be thrown in. And so the person doesn't know how to deal with the odds and ends they have lying around. If they open the closet, everything comes tumbling out. And if they don't open the closet, they don't know what else to do with their problems.

This is just the problem that many of my clients face. As a child, they learned to deal with problem feelings and thoughts by stuffing them deep down, out of awareness. This worked, more or less, for years and years. But finally, there is just too much stuffed down. In psychology, we call this repression.

Eventually, it starts to come out as depression, anxiety, anger, flashbacks, physical symptoms, etc. Now they have a dilemma. Their only mode of coping is to stuff things. But there simply is no more room for things to be repressed. And if they try to sort through the things in the closet, they feel overwhelmed.

This is where the therapist comes in. At this point, there really is no choice but to start sorting through the years of accumulated issues which were not dealt with. Perhaps not every one of them has to be looked at, but the big ones at least. The therapist can help guide the client through this sometimes rather arduous process. But in the end, the closet is cleaned out. The symptoms are reduced. And the client is no longer hiding from their own thoughts and feelings.