Can There Be a "Scientific" Psychotherapy?

For much of my life I have been interested in the science of psychotherapy.  I have tried to bring the best of both worlds to the table.  However, in recent years I have begun to question whether we are anywhere close to that goal.  Even more than that, I have begun to question whether it is a realistic goal at all.  Perhaps there is a contradiction of ideas here that it is a true oxymoron, a logical imipossibility.

On the one hand, I firmly believe that counseling without some scientfic basis is dangerous or slipshod.  Doing what comes intuitively and naturally to a counselor, that is just doing whatever comes to mind, can lead to meandering sessions that are a waste of time and money.  Worse than that, such sessions can even be harmful to a patient.   Even Primal Scream therapy must have seemed logical to somebody at some time, but is there a shred of evidence now that it works?  (Primal Scream Therapy involved having the patient reenact the trauma of birth and doing so at a very high decibel level.)

Here is problem number one with the phrase "scientific psychotherapy."  It is a practical issue.  I have come to realize that some of our traditional research paradigms do not work.  Here is one example of a traditional research model: For patients with characteristic A (e.g., depression) and stresses B (e.g., loss of a spouse) what effect does treatment C have compared to treatment D?  It's an interesting question, but with a major flaw.  Let's suppose that a patieint comes to me with symptoms of major depression.  I then also note that there appears to be unresolved grief over the loss of a spouse.  I decide to use a combination of cognitive behavioral therapy and grief therapy.  However, after ten sessions or so, I begin to notice that the therapy is stalling.  Something is not working.  Finally, after the sixteenth session the patient reveals to me that they have a secret.  They reveal to me that they have been involved in something illegal, and they are afraid of being caught and prosecuted.  They are having nightmares of going to jail and feel terribly guilty.  This issue was not even on my radar as a therapist.  It was certainly not part of the treatment plan.  I do not have a standard question on my intake form which asks if the patient is doing anything illegal.  Furthermore--and this is important--if I did ask the question, it is doubtful that patients would be truthful at the outset.  They do yet know me and have no reason to trust me.  There are of course many other types of secrets which clients bring to counseling which are not disclosed at the outset of counseling..

I now realize that whatever I am working on with a patient for the first ten sessions may be merely the "anteroom" which may both hide and lead the way into the deeper issues.  I have to first pass the test of being deemed by them to be understanding and trustworthy.  If I am not viewed in that way, then the treatment can be a type of charade.  The client may either thank me for their improvement and terminate therapy without telling me their secret, or they may simply disappear and drop out of treatment.

People often carry with them a great deal of shame with their secrets.  Now consider the problem of how to build a scientific experimental model to deal with these hidden agendas.  It might not be impossible; but neither would it be easy.  In an experimental setting, the patient would have to be convinced of the trustworthiniess not only of the therapist but also of the entire research staff.

Psychotherapy at its best involves a human being interacting with another human being.  In the situation above, it is conceivable that the therapist might share something out of his own life that was illegal or brought on a sense of shame.  That would be particularly hard to do when the therapist would also have to decide on the trustworthiness of staff.  Would such self disclosure by the therapist be helpful or unhelpful?  It would probably depend on the timing--and many other factors.  

Psychotherapy is one human being encountering another human being at the deepest levels.  Fritz Perls, a psychiatrist, famously wrote:

    I do my thing and you do yours.
    I am not in this world to live up to your expectations,
    And you are not in this world to live up to mine.
    You are you, and I am I,
    And if by chance we find each other, then it is beautiful.
    If not, it can't be helped.”

This may be viewed as somewhat of an extreme form of laissez faire psychology.  But it serves well to outline the question.  Perhaps the most powerful way I can impact another person is also the least manipulative--just to be there for them.  

This leads to problem number two, the problem of failure in therapy.  It is a fundamental question.  I very much value the rigorous scieintific training that I have received.  I look with scepticism on some concepts, such as chakras and energy fields which some therapists believe can lead to "energy healing."  My scepticism does not mean that I am right and they are wrong.  I am quite willing to consider that they may be right and I may be wrong.  But science is good at holding our feet to the fire and making sure that we do not arbitrarily make outrageous claims.  So far so good.  

But the problem is that science tends to assume that there is an answer for almost every problem.  The idea is that if a solution does not exist, it is only because it hasn't been invented yet.  If a particular type of personality disorder or substance abuse is resistant to treatment, the implicit idea is that there must be a way in which the patient can be "treated."  Treatment failure in a research setting is implicitly understood as a step towards reformulation of theory and practical methodology.  It is not accepted as being somewhat inevitable,at least in some cases.   

Humanistic psychotherapy can be thought of as somewhat opposed to some types of scientific therapies.  It allows theoretically for some degree of free will, and hence it is believed that the patient must choose to participate in their own recovery.  They are not an object to be manipulated.  If they do not make the choice to participate in their recovery then no amount of manipulation will cause them to become healthier.

I have not been able to resolve this conundrum.  The scientific process has led to many breakthroughs and will continue to do so.  However, the day that counseling treats a person only as an object to be medicated or manipulated, that is the day that I will no longer be interested in being a psychotherapist.  

Here's another way of saying this:  Science never takes "no" for an answer.  If it hasn't found a way of curing depression for a certain type of patient, it goes back to the drawing board, looking for more theories and designing new experiments.  In that way, the responsibility for curing the patient always remains on the scientist, sometimes called the "scientist-practicioner."  The humanistic psychotherapist very likely regrets not being able to "cure" a patient but in the end accepts the right of the patient to resist treatment and to resist healthy behavior.  There is the consolation that the patient is in the end a human being with free will.  Science (such as behavior modification) sees no comfort in this idea because it does not believe in it..

All of this lands us in very deep philosophical territory indeed.  Is there free will?  This question has been pondered for millenia and will continue to be.  But the slightly less intimidating question is whether the patienit shares responsibility for their own improvement.  If they do, then failure will always be one possible outcome of psychotherapy.  On the other hand, if patients do make choices and share in the responsiibility for their own recovery and health, then a positive outcome to therapy is not just a success, it is something which is to be celebrated.  This is because the patient themselves has helped to bring it about.

Dealing with the FInal Psychosocial Stages of Life

In my last post, I talked about stages and tasks of adulthood.

Today I am going to focus on the last part of life, beginning around age 65, with what has traditionally been retirement age.

The question is: Is this really a stage?  Erickson saw it to be so.  Jung talked about the last half of life--a much broader concept.

I will use two of Erickson's concepts; Generativity versus Stagnation and Ego Integrity versus Despair.

Generativity begins around age 45 and lasts until around age 65.  However, I would argue that one of the ways of having a successful retirement is to stretch this period into as late in life as possible.

I am going to borrow liberally here from the Verywellmind.com website

( https://www.verywellmind.com/generativity-versus-stagnation-2795734 )

What Are Generativity and Stagnation?

Generativity refers to "making your mark" on the world by caring for others as well as creating and accomplishing things that make the world a better place. Key characteristics of generativity include:

Making commitments to other people
Developing relationships with family
Mentoring others
Contributing to the next generation

Stagnation refers to the failure to find a way to contribute. These individuals may feel disconnected or uninvolved with their community and with society as a whole. Some characteristics of stagnation include:

Being self-centered
Failing to get involved with others
Not taking an interest in productivity
No efforts to improve the self
Placing one's concerns over above all else

Those who fail to attain this skill will feel unproductive and uninvolved in the world.

Benefits of Generativity
Better health
More positive relationships

Greater productivity (including mentoring, and volunteering)

Greater feeling of fulfillment

There is no reason that Generativity needs to stop at age 65, although the form it takes may change when we retire from our occupation.

I believe that there has been a major flaw with the way we have conceptualized retirement, at least among some parts of our society.  It has been seen as a prize, duriing which time we can lean back and take it easy.  For some people, the earlier retirement starts, the greater the prize.  However, many people discover that it is not so great a prize after all if they are not contributing.

The Concept of Being Plugged In

The concept of being :pluged in" refers to people needing something from us. That may not sound like an ideal retirement. However I feel that the definition of hell is for no one to need anything from us. I have two hobbies, jazz piano and painting. One of the problems with being a painter is that unless you're really good no one wants to buy your paintings or even hang them on their wall. In this particular age of our American society it is harder and harder for a professional artist to make a living because paintings are not sought after. It doesn't make any difference how good you are, if you cannot sell your paintings then it's not only hard to make a living but there is a lack of affirmation. One of the worst things for a painter to experience is to have 100 paintings stacked up in a back room.  Similarly I have a piano teacher. During the pandemic it has been hard for her to have an audience except online. For a musician not to have an audience is not to be plugged in. For an artist not to have a buyer is not to be plugged in. For a politician not to have an audience is not to be plugged in. But for the average of us to have a role to play we heed someone who needs us to play that function is to be plugged in, whether it is as a grandparent or a part time worker, or a mentor, or a volunteer. Now the dilemma of old age is that we need to be needed but not as much as we used to do it. There needs to be more rest--more time for recuperation. I have used this concept with my patients and I haveI found that it resonates with them. The ways that they used to be needed are not available to them anymore. The ways they used to contribute may not be supported by their level of physical or even their brain function anymore. But the need to be needed still is there.

Ego Integrity Versus Despair

Erickson talked about the last stage of life as Ego Integrity versus Despair

What Are Integrity and Despair?

Integrity refers to a person's ability to look back on their life with a sense of accomplishment and fulfillment. Characteristics of integrity include:

Acceptance
A sense of wholeness
Lack of regret
Feeling at peace
A sense of success
Feelings of wisdom and acceptance

Despair refers to looking back on life with feelings of regret, shame, or disappointment. Characteristics of despair include:

Bitterness
Regret
Ruminating over mistakes
Feeling that life was wasted
Feeling unproductive
Depression
Hopelessness

The integrity versus despair stage begins as the aging adult begins to tackle the problem of his or her mortality. The onset of this stage is often triggered by life events such as retirement, the loss of a spouse, the loss of friends and acquaintances, facing a terminal illness, and other changes to major roles in life.

During the integrity versus despair stage, people reflect back on the life they have lived and come away with either a sense of fulfillment from a life well lived or a sense of regret and despair over a life misspent.

Benefits of Integrity

There are a number of benefits to successfully achieving feelings of integrity at this stage of life. These benefits include:

Ego integrity: Successfully resolving the crisis at this stage leads to the development of what Erikson referred to as ego integrity.

Peace and fulfillment: People are able to look back at their life with a sense of contentment and face the end of life with a sense of wisdom and no regrets.

Wisdom: Erikson defined this wisdom as an "informed and detached concern with life itself even in the face of death itself."

Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death.

Causes

There are a number of different factors that can influence the integrity versus despair stage of psychosocial development. Some factors that influence the outcome of this stage include:

Family: Having supportive relationships is an important aspect of the development of integrity and wisdom.

Work: People who feel a sense of pride in their work and accomplishments are more likely to experience feelings of fulfillment at this stage of life. 

Contributions: Those who reach this stage feeling that they have made valuable contributions to the world are more likely to achieve a sense of integrity. This often involves contributing to things that will outlast them through their children, friendships, mentorships, work, or community involvement.

Consequences of Despair

Despair can have serious consequences for a person's health and well-being as they face the end of life. Research suggests that ego integrity and despair are important life-space development indicators of well-being.3

Some of the consequences of despair include:

Increased depressive symptoms: Feelings of despair at this stage of life can be marked by feelings of low mood, hopelessness, sadness, and feelings of worthlessness, which are also symptoms of depression.

Increased regret: People who look back on their life with despair are more likely to ruminate over mistakes and feel regret for the life they have lived. 

Decreased life satisfaction: When people feel despair at this stage, they are also less likely to feel satisfied with their lives going forward. This can have an effect on their ability to cope with stress and decrease their resilience.3

Those who are unsuccessful during this phase will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair.

How to Improve Integrity

This stage of psychosocial development often depends on many of the events that occurred during earlier periods of life. However, there are things that you can do to help develop a greater sense of ego integrity as you age.4

Start early: The things you do during middle age will play a role in your feelings about life as you age. Focus on doing things that will support your emotional wellness as you grow older, such as getting involved in your community and strengthening relationships to ensure you have a strong social support network.

Seek meaningful relationships: High-quality relationships with people you care about and who care about you are important. Focus on those relationships and work on making peace with relationships that may not be as strong.

Reframe your thinking: Rather than ruminating over regrets or wishing you can change the past, focus on reframing how you think about those events. For example, you might focus on what you learned from those experiences rather than dwelling on what you wish you could do differently.

Practice gratitude: Focus on the positive aspects of your life rather than paying excessive attention to the negative. 

If you find yourself experiencing a sense of despair as you age, there are steps that you can take to improve your well-being. Some of the steps you can take include:

Reach out to others: Focus on building social support. Discussing your feelings with friends and family can help, or look for new connections by participating in community groups or organizations.

Focus on the positive: Think about the memories and events that brought you feelings of pride and happiness.

Explore new experiences: Seek out activities that bring you pleasure and joy in the here-and-now.

Engage in spiritual practice: Find ways to explore your spirituality, which may help bring feelings of peace and well-being.

Get help: If you continue to struggle with feelings of despair, consider talking to your doctor or mental health professional. You may be experiencing symptoms of a condition such as depression or anxiety. Your doctor can recommend treatments that will help.

A Word From Verywell

According to Erikson's theory, individuals don't experience integrity or despair all the time. Instead, most healthy individuals experience a balance between each as they begin to make sense of their lives.

I would also add, if you are feeling a sense of despair, focus on what you did right in life, not what you did wrong or what went wrong.

Special issue:  Are older people more depressed?

Depression is less prevalent among older adults than among younger adults.  However, because of suicide it can have serious consequences.

Suicide rates in the elderly are declining, but they are still higher than in younger adults.

Depressed older adults are less likely to endorse affective symptoms and more likely to display cognitive changes, somatic symptoms, and loss of interest than are younger adults. 

What helps geriatric depression?  Research says: 

cognitive behavioral therapy

problem-solving therapy

brief psychodynamic therapyl

ife review/reminiscence therapy

group support

A Roadmap Through Adulthood

Wouldn't it be great if we had a map of adult development so that we would know what to expect?

We well do--to a degree.

For example, Daniel Levinson has worked out a map based on his studies of adults.

And before him, others did too, including Carl Jung and Erik Erickson.

Every counselor who has worked in the field long enough has some kind of a basic map in their head of what lies ahead for adults--not one learned from books but from real life experienice.

In the show today [KTOK radio show] I'm going to talk about "tasks" and "stages" of adulthood.  What is the difference? 

Stages are windows of demand and windows of opportunity.  They are time limited.

    Procreation is a good example, it is definitely a time limited opportunity.

    Getting training for a career is almost as time limited--although we have all seen stories of people

    going back to college at an advanced age.

A stage can be approximate (such as mid life reorientation) or it can be absolute (such as menopause and the end of female childbearing).

Stages can flow smoothly from one to the next, or they can be turbulent, with depression, anxiety, divorce, change of career, etc.

We do not yet have a perfect map of adult stages, and as soon as we do, it is likely to be obsolete because our culture is changing so fast.  Nevertheless, there have been adult "roadmaps" going back to Confucius (see the last chapter of Levinson's book The Seasons of a Man's Life.)

A good "map" helps us to navigate through life, just as a ship needs a navigational map to steer through dangerous waters.  We might say that we don't really need a map.  However, ships have run aground due to poor maps.  And adults have run aground in life.

Here is a basic roadmap of adulthood:

Early adulthood 20's--the goal here is to leave the family of origin.  Nature has given us tremendous optimism and energy during this stage.  We can in fact be unduly optimistic.  We pull away from family, either amicably or perhaps with anger.  And often we come home once, twice, or three times before being able to sustain ourselves financially.  We want to be self governing, living by our own rules, even if they are pretty much the same as our parents.

For many persons, sexual drive plays a large role in this pulling away as persons often struggle with parental restrictions of different sorts.  (It has been said that every generation thinks that it invented sex.)

In the 20's, persons are proving, for themselves and for others, that they can be self sustaining.  They are gathering basic skills, e.g. how to pay taxes, how to maintain a car, how to pay bills on time.

For some, the 20's are a period of child bearing and child rearing, whereas for others, it is a period of exploring dating partners and learning about what they like and don't like, and what characteristics to beware of.

By our late 20's we realize that the job we are in may not be a suitable career.  It may make us money, but not enough.  Or it may not bring meaning and satisfaction.  The late 20's can also bring with it the fear of not getting married or not having children.  As the end of the 20's approaches there can thus be a crisis as we try to get into the right career pathl

The late 20's can bring a rapprochement with parents.  They are now approached as equal adults.  A whole new level of communication is often possible, adult to adult.

For reasons that are not clear, the decades seem to play an important role in crisis, turning 30, turning 40, and so on.  Even the mid decades of 25, 35, and 45 play such a role.  It is as if we are prompted to look ahead at each decade.  

(Age 25 does not play a very large role.  The physical organism is at its height.  Death is so far in the future that it is generally only an idea to be acknowledged for brief periods of time.  But 35 and 45 may play important roles as turning points)

Transition to the 30's.  In this transition, the person realizes that the time for experimentation is coming to a close.  It is time to build something substantial in career or family.  In Levinson's terms, it is time to climb the ladder in one's career.  He also refers to this as the "settling down phase."

The 30's are a period of great energy and accomplishment for many people.  By this point most people have made an occupational decision.  They are hopefully climbing the rungs of a career and occupation.  They are honing their skills to take an important place in their organization.  At home, they are settling down to establish something secure for themselves and their families.

The 40's and the midlife reassessment.  Much has been said about midlife transition and midlife crisis.  Looming over life is our ultimate mortality as well as the mortality of our parents, as well as our frriends and our siblings.  It becomes clear at a very real level that life comes to an end.  

For some persons who have been driving themselves hard in their career but without much pleasure in life, this strategy quits working in the 40's.  They may lose their drive to work hard if it is not balanced with pleasure and recreation or other meaningful pursuits.

If we have been wanting our parents to change and give us the love and affection they denied us, we may finally give up on that every happening in the 40's.  

A major change occurs in the 40's and 50's as children leave home.  While they may return home occasionally, it is usually only temporary.  This may be experienced as liberating and freeing, or it may be felt as a tremendous loss.  For many, it is both.  Energy and time can be and must be redistributed.  New goals and activities can be developed and need to be developed.  For some, there is a loss of meaning ("If I'm not a parent, who am I?")

We are now focusing on our legacy.  We want to leave something behind of substance.  Pleasure may take a back seat to leaving something of permanence behind.

There is a transition at 65 when we begin to retire and to take Social Security.  We have to adapt to a new self image as a "retiree".  Friends start to move away or die.  Our social circle begins to dwindle for various reasons.  Mortality looms even larger on the horizon.  Our parents may have been a type of psychological buffer between us and death.  Once they are gone, we realize, we are next.

With retirement, there is opportunity for more recreation, and for fortunate retirees, they discover new sides of their personalities that they never knew existed.  However, there can be disappointment as well.  Retirement may bring boredom.  Moreover, if there wss a plan to travel with one's spouse, the health of one or the other may prevent that from actually occurring.

Erik Erickson refers to the final stage of life as being Ego Integrity versus Despair.  As the body deteriorates, persons have to decide if they are still worthwhile and whether their life still matters.  If they were the smartest, they likely no longer are.  If they were the most beautiful, now they must find a new source of self esteem.  If their job made them powerful, that too no longer provides self esteem.  Victories against old age may be won, but the person realizes that all victories now are temporary and partial.

The physical drives diminish in this age.  Some find this a blessing that they no longer have to cope with sex or anger as much as they used to.  On the other hand, some persons find the absence of sex to leave a great hole in their life.  And anger may become a different kind of problem. If there is any frontal lobe impairment, irritability and anger may become stronger rather than diminishing.

Many persons at this age now turn toward grandparenting as their primary source of meaning in life.  They find great enjoyment in it.  They also want to pass on their values to the second generation down and worry that some values may be lost.  

On the other hand, they often worry that society is losing its most important values.  They see a world that is changing so much that it is starting to feel that it is not THEIR world anymore.  It begin's to feel that their world is receding, and they may mourn for it.  At the same time, they see glimmers of hope--new developments in medicine and the humanities which give them hope for humanity.

As their physical bodies fail them, they have to turn to other resources.  Some focus more on their intellect.   Some focus on spending or managing their money, and some on spending time with their family.  The equation of life has to be re-solved.  One person once joked that this age person checks their stocks in the morning and plays golf in the afternoon.  

Loneliness begins to be a major problem for many, as significant others pass away.  For other couples, both are still alive but there is a change in personality due to changes in the brain.  Some spouses, for example, are in chronic pain or experiencing a mild cognitive disorder.  There may even be the beginnings of dementia.  

The onset of chronic physical disorders and cognitive problems leads to another issue--the ascendence of the younger generation.  Older persons may both enjoy the help they receive and resent the increasing dominance of their children.  In a best case, the adult child assists them in their goals.  In a worst case scenario, the elder finds themselves explicitly or implicitly demeaned, and their autonomy taken away.

The elder struggles to preserve autonomy.  It had been hard won in the first 20 years of life.  Now there is the threat of it being taken away, if not by one's own children then by physical illness or cognitive impairment.  It may also be taken away by financial restrictions.  

The elder may look to preserve a sense of worth by being a source of knowledge for younger generations.  This may work.  On the other hand, they may find that there is no interest in their life wisdom.

*************

Then there are the tasks of adulthood.  These tasks go on more or less perpetually throughout the adult years and are not limited in time as stages are.

Identity development--This begins in the adolescent years but never stops.  The sense of being a unique person with one's own values, goals, strengths, and weaknesses continues to develop.  But it is not only thoughts and actions.  As much as anything it is a feeling of being integrated.  It is a feeling of "I exist, and I know who I am."  But as we age, the question is less and less "Who am I?"  Rather it becomes,  "How do I fit this self that I think I am into a new world of change and loss?"  It becomes partly a question of, "Does the world around me want or need the self that I have become?"  Or to put it differently, "Does my identity make sense in a world that has changed?"  In one sense our identity becomes more fixed as we get older.  But it is always capable of change.  And who we are in relation to the world has to change as the world changes around us.  Take, for example, a person who was a colonel in the army.  He had a job to do.  People looked up to him and respected him.  They looked to him for orders and direction.  After retirement, however, those relationships do not exist.  He or she must define an identity in relation to the people and circumstances surrounding them now.  

Interconnectedness--being known, having friends.  This task never stops because we lose friends as well as make frinds as time goes on.  Friendship patterns can stabilize from 30-65 but then they destabilize also as time goes on.  People move, and they die.  And unfortunately friendships are sometimes tossed aside for no good reason.  They may be lost because of resentments.  There is a danger of losing our interconnectedness with others.  Relationships have to be nurtured and maintained.

Intimacy--This is interconnectedness at the closest level.  It involves both sexual intimacy and emotional intimacy.  In fact it involves a variety of types of intimacy--too much to go into here.  We learn to approach "the other," sometimes to the point of feeling that we are merging and becoming one.  But we discover that merging is not really what we want and that there is a need for distance as well.  We learn to back away and protect a sense of selfhood separate from the other person..  

Assertion and boundaries--Learning to draw boundaries in a healthy manner can be a difficult task.  We have to learn how to say no to others.  Similarly, we have to learn how to handle our anger in a healthy manner.  Anger is such a powerful feeling that employing it in a healthy manner requires adjustments and tweaking throughout the lifespan.  Anger and assertion are not the same thing, but they are linked.  If we create healthy boundaries and assert ourselves, then anger is less likely to build up and get out of control.

Contributing to society versus meeting our own needs--This also continues throughout the lifespan.  Do I give of myself to others and to society?  And if so, how much?  How much do I hold back for myself?  Not just my money, but my time and my emotional energy?

Coherence--Finding a meaning for life.  This involves spirituality, or if not that, then at least a philosophical view of what my life and Life in general are all about.  Is there meaning to my life?  If so, is it purely a meaning that I create out of thin air, or does my life's meaning come from a higher power?

Keeping a sense of hope--Faith, hope, and love are mentioned by the apostle Paul as the greatest of human aspirations.  There must be something to live for.  Just living is not a solution. It is static.  Either we are reaching for something that gives our lives meaning, or we are just marking time until we die.

Dealing with deterioration--dealing with illness and with aging.  We begin to noticeably decline even in our 30's with a few gray hairs or being short of breath climbing a hill.  For some persons, illness leads to decline even earlier.  We are forced to adjust our self view every time we notice a new phase of decline.  We notice gray hair, and then we adjust our self view to that.  We notice less muscle strength, and we adjust to that.  If our doctor gives us a chronic diagnosis, then we have to adapt to that also.  This is both a practical and a psychological issue.  How do I function now that I have arthritis?  Or who am I if I am not able to function sexually anymore as a man or as a woman?  Our "self" has to absorb not just one blow to it, but multiple blows--indeed many blows.

Establishing Financial independence--For some people this is a stage; for others it is an ongong task.  It has been said that making money is easy, and keeping it is hard.  Many persons enter retirement with very little cushion and mainly have just their Social Security retirement income.  

Coming to grips with "the real world" and not just an ideal illusory world--There is a danger at all ages of living in an fantasy world.  This may be an illusory view of ourselves or of the world around us.  We may all be prone to this--liberals and conservatives, religious and non religious.  And yet we cannot live without hopes and dreams.  And we cannot be absolutely sure of the ultimate nature of reality.  We must have dreams of who we are and what the world can become, and these dreams must exceed what we have now.  But also these dreams must remain sufficiently rooted in reality.

Psilocybin for Depression?

Research is beginning to accumulate indicating that the psychedelic psilocybin (think "magic mushrooms) may be helpful for depression.  Ketamine, another hallucinogen, is FDA approved to treat depression, although it is generally not paid for by insurance.  Studies have thus far been with small numbers of subjects.  It had been previously studied in individuals with life threatening cancer.  The most recent publication was in the prestigious Journal of the American Medical Association (Psychiatry).  Treatment effects were rapid; patients were given two separate treatment sessions, a very brief and relatively inexpensive treatment.  

One drawback was that there was only a four week follow up of results.  I have had patients who were referred by their psychiatrist for ketamine treatment.  (I am a psychologist, and I was not involved in the process.)  Most did not find it helpful.  The one who did started needing booster treatments after a few weeks.  Thus, I do not see hallucinogens as a magical answer.  

However, I believe that it is a shame of U.S. drug development policy that these substances have not been seriously investigated before now.  If a substance was labeled as being a street drug or as an abusable drug, it was hard for investigators to get approval to do serious research with it.  

We now need to move rapidly forward to know whether these substances have any legitimate medical value.  Here in Oklahoma, cannabis products are readily available.  Unfortunately, we now have a thriving street corner industry rather than a more traditional model of going to a pharmacy to get medication.  But at least there is a new openness to considering that psychoactive chemicals found in the natural world might, just might, be useful medications, even if they are sometimes abused and sold on the street.

After initial studies of the effects of an hallucinogen by itself are completed, a second wave of research will be needed.  At that point, we will need to look at combining psychotherapy with the experiences patients under its influence, experiences that may break through their normal psychological defenses and set them free from old, repetitive ways of thinking.  I believe that such combined treatment could produce synergistic effects that would be the real value of such drugs.

The Word "Just"

My patients in cognitive therapy know that I am very averse to ever  using or hearing the word "should," except in limited situations.  Here is another word that is on my blacklist--"just."

I don't avoid this word entirely, but it can be destructive at times.

Here are some examples that I think are very unhelpful:
To an ADHD child--"If you would just sit still..."; "If you would just pay attention..."
To an obese person--"If you would just eat less..."; "If you would just exercise..."
To a depressed person--"If you would just start thinking positively..."; "If you would just get out and be around people..."
From one spouse to another: "If you would just try to remember what I tell you..."

And so on.

The fact is that oftentimes, if people could do one of these actions, they would.

What do all of these have in common? They imply that there is a kind of moral failure of willpower which could be remedied by turning on or off a switch.  They ignore the complexities of the brain, of past learning history, of the overall body physiology and chemistry, and of reinforcement patterns in the home.

That is not to say that there are not problems that need to be solved.  However, using the word "just" does not solve the problems and make them better.  It can do the opposite; it can make problems worse by evoking shame in the other person.  

When can the word be used?  I think it can be used in an encouraging way rather than as a put down.  For a child trying to learn fraction division, it might possibly be helpful to say, "All you have to do is just turn the second one upside down and then multiply them."  This could encourage the child to see it as easy extension of something they already know how to do rather than having the mindset that it is hard.  However, if the child has difficulty with math, then this statement could also become somewhat of a put down.

The word is sometimes helpful in our self talk.  For example, if I were anxious about going into a job interview, it might be helpful for me to say to myself, "All I have to do is put on a cheerful face, take a deep breath, and answer his/her questions."  In other words, the word "just" can be a way of telling myself that I am making a mountain out of a molehill.

So be careful with the word "just."  Use it wisely and carefully; and pay attention to how it affects other people when you use it with them.

Coping with COVID

It has been a long time since I published my last blog.  I guess I thought that I had run out of things to say.

Well, I haven't.

COVID came along and my patients have run into many new problems, including and above all, problems with interpersonal isolation.

I have become convinced that we are creatures evolved for close, intimate contact, such as one would find in tribal and village life.  City life with its anonymity is relatively new (in the last 100-200 years).  We are suited for interpersonal contact and interactions.  Our brains function optimally when we have to look each other in the eye and have to talk to each other.

Now even before COVID, there were some problems with people being too isolated.  People stayed in their homes with central heat and air and rarely acknowledged each other on the street.  But COVID has created isolation on steroids.  We are more isolated than we want to be, than we should be.  The effect on most of my patients has been lethargy (a blah feeling) and depression.

For that reason, I am encouraging my patients to see me by Zoom rather than by telephone.  I want them to look me in the eye, and I want to do the same.  I want to experience the illusion that we are in the room together, and I want them to have that, too.

(However, if Zoom and Facetime are not available then telephone is the next best thing.)

Our physical bodies need to distance from each other, but isolation is terrible for our minds.  Our brains need the stimulation of being right there with someone.

I am very fortunate.  I am able to practice what I preach.  Here is what I might be able to experience in a week:

Sunday: Zoom Sunday School

Monday:  3-5 hours therapy by telephone or Zoom

Tuesday:  3-5 hours therapy by telephone or Zoom

Wednesday:  3-5 hours therapy by telephone or Zoom

Wednesday evening:  Sunday School socializing

Thursday:  3-5 hours therapy by telephone or Zoom

Friday: Psychologist consultation and support group by Zoom

Saturday: My wife's extended family meets on Zoom

I am not trying to toot my own horn here.  I am simply saying that I practice what I preach.  I know that I need the interpersonal contact, and I believe that my patient's need it, too.

There are exceptions.  Some of my patients with agoraphobia find it easier to tell others why they stay home so much.  They feel less need to explain themselves.  Other than that, most of my patients appear to be negatively affected.

So, in summary, get on Zoom.  If you can't, then get on the phone with people.  Get out of the house and drive around.  (You can keep your distance or even roll up your windows to be safe if you like).  Stay out of stores if you can, but be creative in how you can interact with others.  Get some visual stimulation.  Drive some places that you haven't been before.  Give your brain something new to look at.

Social contact is not so much like a drug that makes you feel better immediately.  It is more like a vitamin.  If you don't have it, you eventually start to pay the price after awhile.

Is There Such a Thing as Positive Denial?

Positive denial

Denial is considered one of the most primitive of the defense mechanisms.  It is usually thought of as a distortion of reality, and therefore as being very unhealthy.  To put it bluntly, denial sometimes involves a person lying to themselves.

But I am now wondering if there is a healthy form of denial.  Or another way of putting it is, maybe there is a role for extreme optimism which is not fully justified by the evidence.

The issue came up with a patient of mine with Parkinsons.  (I have permission to share this.)  This patient is aware of all of the statistics about the disease's progression.  He is seeing all the appropriate doctors and taking all of the appropriate treatments.  Therefore, the denial in question is not the same as ignoring the warning signs of a disease; this is quite different.

An article came out in JAMA Neurology which suggested that some persons with Parkinson's remain stable, or even get better, over a six month period of time when they have sufficient vigorous exercise.  My patient has seized on this as a touchstone, figuring that he, too, will remain stable, or even get better, as long as he exercises enough.  This may be denial because Parkinson's is always a progressive disease; it's just that sometimes it progresses very slowly.  This person's "denial" is helping him to exercise 75 minutes a day, which will almost undoubtedly help the Parkinson's.  Without this optimism, he might crater, go into depression, and hence might give in to the disease.

Is there a down side to the denial in this situation?  Or is it even denial?  Maybe it's just taking optimism to its ultimate lengths, extrapolating in a very hopeful way on some of the research available.

Now, it could be argued that a slightly toned down optimism might be just as useful.  That is, believing that vigorous exercise will slow the disease rather than keeping it totally stable, might be more realistic and still motivate the required level of exercise.  However, for this particular person I'm not so sure that a toned down level of optimism would be nearly as effective in motivating him.

Moreover, we can't overlook the role of the placebo effect.  If you believe a medicine is extremely powerful, then it is more likely to be.  Placebo effects have been demonstrated even in the treatment of cancer.

So, it is still true that some forms of denial are destructive and prevent growth.  However, I am now seeing that extreme optimism (even up to involving some denial) may be just what the doctor ordered in some situations.