Category Archives: Psychology

January 11, 2010 · 2:02 pm

Psychiatric labeling: The problem isn’t the label


Christians tend to have some strong feelings about counseling, psychology, psychiatry and similar terms. Come to think of it, most people, regardless of faith, have strong feelings about these topics. Experiences dictate much of these reactions. Experiences, such as:

  • experiencing or hearing of a mental health representative (mhp) belittling Christianity
  • experiencing or hearing of an arrogant, controlling, or completely incompetent mhp
  • experiencing or hearing of a positive experience where someone found relief or change or insight
  • feeling either helped or stigmatized by a received diagnosis or a use of medication

In psychopathology class tonight, we will explore the background behind psychiatric classifications. How did we get the Diagnostic and Statistical Manual? What are its underpinnings? There are a couple of common concerns about the DSM

  • It purports to be atheoretical and descriptive only
  • Diagnoses suggest objective and distinct “things”
  • It medicalizes problems in living
  • Under one diagnosis (e.g., depression) you can have such wide variety of symptoms
  • Therapists have sizeable disagreements on diagnoses so are they all that helpful?
  • It is leveraged by insurance in ways that make it a liability
  • It doesn’t address matters of the heart or spirit
  • It has political overtones
  • It treats most problems in an individualistic fashion without account for family systems

Every one of these concerns has merit. However, the biggest problem I have is not with the DSM itself but with many of its users. The complaints that are raised about the DSM usually come from someone mis-using the DSM.

Remember the simple explanation of a problem almost always distorts it. Thus, the simplistic use of diagnostic labels almost always does damage.

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January 8, 2010 · 10:00 am

Are you bringing your friends’ mood down? Why your happiness matters


Did you know that your friends’ friends’ friends can effect your happiness? So says researchers looking at the longitudinal Framingham Heart Study started in 1948.  The previous link is to a research publication on the topic. If you are happy, you likely increase the happiness of those in your social network–even if they do not have direct contact with you. You make your friends happy who in turn make their friends happier…if they live in closer proximity to each other.

Of course this study begs some questions. Does unhappiness make others more unhappy or do unhappy people merely lose their friends? The study looks at positive emotions. What are the differences between positive emotions and happiness? Would the same effect exist if studying contentment? peace? Or, are we really studying the ability of folks to buck up in social networks? Those that do not are on the periphery and therefore more unhappy. Finally, Framingham is a relatively affluent small city. Would the same effect exist in N. Philly?

But, it does raise some good challenges for us. In the midst of suffering (and there seems to be more and more of it in my social spheres!) are there ways that we need to be working to raise our positive affect? Intentionally seeking to think and talk about the good and not just the bad? Have a friend with cancer? How do you make sure to include conversations about beauty, joy, pleasure? Is your church in a funk? Are you stressed at work or school? Listen to your conversations with others. Do they dwell on the negative? Are their positives that you are neglecting to discuss and notice?

Surely you should not be a “pollyanna.” This is not an invitation to denial nor a rebuke of those who find themselves groaning under a burden. But, try laughing a little more heartily. It might cheer your friends up.

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January 6, 2010 · 11:33 am

Some thoughts on “This Emotional Life”


Caught part II of a 3 part, 6 hour, series on PBS last night. This Emotional Life, moderated by Dr. Dan Gilbert. I recommend you check out, at minimum their website but if you get a chance, tonight your local pbs station may air the 3rd part. The website includes lots of info about the various topics, individuals interviewed, and the whole first episode (which I have yet to watch). The series focuses on love and family relationships and attachment (#1), negative emotions such as anger, fear, and depression (#2), and happiness (#3).

Now, there are a number of irritations I have about the program but the good outweighs the bad. What don’t I like?  I don’t like the way they say, “Science says…” and then do not discriminate between data and interpretation of said data. I don’t like the repetitive evolutionary comments. For example, “the newer part of your brain can’t communicate with the older part” assumes that because we have a cerebral cortex and animals don’t have as well-developed cortexes, that part of our brain is “newer.” Further, the view of humanity in episode 2 seems to be that of the human physical robot. There is no space for the spiritual. One quote from the episode, “Mental illness is nothing less than a physical illness that has psychological consequences.” It is as if emotions are only chemical.

But these small problems can be easily forgiven. Here’s what I like from episode 2:

  • The honest admissions of struggles of celebrities (e.g., Katie Couric’s admission she has intrusive thoughts of jumping off high balconies, Chevy Chase’s admission of depression, etc.)
  • The gripping stories of struggler’s with anger, anxiety, and depression (especially two vet’s struggle with PTSD) and the significant impact of the struggles on the other family members
  • You really get a window into their interactions with their therapists. Lots of good video that is rare to see!
  • The scientific discoveries relating to the brain and the experiences of these negative emotions. For example:
    • Stress hormones seem to strengthen memory formation. Thus traumatic experiences likely etch bad memories much deeper than other memories.
    • Re-appraisal (neutral re-evaluation) of events where you experience negative emotions supports more control of these emotions whereas rumination causes us to be more reactive
    • Prolonged exposure therapy (telling, retelling and retelling again) for PTSD patients seems to have significant positive benefits (though it defies logic–most people want to get away from their bad memories)
    • Depressed individuals tend to have reduced hippocampus volume. Antidepressants and ECT seem not merely to change brain chemistry but actually increase cell growth. Depression actually seems to change the brain and antidepressant use stops hippocampus shrinkage

A couple of other interesting tidbits:

  • Emotion regulation: not trying to turn off emotion but tools to change the course of emotion
  • “Don’t believe everything you think.” But, we tend to nonetheless
  • Struggling with overwhelming anxiety? Accept that you have these feelings (crying, tension, fear), accept that they are physiological experiences, avoid labeling them as awful. You will have scary thoughts and you can live with them
  • “What is the worst thing that could happen right now?” I might cry. “And what if you do?” That would be bad. By accepting these emotions you can distance from the meaning you are applying to them.
  • There are biological indicators in those who are highly reactive to stress. These folks can’t help their reaction but they can recognize their tendencies and respond differently to them.
  • Untreated mental illness is harder to treat if left untreated for long periods of time.
  • Richard Lewis on the benefits of therapy and getting to talk about things he never talked about with anyone: “Maybe for the time I left her (his therapist) office til I got in my car I was floating on air”. Hmm, is that worth the 150 dollars he probably paid?

Finally, I leave you with this. Perceptions of progress, or lack thereof, have a huge impact on your perceptions of happiness. One young girl thought her ECT would help sooner than it did. When it did not, she crashed even worse. Even more than our physiology of emotions, our perceptions of our well-being and our progress often dictate our beliefs about ourselves and our futures.

If you saw it, what did you think?

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December 22, 2009 · 2:57 pm

Interesting article in the American Psychologist


Just got my December issue of the American Psychologist (64:9). In it is an article but Brenda Major (and others) entitled, “Abortion and Mental Health.” These authors wrote a report in 2008 for the APA task force on Mental Health and Abortion (available at here). What I find interesting in the article is the discussion of the research on the association of mental health problems with abortion. Set aside, just for a moment, your strong feelings about the topic and consider this question: how would you go about studying the effects of abortion on women using robust measures?

You cannot do a randomized, double-blind study (you subjects get an abortion while you other subjects have your baby). Thus, you cannot fully control pre-existing or co-occurring risk factors. So, what do most researchers do? Try to indicate risk markers–correlations–that may point to possible but not proven causes. The writers of this article point out that the downside of correlation or associations is that folk tend to mistake them as causes. They give one specific example: If age is the “most important known risk factor for Alzheimer’s disease (AD)” one might assume that age causes AD. But it does not. Similarly, one can do a study that shows 100% of convicted sex offenders have their own sexual victimization and wrongly assume that sexual abuse leads to sex offending. Not so.

These authors emphasize the benefits of asking two other questions (on p. 865):

1. What is the relative risk of mental health problems associated with abortion compared to the same risks associated with having an unwanted baby (whether keeping or adopting out)?

2. What predicts individual variation in women’s psychological experiences following abortion?

The authors go on to say that the hypothesis of the researcher really impacts the kinds of research questions asked (and thus conclusions). Some research focuses on traumatic experiences, others on stress and coping, still others on the sociocultural context.

By the way, it is a long article but concludes this way (p. 886):

Mental health among women who experience an unwanted pregnancy reflects a number of factors. It reflects preexisting and co-occurring conditions in a woman’s life that place her at greater or lesser risk for poor mental health in general regardless of how she resolves her pregnancy. It reflects her appraisals of the meaning of a pregnancy and abortion and her appraisals of her ability to cope with either option.

There’s more to their final thoughts but you get the point. How you look at pregnancy, abortion, adoption is likely to have a big impact on your immediate mental health. Sadly, I suspect the research also reflects the biases of the researcher (how could it not?).

I found this article interesting because it does a great job illustrating the benefits AND drawbacks of research. Researching mental health of women with unwanted pregnancies is a good idea but will fail to address the moral and ethical questions that, in my mind, take precedence in the public debate.

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December 8, 2009 · 1:54 pm

End of semester thoughts


Looking at a stack of papers I need to grade and yet not feeling the energy to do so. Late night classes take more out of me than I care to admit. My physiology class ended with student presentations and a look at bipolar disorder. As we concluded the class, I asked them to remember that,

  1. Even with all the advances in neuroscience, we must humbly admit we still know little how we are fearfully and wonderfully made.
  2. It is good for counselors to keep learning about the body and at the same time hold what they know lightly. Tomorrow may bring evidence to the contrary
  3. Yet, what we know about the body can be helpful. We ought not to look down upon our ignorance but remember that doctors do not always explain or walk with patients
  4. There are great medical interventions available, but (and that but shouldn’t diminish what I said before it),
  5. Over and over we saw that the basics (maintaining balance in life, self-care, mindfulness) are so important to health, perspective, etc. No, they aren’t magic interventions. Yes, they pay-off over time rather than immediately.

On this last point I am pondering a bit and so let me be hyperbolic. Most people who come to see me for paid counseling come because they think (naively) I have some expertise that will shed light on their situation and a solution to their problems. They want me to do something. Why else pay that kind of money? And yet much of what I have to offer isn’t rocket science. Beyond a few fun techniques, what I have to offer is a listening ear, a willingness to walk with the other person in their travail, and encouragement to keep going back to the basics. Most people like the first two but balk at the last one. Why do we balk at going back to the basics? Two reasons: (1) we want something that will fix the problem NOW, and (2) we’ve tried the basics and they didn’t seem to work (see reason 1).

Examples of what I mean.

  • If you are a parent and you go to a counselor to deal with your young child’s behavior problem. More than likely, you will get some counselor telling you to use some reinforcement strategies. And what do many parents say? “I tried that and it didn’t work.” Chances are they did try it and either they didn’t keep at it or they didn’t realize they were doing something that reinforced the wrong thing, or they had a misguided view of what success should look like
  • A couple is struggling with fighting. They go to the counselor who encourages them to return to the basics of respectful talk. Usually, they will feel like they have already tried it–and it didn’t work. Chances are… You get the picture.

In physiology, we see that care for the body includes mindful meditation (My friend and former professor says a substitute word would be “watchfulness”) on the world as God sees it, developing and maintaining good circadian rhythms, watching food intake, exercise, maintaining healthy relationships and social supports. In every mental illness, these things are shown to decrease the severity of symptoms and delay relapse.

Here’s the problem: we forget the basics and because they don’t give immediate results, we go searching for other fast-acting mechanisms. For example, I want to feel safe. Instead of engaging in centering prayer over the long haul, I fall prey to the temptation to act in such a way to avoid all possible danger–thereby increasing my fears of danger.

If I don’t exercise (and I don’t much) I rarely get immediate feedback that my body is falling apart. If I don’t eat right, I don’t immediately gain 10 pounds. If I don’t pray, I don’t immediately get embittered. So, I assume that these basics aren’t all that important. Or, I know they are important but since they don’t pay off now, I don’t do them. I only do what demands I do it to avoid a crisis.

How do we stay on track with the basics? We need another person(s) willing to keep us on a short leash. As a kid I ran because I had a friend who was going to wonder where I was. As a doctoral student, I played basketball at 6 am because my peers would  ask me where I was. I lost some weight a couple of years ago because my wife and I worked together. Notice that the social accountability is a key facet to help us build the disciplines long enough to see that the pay off is more than can be delivered by an exciting new technique.

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November 16, 2009 · 5:02 am

Why we fail to act (sins of complicity)


In the wake of the Ft. Hood massacre we are now hearing evidence of a very troubled man–trouble that it appears many observed over the last few years of the Maj. General’s life. Some of his former teachers and supervisors took note of his strange behavior, his loner tendencies, his rages. They even mused about his possible move into psychosis. Despite these notations, they moved him on to a place they thought (so the reporting is going) he would not get into trouble. In the words of one person, where his dangerousness would be limited by the number of mental health professionals serving alongside him.

Lest we pick on the military alone, we could level charges of ignoring problems on those around Madoff, the mortgage crisis, and any other recent scandal.

The truth is this: we see things that need our attention; our voice. And yet, we often fail to act. Why? Here are some reasons:

  1. We’re not sure what we are seeing or feeling. We have trouble adding up the problem
  2. We don’t want to make a mistake and look foolish
  3. We hesitate due to empathy
  4. We don’t want to intrude on the rights of others
  5. We assume someone else is more responsible
  6. We don’t want to make waves, we want to avoid conflict
  7. We think the person we are concerned about it will take care of it on their own
  8. We deem the situation not relating to our own interests
  9. We underestimate that Satan intends to deceive us into doing nothing so that evil may reign

I’ve had a couple of experiences where I didn’t act and should have–a client “playing” around with life threatening behaviors, a friend beginning an emotional affair with someone not her husband. After the fact, everything looks clear and obvious. Duh, hospitalize the client, confront the friend. And yet in both cases I acted but more slowly than I should. If there is one big reason: I think things were fine in the past and so they will be fine in the future, and so I fail to adequately assess the present.

 

 

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November 9, 2009 · 5:44 am

Thinking about moral responsibility and agency in TBI


Tonight I will assigned my Counseling & Physiology students a response paper to the following case study. As you read this fictional case, consider how you might answer these two questions:

  1. What are the spiritual issues in this case and how do you consider Tim’s limitations in considering these spiritual issues? What is his personal accountability in light of his functional limitations and injury?
  2. How might you advise Tim’s wife and pastor as they struggle to understand and respond to Tim’s inappropriate behavior?

Tim is a 34-year-old, married man and deacon in his church. Prior to a serious car accident 2 years ago, Tim was a successful general contractor generating income over $200,000 a year. 2 years ago, Tim suffered a traumatic brain injury when a drunk driver, traveling at a very high rate of speed, slammed into his vehicle. Damage to his brain was located in the frontal and temporal lobes. Tim spent a total of six months in the hospital and in rehab. Initially, He was in a coma for 3 weeks and not expected to recover. However, he did emerge from unconsciousness and with rehab regained his capacities to walk and talk. His memory is mostly intact, missing only the week prior to the accident and the five weeks post accident. He seems to be able to form new memories but complains that he has to write everything down or he will forget tasks. He also complains that it is hard for him to find words. His friends notice that his speech is slower now. He is oriented to person, place, and time.

Tim’s wife and pastor ask you to meet with him. Tim complies. In session he is affable, talkative, but unsure why others think he needs counseling. He notes that he works hard every day, uses his daily contacts in business to talk about God’s miraculous work in his life. He admits that he smokes now and should quit but that shouldn’t be reason enough to warrant counseling. He signs a release to talk to his wife and pastor.

You learn from his wife that Tim has numerous problems that did not exist prior to the accident. Most notably: he doesn’t complete work; fails to bill clients properly; seems to over-estimate what he can complete; work done does not meet his pre-accident quality; he is easily angered and even aggressive; he curses and smokes 2-3 packs per day (none prior to accident); he drinks; he spends beyond his means; he has periods of deep depression; he engages in foul language about sex; is demanding of sexual activity with his wife (but cannot perform since the accident); he flirts with other women.

Tim refuses to return for further appointments. His wife and pastor come to you to discuss options and how to think about Tim’s behavior. The church board has removed Tim from his diaconal position this week and is likely to initiate church discipline after it was discovered that he made a sexual comment to an 18-year-old girl (he commented (spoke admiringly) about her breast size).

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November 6, 2009 · 9:59 am

Orbinski on humanitarianism, dignity, and hope


 

Two days ago I had the privilege of meeting and hearing Dr. James Orbinski at the 2009 Frobese Day, an educational conference held at Abington Memorial Hospital each year. Dr. Orbinski is the former head of Medicins Sans Frontiers (Drs without Borders), current head of Dignitas, professor at U. of Toronto, author of An Imperfect Offering, and central figure in the documentary, Triage. Of interest to me was his work in Rwanda during the genocide.

On a personal note, I found him very engaging. When I was introduced to him, he didn’t do the usual handshake and move on. He really engaged me about Rwanda and what work we did and plan to do there and gave a number of encouraging comments that went above and beyond the call of duty. I guess that is one of the characteristics you need if you are a person who goes into distressed areas. You need to connect to the people, figure out what they need and what can be done, and then do it.

First, an assortment of observations presented:

  • There are about 6.8 billion people in the world. Some 3.8 billion, or about half, subsist on less than 2 dollars a day
  • 1.1 billion go to bed hungry each night. This number grows by about 100 million each year
  • Nearly all famines are the function of political conflict rather than acts of nature
  • There has been a 24% increase in food prices in impoverished areas. One of the key causes is the increase of developing biofuel. Food is more valuable if it can be made into fuel.
  • The World Food Bank is begging for about 23 billion dollars to feed this number of poor. It can’t get it. But, 13 TRILLION dollars has been recently expended to prop up a collapsing international economy.
  • In 2000, it cost 15,000 (a year, I think) to provide an individual in Africa the antiretroviral meds needed to survive. Today, with political pressure, it costs 99 dollars
  • The drug companies say that it costs 1.6 billion dollars to bring a drug from a new chemical to market (through research & Development). While they do not reveal how it costs this much, it is clear that part of the costs they factor in is the income they expect to make on the drug. So, if you expect to make 10% on your investment, can you really consider that a cost to develop a drug. Apparently, they do
  • A recent nonprofit just released three new drugs dealing with neglected diseases in Africa. The costs to bring these drugs to the market was 100 to 300 million dollars. And, the companies selling them are indeed making a profit

A couple of his key ideas:

  • Dignity cannot be granted; it must be acknowledged via engaged collaboration and solidarity
  • Solidarity is not pity but active compassion
  • Hope is not some naive utopian dream, it is “what we do”
  • We all need to be political. The first act of politics: speak the truth; The second act: listen
  • The worst form of suffering is suffering alone
  • We must see it, acknowledge it, give voice to the voiceless and thus allow for dignity even if we cannot solve it
  • Optimism and Hope are two distinct concept. Optimism is confidence that one’s actions will work for the best. Hope is confidence that the action you are about to undertake is the RIGHT one no matter the outcome
  • We need those with daring ideas, with visions of possibilities. That is all there is. Hope, is in his estimation, in himself–that he will do the right thing.

While I do not agree with his definition of hope, I do agree that we need more people to move from insight (that a problem exists) to action (that I can do something of value in a hopeless situation). Folks like Orbinski certainly put many of us to shame.

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November 3, 2009 · 5:38 am

Philip Cushman’s prophetic words


One of my all-time favorite books is Philip Cushman’s Constructing the Self, Constructing America: A Cultural History of Psychotherapy. In this 1995 book he details the social constructed nature of psychotherapy. My Social & Cultural Foundations class is reading a summation of this book published in article form and so I picked the book back up and read through some of my more favorite parts.Here’s some of my choice quotes from the beginning:

“When social artifacts or institutions are taken for granted it usually means that they have developed functions in the society that are so integral to the culture that they are indispensable, unacknowledged, and finally invisible.” (p. 1)

“It [psychotherapy] is thought of as a scientific practice, yet it is anything but standardized or empirical, and it has not yet developed a disciplinewide consensus about how to think about patients or what to do with them. It is thought of as a medical practice, yet it has an enormous social and political impact.” (p. 2)

“…in order to understand American psychotherapy, we must study the world into which it was born and in which it currently resides.” (p. 4)

“Origin myths describe the origins of the discipline in such a way as to demonstrate the discipline’s utility for those in positions of power. This means that mainstream historians will shy away from portraying psychology as critical of the status quo and will avoid including within their work a critical exploration of the sociopolitical frame of reference in which the discipline is embedded.” (p. 5)

“…I will argue that the current configuration of the self is the empty self. The empty self is a way of being human; it is characterized by a pervasive sense of personal emptiness and is committed to the values of self-liberation through consumption. The empty self is the perfect complement to an economy that must stave off economic stagnation by arranging for the continual purchase and consumption of surplus goods. Psychotherapy is the profession responsible for treating the unfortunate personal effects of the empty self without disrupting the economic arrangements of consumerism. Psychotherapy is permeated by the philosophy of self-contained individualism, exists within the framework of consumerism, speaks the language of self-liberation, and thereby unknowingly reproduces some of the ills it is responsible for healing.” P. 6

Now, soon after 2000, Cushman wrote about the transition from the empty self to the “multiple self.” By this he was not talking about MPD or DID. He felt that the younger generation was no longer looking to find their true self in therapy but to maintain a fragmented self in a chaotic world. In this sense, “who am I at church, work, school, friends, dating, etc. and how can I keep all my pieces from crashing down altogether.”

But, it is interesting to read his view of psychotherapy as supporting the consumeristic economy (even encouraging it). I wonder how our current economic woes will impact the world of therapy….

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November 2, 2009 · 11:40 am

Technoethics?


At September’s AACC conference I attended a presentation entitled, “Technoethics” by Jana Vanderslice, a psychologist from Texas. She got me thinking about the use of e-mail and other Internet-based technologies with counselees. Here are some of the issues:

1. E-mail. Do you have a policy about your use of e-mail with counselees? Do you inform them about the limits or possible problems that might be encountered? Problems such as security and confidentiality, whether or not you will read them “in time”, what becomes of them (printed out and kept in a file?), whether or not you provide brief counseling through e-mail and possible charges, etc. Dr. Vanderslice suggests having a start to the email that says, “Confidential! This is not meant to take the place of in person consultation…”

2. If you do e-mail counseling, do you (a) know who you are emailing? What data do you collect from the person you provide email counseling to? And (b), do you think about how your email may sound if it is printed off and/or forwarded to others. You should assume that your electronic communications may be passed on. Further, if you have regular e-mail contact, how will you deal with the nature of always being at the beck and call of clientele?

3. Your Social networking accts. Do you use twitter? Do you have a Facebook or MySpace account or the like? Do you “friend” your clients? Do you have anything personal on the web you’d rather your clients didn’t see? This becomes a form of self-disclosure. There may be things revealed about yourself on-line that you would never reveal to a client. Remember, if the client is in the same Facebook network, they can likely see more of you than you might realize.

4. Google searches. Similarly, it might be worth your while to search yourself and see what is out there. Did you know that there are “rate my counselor” type sites out there? Many of these exist to help you find healthcare providers in your area, but include ratings by current or former clients. Do you know what others are saying about you?

5. IT and other providers. Who has access to your accounts and computer? Does your IT dept (if you are in a larger organization) know to honor HIPAA regulations? If you use a vendor (e.g., Geek Squad), they need to sign an agreement to maintain the privacy of the clientele data on your email or database. Can you encrypt email and/or WORD documents?

Can you think of other technoethics issues?

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