11.20.2010
11.16.2010
11.15.2010
11.13.2010
Well worth reading. Reminiscent of Invisible Cities by Calvino. Small vignette speculations on alternative views of the afterlife, used to reflect on human condition. Swings through funny, profound, poignant. Liked the idea of all humanity's gods hanging around without anyone believing in them, with their lion-heads or flames surrounding them for no particular reason. There are so many different heavens and hells available, and we live in them every day.
11.10.2010
10.19.2010
Neurogenesis and Depression
Provocative ideas on the link between neurogenesis and SSRIs in the Guardian. Suggesting that the effect of various serotonin promoters may act to increase neurons in the brain.
7.31.2010
Intriguing new methods for suicide assessment
Currently, suicide assessment relies on self-report or clinical interview. This has obvious problems, not the least of which is that the more "experienced" patient will control their admissions of suicidal intent or ideation when speaking to clinicians.
Research teams have developed computer tests that compute the individual's response to stimuli to get a better read on suicidality. One team used a Stroop test to help in assessment and got intriguing results. A Stroop test presents words in color and asks the subject to identify the color. If the word "blue" is presented in a red color, the computer can measure the time it takes to respond with the correct color and use that to measure level of attention in the individual. For individuals with attention problems or cognitive disorders (ADHD, brain damage, depression), longer response times indicate issues with executive functions. Turns out that people at high risk for suicide pay more attention to words associated with self-harm, such as "suicide".
The other study used reaction time to measure the strength of association between sets of words. The response rate indicated increased response in some individuals to certain combinations of terms for the self and for death/suicide. Those people with those higher "unconscious associations" were 6 times more likely to attempt suicide in the next 6 months than people who associated self and life.
These studies are intriguing and would be pretty straightforward to implement in even small clinical settings.
7.26.2010
Working with dreams
Interesting article in the New York Times about “rewriting” dreams to repair sleep problems in PTSD. One intriguing finding is the high correlation of PTSD with sleep apnea. An interesting research problem would be if people with sleep problems more apt to get PTSD? Or conversely, is good overall sleep hygiene protective against developing PTSD?
6.14.2010
James F. Masterson, Narcissism Expert
Just spotted this obituary that I missed in April: James F. Masterson, Narcissism Expert, Dies at 84 - NYTimes.com. Masterson was a prime mover away from the belief that personality disorders were untreatable. The article has a nice description of personality disorders and presents one persuasive theory for their development, rooted in very early attachment problems that create a “false self” for the individual, most apparent in the narcissistic and borderline types. The Psychiatric Dilemma of Adolescence and The Search for the Real Self: Unmasking the Personality Disorders of Our Age are on Google Books. The paragraphs that best sum up the article are at the end:
Dr. Masterson became so well known as an expert on narcissism that he sometimes attracted patients for whom only a high-profile therapist would do — in other words, narcissists. In the 1980s, after The New York Times cited him as an authority on the disorder, he received a dozen calls from people wanting treatment.
Too busy to accept new patients, Dr. Masterson referred the callers to his associates. As The Times reported in 1988, not a single one made an appointment.
6.09.2010
Finding Mental Illness in Movies
Melinda Beck in the Wall Street Journal has an article on using fiction films to train psychiatrists. I’ve used clips from Girl Interrupted
and A Beautiful Mind
in classes on psychopathology. The Harry Potter references seem a bit, um, Freudian in the least interesting sense. The Interactive section has a little quiz where you can match diagnosis up with a film, then watch clips from the movie.
Interestingly, a third of the disorders in the quiz are what are classified as personality disorders. Perhaps because the more florid types of personality distortions (antisocial, narcissistic, borderline) are dramatic, while depression and paranoia are a little more uncomfortable for people. Personality diagnoses are pretty rare in practice, though I would argue they need to be more taken into account in treatment. In some way, some filmmakers are more tuned in to the force of personality in shaping human behavior than many clinicians.
I liked Beck’s mention of the few good portrayals of therapists in popular fiction. I would add the therapists in HBO’s In Treatment to the list. The drama in the show is more about the overidentification and over-involvement of Paul Weston (Gabriel Byrne) with his patient’s problems (and ultimately one of his patients). Even though most therapists may have found themselves jumping up and yelling at some of Paul’s more ludicrous faux pas, it was a generally good view of what happens in the therapy room. I have a feeling that most non-therapists can probably separate out what is fictional license, in the same we non-police have a sense that real life as a cop is fairly un-like what is seen in film.
and A Beautiful Mind in classes on psychopathology. The Harry Potter references seem a bit, um, Freudian in the least interesting sense. The Interactive section has a little quiz where you can match diagnosis up with a film, then watch clips from the movie.Interestingly, a third of the disorders in the quiz are what are classified as personality disorders. Perhaps because the more florid types of personality distortions (antisocial, narcissistic, borderline) are dramatic, while depression and paranoia are a little more uncomfortable for people. Personality diagnoses are pretty rare in practice, though I would argue they need to be more taken into account in treatment. In some way, some filmmakers are more tuned in to the force of personality in shaping human behavior than many clinicians.
I liked Beck’s mention of the few good portrayals of therapists in popular fiction. I would add the therapists in HBO’s In Treatment to the list. The drama in the show is more about the overidentification and over-involvement of Paul Weston (Gabriel Byrne) with his patient’s problems (and ultimately one of his patients). Even though most therapists may have found themselves jumping up and yelling at some of Paul’s more ludicrous faux pas, it was a generally good view of what happens in the therapy room. I have a feeling that most non-therapists can probably separate out what is fictional license, in the same we non-police have a sense that real life as a cop is fairly un-like what is seen in film.
6.08.2010
Bibliotherapy 2
One of the most venerable books on therapy is also one of the more accessible and insightful for patients and therapists. Sheldon Kopp’s 1972 If You Meet the Buddha on the Road, Kill Him! The Pilgrimage of Psychotherapy Patients
is well worth reading. Includes the excellent “An Eschatological Laundry List" which starts with “1. This is it.” and ends with “43. Learn to forgive yourself, again and again and again and again....”
6.07.2010
Treated Well: Are We Getting Anywhere?
I’ve had two or three sessions with a new therapist. I’m not sure we’re getting anywhere. How do I know this is right for me?
If you have specific feelings about the therapist (like how they might respond to or interrupt your presentation or how they part their hair), it’s usually best to take note of and file your gut reaction at first. It’s not necessarily a sign that this therapist is wrong for you.
There may be underlying issues in these feelings that can add richness to the therapy if you can push past them. However, if something particularly bothers you and it persists, address it with the therapist. They should be able to roll with criticism and use it to focus more effectively on your needs. Extreme defensiveness from the therapist can be a red flag.
Here are some good questions to ask yourself after a few sessions:
Who’s doing the talking? (You should be.) It may take three or four sessions before a working therapeutic relationship is established and you feel engaged. If it takes much longer, that needs to be dealt with as soon as possible. If the therapist doesn’t bring it up, you need to.
The best approach may be to state your feeling, describe the specific behavior that causes you discomfort, and verbalize what you would like the therapist to do about it. For instance, “I feel my concerns are not being addressed when you give such lengthy responses. I need you to give me more chances to speak in the session.” (Not a bad assertiveness technique to use for many life situations outside therapy as well.)
Is there work being done? After a few sessions together, can the therapist articulate a treatment plan? Not necessarily a formal plan, but is there a sense of working toward a goal and some gauge for knowing that you’re making progress in that direction?
For example, a therapist might say “Over the next two sessions, I think we should focus on specific situations that happened during the week that caused your anxious feelings” or “A good goal for the next week is to see if your anxiety level goes from a 9 to a 6 when you are think about speaking with your boss.” Notice the specificity in both, and the use of a scale of discomfort in the latter.
Is the therapist giving advice? (They shouldn’t be.) This may seem counterintuitive—“I came for help!”—but the role of the therapist is not to make decisions for you but to empower you to make better decisions for yourself. Suggestions are fine: “You might try taking a walk in the park every day for stress relief.” “Have you tried meditation?”
But these should not be mandated activities (unethical) and the therapist should never express disappointment that you failed to follow through on the suggestion (unprofessional). There are technical terms for feelings the therapist raises in you, and it is always worth discussing.
Does the therapist follow up with you from week to week—how did that interview go? did you manage to take that walk you wanted?—in a way that’s not judgmental or guilt-inducing. “Last time we spoke, you talked about looking for ways to reduce your stress. How did that go?” Questions like this reflect their engagement with you.
As you go along, a good therapeutic relationship is one where you feel that you’re beginning to internalize the questions and problem-solving approach voiced by the therapist. You’re aiming, in the end, not for perfection, or to be a completely different person, after all, but to acquire skills and competencies to deal with the ups and downs of life.
If you have specific feelings about the therapist (like how they might respond to or interrupt your presentation or how they part their hair), it’s usually best to take note of and file your gut reaction at first. It’s not necessarily a sign that this therapist is wrong for you.
There may be underlying issues in these feelings that can add richness to the therapy if you can push past them. However, if something particularly bothers you and it persists, address it with the therapist. They should be able to roll with criticism and use it to focus more effectively on your needs. Extreme defensiveness from the therapist can be a red flag.
Here are some good questions to ask yourself after a few sessions:
Who’s doing the talking? (You should be.) It may take three or four sessions before a working therapeutic relationship is established and you feel engaged. If it takes much longer, that needs to be dealt with as soon as possible. If the therapist doesn’t bring it up, you need to.
The best approach may be to state your feeling, describe the specific behavior that causes you discomfort, and verbalize what you would like the therapist to do about it. For instance, “I feel my concerns are not being addressed when you give such lengthy responses. I need you to give me more chances to speak in the session.” (Not a bad assertiveness technique to use for many life situations outside therapy as well.)
Is there work being done? After a few sessions together, can the therapist articulate a treatment plan? Not necessarily a formal plan, but is there a sense of working toward a goal and some gauge for knowing that you’re making progress in that direction?
For example, a therapist might say “Over the next two sessions, I think we should focus on specific situations that happened during the week that caused your anxious feelings” or “A good goal for the next week is to see if your anxiety level goes from a 9 to a 6 when you are think about speaking with your boss.” Notice the specificity in both, and the use of a scale of discomfort in the latter.
Is the therapist giving advice? (They shouldn’t be.) This may seem counterintuitive—“I came for help!”—but the role of the therapist is not to make decisions for you but to empower you to make better decisions for yourself. Suggestions are fine: “You might try taking a walk in the park every day for stress relief.” “Have you tried meditation?”
But these should not be mandated activities (unethical) and the therapist should never express disappointment that you failed to follow through on the suggestion (unprofessional). There are technical terms for feelings the therapist raises in you, and it is always worth discussing.
Does the therapist follow up with you from week to week—how did that interview go? did you manage to take that walk you wanted?—in a way that’s not judgmental or guilt-inducing. “Last time we spoke, you talked about looking for ways to reduce your stress. How did that go?” Questions like this reflect their engagement with you.
As you go along, a good therapeutic relationship is one where you feel that you’re beginning to internalize the questions and problem-solving approach voiced by the therapist. You’re aiming, in the end, not for perfection, or to be a completely different person, after all, but to acquire skills and competencies to deal with the ups and downs of life.
“Treated Well” offers guidance on getting effective treatment for yourself or a family member. Coming Soon: “Red Flags to Watch For,” “How to Find Affordable Care,” “A Quick Guide to the Alphabet Soup Following Therapists’ Names”
6.03.2010
Bibliotherapy 1
If you’re like me, you can never embark on a venture without learning as much as possible. For the same reason people buy books on travel before they go on vacation, you can read books on therapy by great therapists. (Of course the danger is that my patients might start comparing me with these great therapists, but I like to think I have the ego strength to be myself in the face of the comparison). Among the best is Yalom, whose 
The Gift of Therapy is a gift to patients as well.
Treated Well: the first visit to a therapist
I have the name of a therapist and I’ve made my first appointment. How can I get off to a good start?
You’ll have the best chance for a productive experience in therapy if you are an informed consumer working in a structured manner and environment with a trained professional. You’re smart to think about prepping yourself a little.
Before you go:
Think about what you hope to achieve from seeing a professional. At least start to identify some tentative goals. For instance: decrease my anxiety, communicate with people better, stop procrastinating, deal with my anger, stop drinking so much. In one sentence, can you state why you are going to a therapist? Even if the answer is “my wife/boss/friends think I should see a shrink,” that’s fine. Another way of putting that last statement: “Important people in my life feel that I have a problem that is affecting me and them adversely. I may not be quite sure what their problem with me is, but I am willing to explore what I could do better in my relationship (life, marriage...).”
Spend some time thinking about your strengths! Can you think of a concise way to describe yourself? If you’re having trouble coming up with anything, ask yourself: “What do people say I’m good at? Is there something I’m especially proud of?”
In the first meeting:
Questions to ask the therapist (if he/she doesn’t volunteer information in the session):
You’ll have the best chance for a productive experience in therapy if you are an informed consumer working in a structured manner and environment with a trained professional. You’re smart to think about prepping yourself a little.
Before you go:
Think about what you hope to achieve from seeing a professional. At least start to identify some tentative goals. For instance: decrease my anxiety, communicate with people better, stop procrastinating, deal with my anger, stop drinking so much. In one sentence, can you state why you are going to a therapist? Even if the answer is “my wife/boss/friends think I should see a shrink,” that’s fine. Another way of putting that last statement: “Important people in my life feel that I have a problem that is affecting me and them adversely. I may not be quite sure what their problem with me is, but I am willing to explore what I could do better in my relationship (life, marriage...).”
Spend some time thinking about your strengths! Can you think of a concise way to describe yourself? If you’re having trouble coming up with anything, ask yourself: “What do people say I’m good at? Is there something I’m especially proud of?”
In the first meeting:
Questions to ask the therapist (if he/she doesn’t volunteer information in the session):
“What will we do here? What’s a session like? How long does it last?
“What is the cost ? What are your policies about payment?”
Like doctors, therapists usually expect to be paid after each session. Some take insurance; others don’t. Some have a sliding scale, depending on your financial situation.
“What is your training? Credentials?”
Generally, in NYC, at the minimum the therapist should have an advanced degree (master’s or doctorate) and be licensed. Licenses are issued by the New York State Department of Education which publishes parameters for practice and ethical standards that anyone can review on its website. A license assures a standard for educational and professional achievement.
“Do you have previous experience with my kind of problem? Any specialized training?”
For instance, there are addiction and ADHD specialists.
“What is your feeling about medications for treating mental health?”
Be cautious about therapists who come across as too anti-medication. This is an area, whatever your personal feelings and opinions, where modern science has made great advances. A moderate perspective balancing positive and negative results is preferable.
“If something comes up that you can’t handle (prescribing medication, a specialized problem—traumatic brain injury, say), what is your referral process?”
Good professionals will have a multi-disciplinary network of other mental health professionals, and because your health is their top priority, they will be open to referring you.
5.31.2010
Social connectedness affects health
Good reviews for Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives
(Christakis & Fowler, 2009). Lots of intriguing material in the sections of the book I have read, including the authors’ Rule 2: “Our network shapes us.” Cascading effects in network dynamics tend to drive behaviors in positive or negative directions. The authors are known for health studies in eastern Massachusetts in which they demonstrated over time that obesity tends to increase in clusters, and that smoking cessation also tends to grow through network effects.
In my work as a therapist, I have found that many patients discount the importance of their social relationships as modifiers of their conditions. Yet the evidence is very persuasive that health is as much a result of building relations with other healthy people as with any medical or “therapy” intervention. To a degree, a therapist should focus on aiding the patient to rebuild and extend their social networks. Traditionally, this has been the domain of couples or family therapy, working to repair communication and family roles, but usually within a limited scope network. Individual therapy may address the issues but tends to be somewhat more internal- than network-driven. Yet, object relations theory would seem to point out to the network rather than inward.
Often, in the specific treatment of, say, substance abuse (to use a modality I am very familiar with), the groups formed are of “unhealthy” people, i.e. those bearing a specific diagnosis. Normally, these groups are also opportunistic, with very little patient matching, although there is sorting by “co-occurring disorders”, which covers a multitude of issues, not all compatible. On one level, the content and setting address the common diagnostic problem, but the relative paucity of positive social connections in the group blunts the effectiveness of the therapy.
Recently, I started a group with the express intention of focusing solely on the network effects for the patients. Unfortunately, the group ended very prematurely when I left the agency, but I am looking to find a venue to explore the power of the network on health. Right now, I am actively looking for supporting materials and ideas for activating network effects for therapy.
This blog is in part directed at these issues.
Links: The Christakis Lab at Harvard
(Christakis & Fowler, 2009). Lots of intriguing material in the sections of the book I have read, including the authors’ Rule 2: “Our network shapes us.” Cascading effects in network dynamics tend to drive behaviors in positive or negative directions. The authors are known for health studies in eastern Massachusetts in which they demonstrated over time that obesity tends to increase in clusters, and that smoking cessation also tends to grow through network effects.In my work as a therapist, I have found that many patients discount the importance of their social relationships as modifiers of their conditions. Yet the evidence is very persuasive that health is as much a result of building relations with other healthy people as with any medical or “therapy” intervention. To a degree, a therapist should focus on aiding the patient to rebuild and extend their social networks. Traditionally, this has been the domain of couples or family therapy, working to repair communication and family roles, but usually within a limited scope network. Individual therapy may address the issues but tends to be somewhat more internal- than network-driven. Yet, object relations theory would seem to point out to the network rather than inward.
Often, in the specific treatment of, say, substance abuse (to use a modality I am very familiar with), the groups formed are of “unhealthy” people, i.e. those bearing a specific diagnosis. Normally, these groups are also opportunistic, with very little patient matching, although there is sorting by “co-occurring disorders”, which covers a multitude of issues, not all compatible. On one level, the content and setting address the common diagnostic problem, but the relative paucity of positive social connections in the group blunts the effectiveness of the therapy.
Recently, I started a group with the express intention of focusing solely on the network effects for the patients. Unfortunately, the group ended very prematurely when I left the agency, but I am looking to find a venue to explore the power of the network on health. Right now, I am actively looking for supporting materials and ideas for activating network effects for therapy.
This blog is in part directed at these issues.
Links: The Christakis Lab at Harvard
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