Category: psychotherapy

Our mental health crisis

Posted in mental health system, Peace Corps service, psychiatry, psychology, psychotherapyLeave a comment

John F. Kennedy was one of our most visionary presidents. He set a ten-year goal for landing on the moon and, although he didn’t live to see it, the goal was met. He envisioned an agency, separate from the State Department, that would give American citizens the opportunity to live and serve as volunteers in developing countries around the world; and the Peace Corps became a reality. He envisioned, and provided funding for, a national mental health system, made up of local mental health centers, to replace the system where most mental health treatment was provided in large, centralized state institutions.

For most of my career as a psychologist, I was employed at community mental health centers (CMHCs). Little did I know when I started out in 1976, working for a CMHC in rural Alabama, that these were the halcyon days of our national mental health system. Mental health agencies had adequate funding to meet community needs. The plan was to decrease reliance on expensive (and often unnecessary) inpatient treatment in state “mental hospitals,” by providing outpatient mental health services at the local level. Almost all of the initial funding was federal dollars, with the understanding that the federal funds would gradually decrease, and states would allocate a portion of the money saved, to replace the federal funding for community outpatient treatment. The goal of the well-intentioned plan was called “de-instititutionalization.”

All across the country, states made plans to eventually shut down the massive institutions that often “warehoused” patients with chronic. severe mental disorders. This saved the states a lot of money over time, but the state legislatures failed to carry out their part of the plan and replace lost federal funding for community mental health treatment with state dollars. Instead, the money saved went straight into state general funds, and funding for community treatment gradually diminished, year after year. The range of services provided shrank over time. Community outreach and support services programs closed down and CMHCs became understaffed. Clinicians (like me) initially hired to provide individual, family and group therapy found themselves doing less therapy, and more and more bare-bones case management services for their ever-increasing caseloads of underserved clients. A lot of seriously mentally ill people received only occasional fifteen-minute medication management sessions with a psychiatrist.

With the big, centralized institutions shut down or downsized, and with the inability of most CMHCs to adequately meet community needs, across the country more and more people with mental illnesses and substance abuse problems have joined the ranks of the homeless. In many cities, hospital emergency departments stay backed-up because of all of the severely mentally ill people who need treatment and can’t get it elsewhere. Jails and prisons have become primary providers of (often inadequate) mental health services. Often, police officers are the first point of contact with people who are psychotic and out of control, sometimes with tragic results.

Few police officers are adequately trained to do effective interventions with manic and psychotic people. If the states had done their part and adequately funded community-based treatment, and we had the national mental health system that Kennedy envisioned, the first responder in a psychiatric crisis situation would be a social worker or a psychologist, not a cop. Police have enough responsibilities, without having to respond to psychiatric emergencies. Jails and prisons have enough problems to deal with, without having to be de facto mental health centers. Jails and prisons are obviously not environments conducive to stability and recovery.

Mental illness and substance abuse are some of the root causes of the rise in homelessness, and too many Americans are more judgmental than compassionate when they encounter homeless people. There remains in our society a stigma that brands mentally ill people as the Other, not as individuals whose impairments should be recognized and addressed on a societal level. Our national mental health system is a disgrace, partly due to stigma and the consequent marginalization of people with mental illnesses and substance abuse problems. We need to elevate our compassion for these people to the level of our compassion for people suffering from cancer and other physical diseases – maladies that have ad campaigns promoting awareness and compassion We need to treat substance abuse as more a public health issue than as a criminal issue.

Prevention is a vital part of medicine, and gets a lot of attention when it comes to physical illnesses. Kennedy’s plan emphasized prevention, and we need to develop a national model that puts the treatment of mental illness and substance abuse on a par with the treatment of physical injuries and diseases.

Why I write

Posted in language, mental health system, Peace Corps service, propaganda, psychology, psychotherapy1 Comment

Those of you who follow my blog may have wondered what’s happened to me, since I haven’t posted anything for months. I’m back, and I owe you an explanation. I plan to resume posting on a regular basis, but time will tell how frequently. I haven’t succumbed to the Plague. My only excuse is that in late May I injured my left knee in a fall, and required surgery. I realize that recovery from a knee injury doesn’t explain my silence as a writer; but it’s been part of a confluence of events that I’m trying to make sense of.

I knew from an early age that I wanted to be a writer, even though I didn’t know what I wanted to write about. It wasn’t just a fantasy about achieving fame or making money; I just knew that I had things to say. I read a lot and admired good writers.

I started out as a political science major in college, but discovered that my favorite classes were English literature courses. It didn’t take me long to switch majors. As a boy and as a teenager I’d mostly read adventure (including all of the Tarzan novels) and science fiction but, awed by the brilliance of such literary masters as Milton, Shakespeare and Goethe, I fell in love with literature. My first short story (science fiction) was published in The Citadel’s literary magazine, The Shako, and I served as poetry editor during my senior year. (Pat Conroy, The Citadel’s best-known alumnus author, held that job my freshman year.) It would be years before I wrote my next short story, but my brain was brimming with ideas.

Most of my fiction remains unpublished, but I hope that will change. I’ve written over a dozen short stories that I’m still proud of, as well as a crime novella and a speculative fiction novel. My two published books are non-fiction. Two years in Kingston Town is a memoir of my Peace Corps service in Jamaica (1991-93), with my wife Maria. Ad Nauseam: How Advertising and Public Relations Changed Everything, an examination of how we became a Propaganda Society, was the result of much research, and received several favorable reviews – including one in Kirkus Reviews. I had hoped it would be used as a textbook in high school and college social science and English classes, as an aid to teaching students about propaganda. But that didn’t happen.

Most writers — even good ones — have to get used to rejection and to persist in their efforts to get published. I’ve come to understand that what distinguishes true writers from dilettantes and people who write, motivated by fantasies of fame and money: we write because we must. I’ve said for years that writing is my therapy and, sure enough, now that I’ve had several unproductive months, I ‘ve been feeling that there’s something missing from my life. Writing is part of who I am. Whether it’s fiction or non-fiction, it’s like I get an idea in my head, and it wants to get out. So I start to put it into words, usually on paper for the first draft.

As I re-read and re-read the first draft, I make changes until I’m satisfied with it as a first draft. (Bestselling author James Michener said that he wasn’t a good writer, but was a very good re-writer.) I write my second draft on WORD, editing as I go, and print it out. As I read it over and over again, I continue to make improvements, polishing my prose until it says what I set out to say. Writing fiction, I continue to edit on WORD until I achieve what I consider a “final draft.” Blogging, as I type out my latest post on my WordPress blog site, I continue to find things to improve upon. So, what you read is a polished third draft.

At various times during my career as a psychologist, I wrote “You and Mental Health” columns for local newspapers. In them, I tried to de-mystify esoteric psychological concepts, and to educate readers about psychotherapy. While my father enjoyed my fiction, he told me that he most liked my mental health columns. He said that I had a gift for explaining complex things in layman’s terms. This praise and encouragement is part of what got me to start blogging.

Everyone is adapting — or trying to adapt –in their own way to this strange parenthesis in our lives that is the pandemic. I consider myself fortunate that I haven’t been significantly anxious or depressed, or afflicted by “cabin fever.” But that doesn’t mean that I haven’t been affected. The confluence of socially-distanced living and my knee injury seems to have temporarily sapped me of my creative momentum. I feel like I haven’t been fully myself lately. Until today, having written these words. It’s good to be back.

Mind Magic

Posted in consciousness, mindfulness, psychology, psychotherapy, rational thinking, shamanismLeave a comment

Being a psychologist, I’ve done a lot of thinking and studying about the human brain – the organ that makes us “the magic animal.” Humans can not only see things as they are, but as they could be. Our cognitive abilities and our imaginations allow us to create cultures and cities and symphony orchestras and entertaining stories about things that never happened.

It was my privilege, as a therapist, to be a witness to people changing their lives in positive ways. I’ve seen parents become better at raising their children. I’ve seen violent people learn that anger needn’t lead to violence, and learn to control their behavior no matter how angry they got. I’ve seen couples discover deep emotional intimacy while respecting one another’s boundaries. I’ve long suspected that major changes in a person’s behavior patterns (i.e. mastering anger management) was probably causing structural synaptic changes in their brains. Synaptic pathways mediate both emotions and behaviors.

My suspicions have been validated in recent years by research on brain neuroplasticity. Our brains have the ability to reorganize themselves structurally and functionally, by forming new neural connections. Brains can “re-wire” themselves to compensate for injury or disease, and to adjust to new or changing situations. My guess is that the brains of bilingual people have more complex neural pathways related to speech and language than people who only speak one language. I suspect that it gets easier over time for formerly violent people to use their anger management skills, because daily practice creates new neural connections, new reflex behaviors.

The human brain has a wide repertoire  of states of consciousness (SOCs). The very notion of “altered states of consciousness” presupposes that there’s a “standard” SOC – which is clearly not the case. Your SOC is different when you solve a math problem, or listen to music, or perform in front of an audience, or make love. So, I submit that we have a range of standard SOCs, which everyone experiences, as well as a range of alternate SOCs – some of which not everyone will experience. Taking drugs – including alcohol and nicotine – reliably alters consciousness in a variety of predictable ways. I won’t get into drugs as a means of altering consciousness in this post, other than to recommend Michael Pollan’s  book, How To Change Your Mind, which is about the potential of psychedelic experiences to bring about  lasting positive changes in peoples’ lives – even after a single “trip.”

I’d like to briefly share some of the things I’ve learned about our potential to “change our minds” without using drugs. Rational thinking  is a learnable skill. We all have rational and irrational thoughts. Many people can’t tell the difference between  them and sometimes act on irrational thoughts, complicating their lives. Rational thinkers are people who can differentiate their rational thoughts from their irrational thoughts, and make rational decisions. I believe that the brains of rational thinkers are wired differently – through practice – than the brains of those who can’t tell the difference. Active listening is a learnable skill that improves receptivity to nuances of interpersonal dialogue and music appreciation, among other things. Over decades of listening to classical music, I’ve become a better listener. Listening is often a passive process, but active listening is mindful listening, with no intruding thoughts.

Hypnosis is generally understood as a SOC “induced” by a hypnotist, where the brain is receptive to suggestion. People who are good hypnotic subjects can learn self-hypnosis to relieve pain, overcome bad habits, and otherwise improve their lives. Meditation is similar to active listening only in that it involves mental focus. But in active listening, the mind is focused on some external thing, whether words or music. Experienced meditators can maintain awareness,without any object of that awareness. There are things to be learned by simple, sustained awareness that can’t be learned by thinking, or be put into words. Mindfulness is a kind of meditation where the meditator is focused on their immediate experience, to the exclusion of thoughts about what they’re experiencing – especially judgments like good or bad, beautiful or ugly. Walking or chopping wood can be the focus of mindfulness meditation.

Not everyone experiences all of these SOCs; some require preparation and effort. Training that I received from anthropologist and practicing shaman Dr. Michael Harner enabled me to experience the shamanic state of consciousness, in which I’ve had vivid experiences of “journeying” in Dreamtime and encountering spirit animals. You can learn more about the techniques of shamanic journeying at http://www.shamanism.org, the website of the Foundation for Shamanic Studies, which Dr. Harner founded.

While I agree with Michael Pollan that psychedelic “trips” can, under the right conditions, be profound, positive life-changing experiences, I wrote this post as an overview of non-drug SOCs that can change our minds and lives. If you want to know more about any of these tools for personal growth, I’ve written in more detail about psychedelic consciousness, shamanic journeying, rational thinking, active listening, hypnosis, meditation and mindfulness in previous posts. You’ll also find a few entertaining stories about things that never happened.

Your mind is magical.

Turning off your mental radio

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Although this post is about meditation, and I’ve taught basic meditation techniques to people for years, I’m not a daily meditator, myself. I think of meditation as an ancient, effective psychotechnology – a tool/skill for controlling mental activity. I’ve found it to be helpful in many situations, and have described learning to meditate as learning to “turn off your mental radio” at will.

A Buddhist text describes the mind as a “drunken monkey bitten by a scorpion,” and thinking is the source of much human suffering. Many people that I worked with as a therapist often felt overwhelmed by the unending press of their own thoughts, resulting in high levels of stress and distress – often in the form of anxiety and depression. People suffering from insomnia complained that they couldn’t stop thinking when they needed to be sleeping. I’ve written about rational thinking as a learnable skill in previous posts, but meditation gets at the root problem of runaway thoughts – regardless of content. Practicing it can prevent a thought from becoming an unwanted “train of thoughts” that might take you to places you don’t want to go. In a meditative state one can be aware, without being aware of any thing.

I’ve never had chronic sleep problems, but my rare experiences of insomnia used to be hellish, as I tossed and turned in bed, telling myself that I was having a terrible time. Now, when I have trouble falling asleep, I can avoid being aroused by the content of my thoughts. I can turn off my mental radio and experience getting needed rest, until I fall asleep again. I no longer torment myself with unwanted thoughts that keep me awake. There are other benefits that come from learning to meditate. You can learn it all by yourself. All it takes is practice.

There are many ways to learn how to meditate, and you don’t have to learn yoga or tai chi to discover how to control your mental activity. Daily meditators extol the benefits of their practice, but even occasional meditation can be a helpful skill, enabling you to keep your focus and to reduce your stress. As a therapist, I felt obligated to remain 100% present in the here-and-now with each client. Sometimes I would do a brief meditation between therapy clients, to clear my mind.

I started out with what I call one-point meditation, and went on to learn to maintain awareness, without any object of my awareness – no-point meditation. There are many different focal stimuli that can be used to learn one-point meditation. Probably the most popular method is to focus on your breath, to the exclusion of all thought. But learners can also focus on a visual stimulus such as a candle flame in a dark room or a mandala, or an aural stimulus – a ringing bell or a mantra such as “Om.” In mindfulness meditation, you focus on your present surround or activity, to the exclusion of thoughts about the situation or activity. Walking, or washing the dishes, can be a meditation.

Other than mindfulness meditation or movement meditations such as tai chi, most meditators sit, keeping a straight spine. As you follow your breathing, or try to lose yourself in a mandala or a candle flame or a mantra, thoughts will intrude on the purity of your concentration. One thought can easily lead to a train of thoughts that distracts you from your focal point. Learning to meditate involves learning not to let these thoughts carry you away from the object of your concentration. You notice the thought but don’t follow it, letting it pass, while focusing back on the candle flame, the mantra, your breath, or the activity you’re engaged in. When you first achieve a meditative state, you’ll know it; but as soon as you think, “I’m meditating!” you’re not. Repeat. With practice, you can extend the time that your awareness is one-pointed, uncontaminated by thought.

Once you make progress in one-point meditation, and can let intrusive thoughts drift by without distracting you from simple awareness, you can start to practice turning off your mental radio altogether, with no focal stimulus. I know from long experience that I can be alert and aware, without being aware of any thing, including my own thoughts. In the meditative state, I’m free from stress. I can meditate briefly, to clear my mind between mentally taxing activities. I can clear my mind of intrusive thoughts when I want to fall asleep.

Rhythmic breathing is central to learning meditation, even if you’re focusing on a candle flame or a mantra or an activity. Breathing is a constant, automatic activity. When you bring it into conscious awareness, you can learn to empty your mind of thought – if that is your goal. (Pranayama yoga teaches people to alter their consciousness in a variety of directions, by altering their breathing in prescribed ways.) Your initial practice sessions need not last long. If you set aside ten or fifteen minutes, several times a week, you can teach yourself how to turn off your mental radio.

 

 

Plutophilia – a proposed diagnosis

Posted in Addiction, philosophy, psychiatry, psychology, psychotherapy1 Comment

Psycho-diagnostics are culture-bound. The “Bible” of psychodiagnosis in this country is the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM), and from time to time a committee of psychiatrists updates it. The current edition is DSM 5. In DSM 2, homosexuality was classified as a mental disorder, but this error was corrected in the next edition. The DSM 3 also eliminated the “neurotic disorders” listed in the prior editions. What used to be called Multiple Personality Disorder is now called Dissociative Identity Disorder. Some diagnoses have a limited lifespan.

Each diagnosis establishes multiple criteria (e.g.descriptions of symptoms), a certain number of which have to be met in order to establish the diagnosis as accurate. Psycho-diagnostics isn’t rocket science. It’s often imprecise, and relies more on theories than on verifiable data. Unlike most physical disorders, there are no biological markers to distinguish (for instance) Schizophrenia from Schizoaffective Disorder or Bipolar Disorder, manic. Much psychodiagnosis is educated guessing. The criteria for what’s considered psychopathology are values- and culture-bound, and sometimes arbitrary.

Mental illnesses exist in other cultures that aren’t found in the DSM.  Amok  is a mental disorder that occurs in Malaysia, Indonesia, and Polynesia, where people (mostly men) go berserk and assault anyone in their path. Koro is a persistent anxiety state that manifests in some men in Southeast Asia, based on their belief that their penis is shrinking, or retracting into the body, and that this can lead to death. Susto is a belief in “soul-loss” in some Hispanic cultures, which is believed to cause vulnerability to a variety of illnesses. A lot of people around the world believe in illnesses caused by voodoo/obeah/root magic hexes or spells, or the “evil eye.”

Having stated that psychodiagnosis is somewhat arbitrary and culture-bound, I’ll try to make the case for a new diagnosis that is bound, not to an ethnic or national culture, but to the multinational corporate culture. Only the very rich can develop this pathology. I believe  that there are cultural, economic, and political reasons why Plutophilia – excessive love of wealth –  isn’t a recognized  “paraphilia,” alongside necrophilia and  pedophilia. (Plutophobia – fear of wealth or money – is believed by some clinicians to be  a treatable psychopathology.) According to the Bible, it’s not money, but the love of money that’s the root of all evil.

Here are my suggested diagnostic criteria for a diagnosis of Plutophilia: (1) Obsession with the endless accumulation of wealth, far beyond what is needed or will be spent in a lifetime; and persistent or compulsive behaviors in the service of wealth accumulation. (2) Compulsive competition with other plutophiles in amassing the greater/greatest fortune. (3) Unconcern with the negative economic, social, and ecological consequences of their exploitation of workers and/or other resources, and of their obsessive profiteering. (4) Delusional belief in their (social Darwinistic) superiority as human beings, and in having “earned every dollar.” (5) Insatiability. No matter how much wealth is accumulated, it’s never enough. (6) The belief that their psychopathology  is a virtue. I’d say that meeting five of these six criteria would suffice to establish the diagnosis.

Plutophilia is responsible for the vast gap between the wealthiest few and the masses that live in, or on the edge of, poverty. It harms society as surely as an unending drug abuse epidemic. However, having the disorder can’t be the grounds for involuntary commitment and/or court-ordered treatment. Sadly, there is no known treatment or cure.

Rules for “fair fighting”

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Lovers are going to fight sometimes – hopefully, only with words. It’s inevitable, because no two people in an intimate relationship are a “perfect match” in terms of habits, preferences and expectations. Boundaries have to be set (and re-set) because each of us is unique, and adjustments are inevitable in a healthy relationship. The balance of power is an issue in many or most romantic relationships. Joni Mitchell wrote  (and sang) “You and me are like America and Russia,/ We’re  always keeping score./ We’re always balancing the power,/ And that can get to be a bore.” I know a lot about balancing the power, not only from my own personal experiences, but from years of doing couples’ therapy, as a psychologist.

Knowing that conflict is inevitable in lasting intimate relationships, I studied, and came up with my own set of rules for “fair fighting,” to minimize destructive messages and to keep open the possibility of mutually satisfactory resolutions. Dialogue can be constructive or destructive. Destructive arguments can leave wounds, which can either fester or heal over time. If both partners act in good faith with one another over time and earn to fight fairly, old wounds can heal, and they can avoid lasting damage to the relationship. Here’s my list of rules:

(1) Practice the Golden Rule, and remember that there needn’t necessarily be a Winner and a Loser when you and your partner have a disagreement. The Golden Rule doesn’t mean that you always have to treat your partner the way they want to be treated; it means mutual respect for boundaries. “Okay. I agree to stop bringing up that time you got drunk and cheated on me ten years ago, but you don’t get to shout at me.” Yelling, cursing, and degrading language are all counterproductive to mutual understanding and harmony.

(2) If one or both of you has lost your temper, either of you can call a time out. Stop talking, trying to get the last word in. It’s hard to be rational when you’re angry. You may or may not need to  physically separate during the time out, but don’t resume the discussion until both of you have cooled down. Repeat as necessary. It might help to write down your thought and feelings during the time out, if that helps you to get perspective.

(3) Stay on topic. Deal with one problem/issue at a time. Avoid “and while I’m at it . . .” digressions, and don’t drag in past grievances. Don’t stonewall, i.e. refuse, over time, to discuss a topic that your partner thinks is important. Don’t deflect or pivot: “Let’s not talk about me, let’s talk about you.” Try to avoid blaming statements. Take turns doing active listening and ask for clarification if you need it. Ask neutral questions that elicit feedback, such as, “Does that make sense to you?”

(4) Try not to generalize. Be as specific as you can, and avoid absolutes like “always,” “never,” and “every time.” These generalizations are seldom objectively factual, and tend to elicit defensive responses. Statements like, “We never make love anymore” trigger thoughts counter to that statement, i.e. “We made love last Wednesday.”

(5) Avoid questions-that- aren’t-really-questions – statements phrased as if they were queries, usually starting with “why” or “what.”: “Why are you always on my case?” “Why don’t you act like a real man (or woman)?” “What do you take me for – your maid?” “Why are you such a big baby?” Such statements in the form of questions invite a defensive, and sometimes angry, response. There’s no “answer” to the “question” that would satisfy the asker.

(6) I-statements (first-person) are usually much easier to digest than you-statements (second-person), which can be contradicted, argued over. If you start a sentence with “I feel/want/think/wish . . . ” your partner can’t contradict you, because you’re the final authority on how you feel and what you think. It’s easier to hear and understand, “I wish you’d spend more time with the kids” than ” You hardly ever spend tome with the kids,” let alone “Why don’t you ever spend time with the kids?” It’s easier to hear “I think you’re wrong” than “You’re wrong.”

Metacommunication is talking about the way we talk. Here’s an example: Pat “How do you think we’re doing, applying those fair fighting rules we learned in counseling?” Lindsey “I think we’re doing better, but I wish you’d stop bringing up the past when we argue. How do you think we’re doing?” Pat “Well, we haven’t had a shouting match in weeks, so there’s improvement. I need to work on ‘one topic at a time.’  But I don’t like it when you get angry and keep going on, after I call a time out. We need to stop talking and cool off when either of us calls a time out. It’s just not important for one of us to get in the last word.”

Shakespeare wrote, “Love does not alter when it alteration finds . . .”. True, lasting love involves tolerance. True love will find a way to rise above conflicts, in service of harmony.

Models of Madness

Posted in Addiction, mental health system, psychiatry, psychological models, psychology, psychotherapyLeave a comment

In prior posts I’ve written about the pros and cons of the medical model (psychiatry) as the predominant model for the treatment of mental illness, and about what I call “the model muddle.” Models are ways of organizing and framing ideas in a way that serves as a guide. A good model is like a good map: it helps you to get where you want to go. The map is not the territory, but merely a helpful representation. No model is perfect and complete, or demonstrably superior to all other models, in all situations. Each one has its flaws and limitations.

Psychiatry is the medical model’s methodology for treating mental illnesses – primarily with medications. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to an appropriate treatment.  The medical model is very good at what it’s good at, such as mending broken bones, doing surgery, and treating many physical ailments. But psychiatry is built more on theory than on scientific evidence.

One limitation of the medical model is that it’s mainly focused on what you do after you have symptoms, not so much on wellness and prevention. A distinct limitation of the medical model as regards mental disorders is that, unlike most common physical disorders, there are no identifiable biological markers to distinguish (for instance) what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psychodiagnosis is not rocket science, because mental illness isn’t measurable in the way that many physical illnesses are (i.e. medical science can distinguish between asthma and pneumonia). At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

Critics of psychiatry have argued that mental illness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. The negative side effects of some psychotropic medications and mood stabilizers outweigh the benefits for many patients. The term iatrogenic effects refers to treatments that do harm. Unfortunately, contemporary psychiatry is wedded to the pharmaceutical industry. That having been said, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need for primary reliance on drugs as the default treatment for psychopathologies.

The biopsychosocial model takes into account such factors as physical health, heredity, stress, social stigma, social support system, mental habits, chemical dependency,  economic status, nutrition, and homelessness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that gives people who’ve been labeled as mentally ill more autonomy and more options for resolving problems related to their mental health. Unfortunately, the national mental health system is severely underfunded, and many people in need of help are underserved. This is a national disgrace.

The recovery model is an alternative to the medical model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” substance abusers, but did it apply to the mentally ill? Many mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers/programs in some cities, that aren’t run on the medical model. Such programs don’t necessarily preclude psychiatric interventions, but also offer educational resources to empower patients, professional and peer support, and access to community resources, to reduce the stressors that exacerbate symptoms of mental illness.. The concept of recovery from mental illness doesn’t mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom remission and control of one’s life. To find out more about the recovery movement and alternatives to traditional psychiatric treatment, check out madinamerica.com.

Changing habitual behaviors

Posted in Addiction, behavior modification, mindfulness, psychology, psychotherapyLeave a comment

Everyone has habits – some good, some bad, some inconsequential. One study suggests  that something like 43% of our behavior is habitual. This includes sequences of behavior that we’ve “chunked” together, and often perform automatically, so we don’t have to make myriad decisions every day. When you get in your car to drive to your friend’s house, you’re probably thinking about your destination or what you want to say to your friend. You don’t have to decide on each action as you automatically depress the clutch, turn on the ignition, fasten your seat belt, release the parking brake, shift into first gear or reverse, and  step on the gas pedal while easing off on the clutch. You don’t always have to be mindful about driving until you’re in traffic. We spend part of each day on “automatic pilot,” not having to make individual decisions about routine behavior sequences – which can include such things as drug abuse or “screen addiction.”

Throughout most of history, an individual’s habits arose from the culture and that individual’s circumstances and proclivities. These days, many of our habitual behaviors have been conditioned by corporate social engineers, applying principles of social science in the fields of advertising, marketing, public relations, and political consultancy. Using classical (Pavlovian) conditioning and other psychotechnologies of influence, they “invisibly” shape habitual behavior on a mass scale. I’m convinced that America’s obesity epidemic is largely due to the constant barrage of advertisements for tasty, if not necessarily healthy, foods. I’ve written about this corporate social engineering in my book, Ad Nauseam: How Advertising and Public Relations Changed Everything.

Everybody knows how hard it can be to change a bad habit. During my career, I had many clients who entered therapy because they needed professional help in order to change a bad habit. Willpower by itself is seldom sufficient to establish a desired change, because you have to maintain mindful awareness of your triggers and urges/cravings every waking hour, and to persistently resist temptation. The rewards of (for instance) dieting are long-term; the reward of giving in to a food craving is immediate. The good news is that once you’ve successfully changed a habit, it gets easier and easier to  maintain the change as time goes on. Quitting smoking, my nicotine cravings used to last all day. Eventually they only lasted for seconds, and now I haven’t had one for years.

Whether smart phone use can be addictive depends on your definition of addiction. I’m “old school” on the subject and believe that tolerance (needing more over time to meet your need) and physiological withdrawal are hallmarks of true addiction. Sex and gambling and screen time don’t qualify as addictions by the classic definition, but the physiological responses of gambling/sex/smartphone/gaming “addicts” are very similar to the responses of drug addicts. There may be withdrawal, in the form of cravings, but they’re psychological in origin.

Changing a habit often requires  a strategic approach to the problem. What mental, emotional, and social factors tend to keep the undesirable behavior in place? Once you’ve analyzed the factors that support your bad habit, make a plan. Visualize how your life will be better when you’ve succeeded.

Here are four things you can do to replace a bad habit with a good one. (1) Your plan should take into account the things related to the bad habit, such as time, place, emotional states, and social factors ( i.e. It’s not a good idea to hang around with your drinking buddies early in sobriety). (2) Declare your intention and your criteria for success to friends and family. This gives you an added social incentive to succeed. (3) Build-in  consequences, positive or negative. They can be natural consequences, or constructed. A natural, positive consequence if you’re quitting smoking is to add up the money you’re saving, and when you accumulate enough, treat yourself to a trip to Disneyland, or Vegas, or wherever. A negative, constructed consequence might be writing a $100 check to some organization that you despise, and giving it to a friend, to be mailed if you fail to change the targeted habit. (4) Don’t rely on good intentions and willpower, but structure your environment to make the bad habit more inconvenient. You can’t binge on cookies and ice cream while watching TV if you don’t buy them and bring them home in the first place. Other environmental factors are social – enlisting the support of those around you to help you meet your goal, and avoiding those who might undermine your resolve.

I’d never say “Good luck” to someone who announced his or her intent to kick a bad habit. Luck has nothing to do with it, and willpower is only one of the things you’ll need to succeed.

Existentialism and psychotherapy

Posted in comparative religion, philosophy, psychological models, psychology, psychotherapy, religionLeave a comment

Although I studied a variety of therapies in my preparation for a career as a psychotherapist, I never identified exclusively with one approach – gestalt, client-centered, behavioral, psychodynamic – as a descriptor of my style of therapy. I was an eclectic practitioner, but have always considered my therapeutic orientation to be existential.

I respect that there are therapists whose work has a religious foundation, but mine was a secular practice. I validated faith in God and prayer as best I could, with clients who found meaning in their religious beliefs; but if clients asked me to pray with them, I declined. Although I was raised as a Christian, and most of my values are rooted in the Judeo-Christian ethic, I’m an agnostic of the kind that’s very comfortable with saying “I don’t know” when asked about specific religious beliefs. I think that it’s just as arrogant for an atheist to assert sure knowledge that there is no God as it is for a religious person to assert that I’m in error for not believing what they believe. Define God, then we can talk.

I don’t believe that I have the authority to definitively answer questions about religion and am tolerant of  those who claim to “know” that their beliefs are true, as long as they do no harm as a result of religious beliefs. Of course, there’s considerable room for debate about what constitutes harm. (I personally consider any form of indoctrination to be harmful.)  I consider myself an existentialist because existentialism directly addresses morality and personal responsibility, without the excess baggage of sin and redemption and pleasing God. I’ll briefly summarize some of the basic principles of existentialism, as I understand them.

First, existentialism asserts that there’s no universal Meaning “out there” that all right-thinking people can apprehend – as opposed to religions, which assert that there is, i.e. “God’s plan.” To existentialists, concepts like Sin and Redemption and Divine Intercession are constructs based on religious doctrine. They don’t exist in any objective sense. Meaning only exists in the eye of the beholder. Life is absurd, as illustrated by Albert Camus in “The Myth of Sisyphus.”  Sisyphus continues to push the boulder up the hill, despite knowing that it will just roll back down. He persists, despite the absurdity of his efforts, because the act has meaning for him.

Because there are no absolute rules, or Divine rewards or punishments in an afterlife, we are each free to do whatever we want. But the other side of the coin of freedom is responsibility. We’re absolutely responsible for whatever we choose to do, and can choose to behave morally even if we don’t believe in Heaven and Hell. We can choose to live in good faith with others, because of our moral responsibility for all of our actions. Although we can find joy and meaning in authentic relationships, we’re all essentially alone in our lives. (A song sung by Country singer Bill Monroe expresses this as well as anything I’ve read on the subject; “You’ve got to walk that lonesome valley,/ You’ve got to walk it by yourself,/ ‘Cause nobody else can walk it for you./ You’ve got to walk it by yourself.”) We each have to deal with Angst (anxiety) and dread that comes from the knowledge that we will someday cease to exist. Existentialists don’t rely on the comfort of religious promises of eternal life for the faithful, to come to terms with our mortality.

To say that there’s no objective Meaning to existence “out there” isn’t to say that meaning is unimportant. As an existentialist I’m free (like Sisyphus) to find, or create, my own meaning. One of the best-known existential therapists, Viktor Frankl, named his school of psychotherapy logotherapy – from the Greek “logos”: meaning, or reason. (I’ve written about Frankl in previous posts. I’ve recommended his book, Man’s Search for Meaning, to more clients over the years than any other book.) Although I didn’t practice logotherapy, per se, I’ve worked with many therapy clients to help them find or create meaning in their lives. It can be a life-or-death matter with people who are suicidal.

I initially saw existentialism as grim and forbidding: if there’s no extrinsic Meaning to existence, then all we can do is to sweat along with Sisyphus, acting as if there was meaning to our lives. But now I see the richness of choice, where I once saw austerity. Existentialism gave me a philosophical context for the I-Thou encounters of psychotherapy. We all have a need for our lives to mean something; but we needn’t rely on “God’s plan,” as taught by this or that religion, or on promises of eternal life, to find meaning in our lives.

If you want to learn more about existentialism and the colorful characters (Jean-Paul Sartre, Simone de Beauvoir, as well as Camus, Heidegger and Merleau-Ponty) who formulated its principles, I recommend Sarah Bakewell’s highly-readable At the Existentialist Café: Freedom, Being and Apricot Cocktails. I’d never have guessed that phenomenologist Maurice Merleau-Ponty was good at dancing the Jitterbug.

Suicide prevention

Posted in Humanistic Psychology, philosophy, psychology, psychotherapy, suicideLeave a comment

While the act of suicide is sometimes a long-considered, planned option which nobody can prevent, most suicide attempts are impulsive. According to one study, approximately one quarter of the people who try to kill themselves do so within five minutes of their decision to attempt suicide. Only a small fraction of people who survive a suicide attempt go on to die by their own hand. Throughout my career as a psychologist, I assessed many people shortly after a suicide attempt. A question I always asked of them was, “Are you glad that you’re still alive?” Almost all of them were glad that their suicide attempts had failed. I concluded that most suicide attempts are mood-specific behaviors, often involving intoxication on alcohol or other drugs. Once their mood changes, or they sober up, they no longer want to end their lives.

While in grad school, I volunteered as a telephone crisis hotline worker. I was trained to talk to people who were in crisis, to keep them from engaging in attempts to harm themselves or others. From early in my clinical practice I was called on to evaluate the suicide potential of clients. I learned that many people who attempt suicide are ambivalent about living. “To be, or not to be; that is the question.” At the core of this ambivalence is the issue of existential meaning.

One of the major existential therapists of the twentieth century was Viktor Frankl, an Austrian psychiatrist that I’ve written about in previous posts. His book Man’s Search for Meaning was based on his experiences as a survivor of a Nazi death camp. He observed that in such a hellish environment, those who fought to live were people who had a sense of meaning in their lives. He called his method of psychotherapy logotherapy (logos means “reason” or “plan” in Greek), and his therapeutic approach was to help patients find, or create, meaning in their lives.

Lives bereft of meaning are empty lives, but sometimes the vacuum can be filled. Although I was able to help some suicidal clients to find something to live for, one of my severely depressed therapy clients died by his own hand. It was the worst thing that happened in my career. I really liked “Allen,” saw strengths and personal qualities that he couldn’t see, and worked in therapy to help him find reasons to go on living. I saw him on Wednesday afternoons, and he always kept his appointments. When he didn’t come in one Wednesday, I immediately called his apartment. When he didn’t answer after several tries, I looked up his address and drove to his apartment. When he didn’t come to the door when I knocked and rang the bell, I intuited that he was dead, inside. Sadly, this proved to be the case. It turned out that he’d bought a gun that morning, gone home, and used it. On a Wednesday, instead of keeping his therapy appointment.

I went through predictable self-recriminations and judgments. Could I have done anything differently that would have prevented his suicide? But I recognized this as a question that could never be answered. My colleagues knew that I was grieving as if I’d lost a family member, and supported me in my grief process. A peer review of my clinical records found that I’d done and documented everything properly, in terms of recognizing and dealing with Allen’s suicide risk.

A few years ago a close friend committed suicide. She suffered from bipolar disorder, and had confided in Maria and me that she would take a drug overdose in certain future hypothetical situations. She said it matter-of-factly, and wasn’t depressed when she said it. We knew that there was nothing we could say that would change her mind. We hoped that she’d never find herself in one of those imagined situations.

Philosophically, I’m torn on the issue of the “right to die,” because if suicide were to be legalized, it’s inevitable that some depressed people would convince themselves – or be convinced by others – that it was their duty to die, perhaps because they felt useless, or they wanted to leave an inheritance, rather than spend their money on their own medical care in old age. I’m no longer a therapist, but if I knew that someone was acutely suicidal, I’d do whatever I could to try to prevent an impulsive suicide attempt. (Many times, as a Designated Examiner in the Probate Court, I recommended involuntary hospitalization for suicidal people.) But once a person has suicided, I don’t make judgments about their decision to end their life. I don’t have the authority to judge.

Most people who end their own lives do it to escape intolerable pain – whether physical or emotional. Allen killed himself because he could no longer endure living with severe depression. His life had no meaning worth living for. I tried unsuccessfully to help him find reasons to live. Albert Camus considered suicide to be “the fundamental question of philosophy.” He wrote, “I see many people die because they judge that life is not worth living. . . . I therefore consider that the meaning of life is the most urgent of questions.”

Which takes us back to Viktor Frankl, who found meaning in the Hell of a Nazi death camp, survived, and went on to be a founder of the humanistic psychology movement.