How Does Your Therapist Perform?

Three weeks ago I was in Washington, DC for the First Summit on Diagnostic Alternatives. The event was sponsored by the Global Summit on Diagnostic Alternatives, a joint initiative of the American Psychological Association’s Society for Humanistic Psychology and the British Psychological Society’s Division of Clinical Psychology. Both associations have been leaders in challenging the monopoly of biologically-based diagnostic manuals such as the DSM and ICD to insure that people have more choices than a biological approach to emotional distress.

The August Summit may have marked an important turning point for what has been a loud outcry against the DSM-5. It was inspiring to be with serious and creative psychologists and others—discussing, strategizing and planning what hopefully will become a large-scale campaign involving many thousands. At the Summit we came up with our mission: “To develop, evaluate, advocate and disseminate alternatives to current diagnostic systems.” We formed working groups, which are already beginning their activities even as summer is not officially over.

You can read more about the Summit at http://dxsummit.org/. The entire site is a treasure chest of both scholarly and personal narrative essays and commentary that professionals and lay people can learn an enormous amount from and use as the basis for rich conversations with family, colleagues, clients and therapists. See also Eric Maisel’s terrific summary and expansion of his thoughts on the issue at his PT column,

Six weeks from now, about 450 people will gather in NYC for the 8th Performing the World conference. Diverse in so many ways, what they have in common is a belief in people’s capacity to create and see in new ways—and the fact that they’ve developed many ways to make this possible. They are performance activists, sharing their responses to the conference theme, How Shall We Become?

Why “How Shall We Become?” Because it captures the cutting edge question for our time.

That’s what I think every time I see or read the news. With revolution and counterrevolution raging in the Middle East, seemingly endless war laying waste to much of central Africa, economic collapse and stagnation in southern Europe, Eastern Europe fighting over borders, paralyzing political polarization and increased racial tensions in the U.S., increasing poverty combined with growing disparities in opportunity everywhere, and millions of people moving around the globe seeking a better life, “How are we becoming?” is the key to solving our mental health crisis.

This is because “what” we become—in therapy as well as in culture,politics,economics, education, medicine, and in how we live our daily lives and carry out our interpersonal relations —is shaped by the “how.” How we’ve been doing these things hasn’t worked. That’s where performance comes in, as the harnessing of the power of people to create new ways of relating, new ways of feeling, new ways of learning, new kinds of institutions—new possibilities of all sorts.

This sounds like great mental health practice to me! And I know from the previous seven Performing the World conferences that it’s an eye-opening and incredibly inspiring experience for psychologists, social workers, therapists, counselors and all mental health workers, especially those who are unhappy and disillusioned by what their jobs have become under the medicalization of their fields. And yet, they remain the minority at Performing the World.

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Art Therapy + CBT Treats Panic Disorder–Maybe

The Scream

 

Recently, the website Anxiety.org News announced that, “Art Help Treat Anxiety in Panic Disorder with Agoraphobia.” Because I am a strong believer in the self-regulating possibilities of art-based intervention, I am always excited to see a headline like this. It also makes good sense that pairing art therapy with a proven strategy for anxiety-related challenges like cognitive-behavioral therapy (CBT) (Malchiodi & Loth Rozum, 2012) could result in a form of effective treatment for panic disorder and generalized anxiety disorder.

Okay, before those of us who believe in the capacity of art therapy to support positive change get too excited, Anxiety.org News appears to have jumped the fence a bit in its bold headline. In brief, the article (Morris, 2014) cited refers to two case studies with participants including one who was diagnosed with panic disorder with agoraphobia (PAD) and the other with generalized anxiety disorder (GAD). A seven-session program (based on Marchand, 2007) was designed to include CBT principles such as psychoeducation, breathing training, cognitive restructuring, exposure and other accepted strategies. “Art-based therapy” was designed to complement these approaches and to address the participants’ symptoms. Using an A-B, single subject design, in the case of the participant with PAD, results indicated statistically significant reductions lower levels of panic frequency. In the case of the participant with GAD, the decrease in general anxiety was marginally significant.

So with a sample size so limited, why even discuss these findings? I believe this study is worthy of discussion for several reasons. First, one of art therapy’s strongest potentials is in the area of self-regulation and affect regulation. It is known from repeated studies involving stress reduction and repeated reports from participants in art therapy that there is a self-regulating impact achieved through specific art making experiences. Additionally, studies involving a combination of interventions such as mindfulness and art therapy (Monti et al, 2006) support the idea that combining art-based therapy with other approaches may be make a good thing more effective. For example, research on mindfulness-based art therapy underscores that it may reduce perceptions of fatigue and increase a sense of quality of life, two aspects relevant to an individual’s ability to self-regulate.

Perhaps these sample-limited research findings highlight two other important aspects. Art therapy research continues to be a challenge to the field, with limited participants and randomized clinical trials; fortunately, the author of this current study has published the procedures used in the course of treatment, thereby making this study replicable by other researchers. Finally, on a practitioner level, I was reminded that what often makes what can be a rather dry intervention like CBT more palatable is the value-added aspect of creative self-expression. Anecdotally, I can say that it is a lot easier to get the individuals I see in therapy to comply with their “CBT homework” if I infuse some relevant art making or visual journaling into the mix. In essence, art therapy not only helps people challenged by anxiety express their experiences, but it also supports the sensory-based understanding of how both the mind and body respond to stress. To quote Carl Jung (with my additions), “The hands (creative process of art making) will often solve the mystery that the intellect (cognition) has struggled with in vain.”

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Happiness With Others 10: Leave A Trail Of Happiness

A husband-and-wife seek out a counselor after 45 years of marriage. The counselor asks them what is the problem. The wife goes into a tirade, listing every problem they have ever had and all the 45 years they’ve been married. She goes on and on.

Finally, the counselor gets up, embraces the woman, and kisses her passionately. She sits stupefied.

The counselor turns to the husband and says, “That is what your wife needs, at least three times a week. Can you do that?”

The husband thinks for a moment and replies, “Well, I can get her here on Mondays and Wednesdays, but on Fridays I play golf.”

As this joke suggests, we carry into each of our people encounters an opportunity to either amplify or diminish the happiness of others. Imagine the trail of happiness this husband could have left had he bothered to show his wife, everyday, how important she was to him.

But, it stretches beyond just enhancing the happiness of others. You see, people remember how we make them feel long after they forget what we say to them. By consciously and purposely leaving a trail of happiness wherever we go, we create the conditions to magnify our happiness as well. We….

Studies show that people who leave a trail of happiness are indeed more happy themselves. They keep their eyes are open to the gifts they can deliver to other people in their lives. They extend this beyond their family to people they encounter in the most ordinary of situations – the clerk at the pharmacy, the ticket agent at the airline counter, the waiter who serves their dinner. They don’t do it to manipulate other people’s approval, but out of an overflowing sense of generosity and gratitude.

Like the other happiness-producing practices I have offered in this blog series, Happiness on Purpose, anyone can cultivate the trail of happiness practice. It just takes your willingness to become aware of the opportunities that exist to do so and a commitment to practice till you develop the habit. Once you habituate this practice, just watch your mood rise, your pleasures multiply, your happiness elevate.

Live It

Here are a few things you can do to leave a trail of happiness. Start these practices today. Fake it till you make it.

1. Act local. I have this theory that, if everyone in the world contributing each day to the happiness of those within their immediate family, we’d transform the world. So, start at home. Make a conscious effort to compliment, affirm, or reinforce each of the people you live with, each one of them at least once each day. Observe how they react and enjoy the pleasure you give them. As a bonus, enjoy it when they start reciprocating in-kind, that is, if you sustain your practice for a couple of weeks.

2. Thank you’s. Say “thank you” as often as you can – to family members, to friends, to coworkers, to casual acquaintances, to service people, to whomever. People appreciate the recognition, and they often respond in kind, enhancing your own pleasure quotient. Moreover, be alert to the kindness and courtesies we receive from others can keep us positive, appreciative, and hopeful, all bedrock perspectives necessary to experience our own daily happiness.

3. Stay connected. It is oh-too-easy in this busy life we lead to let relationships with friends and relatives slide. What a trail of happiness we can leave – and receive – when we make a point to keep connected with these special people. Call, email, visit these people on some regular schedule. By doing so, you not only bring happiness into their lives, but put yourself in a position to be pleasured as well.

4. Volunteer. I remember the pleasure I got from delivering Thanksgiving turkeys to needy families when in high school. One of my close friends sponsors a 5K run each September to collect money to help educate the children of wounded vets; he practically glows that time of year despite the hard work involved. Friends, colleagues, and even patients of mine reported how rewarded they feel when they do volunteer work at soup kitchens, the SPCA, homeless shelters, and the like. In addition to the benefits these type activities give to others, there is no calculation the amount of personal satisfaction one gets as a giver.

5. Be there. Nothing communicates love and appreciation more than just being there for another person at significant times in their lives. These can be happy times, say birthdays, weddings or anniversaries. Or, they can be times of adversity, such as the death of a parent, when one goes through a relationship break-ups, or perhaps when ill. You don’t need to do more than just be there. You will be appreciated, you will most likely earn this person’s loyalty, and, yes, you can feel proud of what you’ve done.

Going Forward

This blog concludes the group of ten I have devoted to strategies to increase your experience of happiness with the people of your life. In addition to Leave a Trail of Happiness, the other nine included:

(1) Practice premeditated acceptance and forgiveness;

(2) Take nothing personal;

(3) Be generous of spirit;

(4) Don’t be needy;

(5) Expect misbehavior;

(6) Choose friends and lovers wisely;

(7) Be a generous giver;

(8) Listen, listen, listen; and

(9) Practice win-win.

The more you integrate these ten Happiness With Others strategies into your life, the happier you can expect to be. Spend an hour or two reviewing all ten of these blogs. Decide which ones would be of most benefit to you. Put them into practice in your daily life. See the results in your happiness quotient.

Starting in my September, 2014 blog, I will devote the next ten months to sharing strategies to be happy with your life in general. I welcome you back, with the hope that these new blogs, plus the ones already posted, will contribute to the happiness you want and deserve in your life.

Until then, with healthy, happy, and with passion.

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Diagnosing Depression In The Wake Of Robin Williams’ Suicide

The importance of diagnosing depression has been highlighted in the wake of Robin Williams’ suicide. While most discussions, articles, and media outlets focus on the value of diagnosis, there are two sides when considering mental health diagnosis – one that sees it as “the answer” and another that questions the mainstream paradigm in terms of its usefulness, effectiveness, and the harm it may cause. Both of these sides are critical; both sides together create a whole picture. Here are the pros and cons of diagnosis:

 

Pros: The Light Side of Mental Health

Diagnosis

Being able to name and diagnose symptoms may be the first step in healing; for some, it can save their lives. From the perspective of mainstream psychology and psychiatry, as with most medicine, there is no possibility of proper treatment and symptom relief without categorizing symptoms in a way that helps understand the underlying pathology and that allows clinical research to determine the effectiveness of various treatments.

Several individuals I spoke with highlighted the value of diagnosis. One said, “For me a formal diagnosis was a godsend really. It provided an explanation for what was happening to me and opened up opportunities for treatment and medication that are just not available without a psychological diagnosis.” Another said, “For me, getting diagnosed with and medicated for depression and anxiety probably saved my life.” Clearly, the value of diagnosis is not to be taken lightly.

Diagnosis can protect people from ignorant criticism, projection, and shame. According to Professor Richard Bentall, Ph.D., and Nick Craddock, M.D. a diagnosis “can reduce stigma by explicitly acknowledging the presence of illness (and, thus, that the feelings or behavior cannot be dismissed as character weakness or bloody-mindedness).”

In the words of one woman I spoke with, “It let people know that I was not lazy, stupid, bizarre, etc.” A diagnosis can be akin to saying “There is nothing wrong with you as a person morally or intellectually. I see you’re not simply resisting acting functionally or appropriately.”

Diagnosis can legitimize peoples’ symptoms, pain, and suffering. When people “know what is wrong” by having a diagnosis, they often experience significant relief, understanding, and compassion for themselves. A diagnosis removes the mystery of their symptoms, encourages them to take themselves seriously, and lets them know that they are not alone – others suffer similarly.

In the words of one person I spoke with, “Diagnosis in a way legitimized my struggles. It was a real thing!” Another person said, “Finally, I understood so many of my behaviors that have always made me feel misunderstood my whole life.” A third person told me, that her brother’s diagnosis was freeing “because of identifying that there are a lot of other people like him: weird, awesome and sometimes hurting, too.”

 

Cons: The Shadow Side of Mental Health Diagnosis

Labels marginalize people, treating them like they are broken or not normal. In addition, these labels get internalized in a way that injures the way people see themselves over time. Diagnosis creates labels that can stigmatize individuals. Stigmas are hurtful stereotypes causing people to be viewed as different from others in ways that are undesirable and shameful, reducing them from a whole and worthy person to a tainted, discounted one.” [1] Research tells us that these stigmas also lead to separation, status loss, and discrimination. [2] Specifically, being labeled “depressed” causes some people to think we are unreliable, unstable, untrustworthy, and even dangerous. Further, research by the National Institute of Health found that diagnostic labels get internalized leading people to see themselves in these same negative ways.

Making matters worse, Jerry Kennard, Ph.D. warns that, “The label itself becomes self-fulfilling and can bias the way clinicians and the public see the person. Ordinary aches and pains, grumbles or personal setbacks, may seen as symptoms of the disease. Even the patient can fall into the trap of behaving in ways they think are expected of them.”

Diagnosing individuals creates an “identified patient” to be treated and fixed dismissing the significant family, group, and cultural conditions that are also responsible for the symptoms and require treatment. Most healing paradigms focus on diagnosing, understanding, and treating individuals. However, while some individuals suffer certain symptoms more than others and need more care, this approach can dismiss the role played by other people, communities, or cultures. For example, individuals who are more sensitive to being affected by abuse, toxic atmospheres, or hurtful cultural biases are more readily viewed and labeled as sick while the families, organizations, or cultures they are reacting to are more likely to be viewed as healthy and remain untreated.

Salvador Minuchin, founder of Family Systems therapy, enlightened a generation of therapists finding that the children he saw were symptomatic not because they were sick but because they were more apt to express their family’s problems. While those children were the “identified patients” – seen as sick and sent for treatment – actually it was the whole family that was ill. [3] Identifying one person as the “patient” not only marginalizes them, causing them to feel responsible for the family’s troubles, but it ignores a more complete understanding of the illness and how to treat it.

Similarly, some indigenous cultures consider the individual who expresses a symptom to have a special gift or sensitivity for expressing something that belongs to the tribe. From this perspective, folks who suffer mental illness are bearers of information and even healing for their families as well as for the larger culture and the planet. From this point of view, we are responsible for treating those who bear these symptoms as teachers, healers, and messengers of the early warning signs about a collective illnesses requiring treatment in all of us. This could lead us to not only think “How could we have helped them? What were they hiding? What was wrong with them?” but also ask these questions of ourselves.

African shaman Malidoma Somé, Ph.D. puts it this way: “What those in the West view as mental illness, the Dagara people regard as “good news from the other world.” The person going through the crisis has been chosen as a medium for a message to the community that needs to be communicated from the spirit realm.”

Diagnosis supports a “fix” mentality that ignores deeper processes in the background, a process that often leads to the discovery of gifts, life changes, and the uniqueness of the person.  When we look at a person as if their symptoms indicate that something is wrong with them we can neglect to see what is “right” or intelligent about their symptoms.For example,Somé noted that a person was sent to a mental institute for “nervous depression” was exhibiting the same symptoms he saw in his village. What struck Dr. Somé was that the attention given to such symptoms was based on pathology, on the idea that the condition is something that needs to stop. This was in complete opposition to the way his culture views such a situation. As he looked around the stark ward at the patients, some in straitjackets, some zoned out on medications, others screaming, he observed to himself, “So this is how the healers who are attempting to be born are treated in this culture. What a loss!”

Not all depressions are the same; treating them as such could be ineffective at best or harmful at worst. While the label “depression” creates the sense that depression is one kind of difficulty requiring anti-depressants as the treatment, not all depressions are the same and thus, “anti-depressing” may not be the most effective form of treatment. For example, many people describe depression as a feeling or energy of going down. That person may slump in their chair, their tone of voice my trail off, their head my hang a bit downward or to one side or the other. In these cases, it is sometimes helpful to support a person to “go down” – relax further, surrender, let go, or even lie down and close their eyes. When they do this, some people find deeper feelings that they were unaware of (e.g., resentments, a sense of floating and ease, tiredness for living the life they are living) or values that are being unlived as they try to cope with a more “normal” life.  Treating this kind of person as if they need lifting up or anti-depressing, can miss the meaning behind the depression and the direction they need to go in order to get sustainable relief. On the other hand, some people describe depression with anger in their voice. They sound pissed off at themselves and their lack of energy. In some cases these people are putting themselves down or are being put down by others, a cultural norm, or a group. Unlike the example above, these people may be more served by accessing their “angry energy” in order to fight against this kind of bullying. In this way their “angry energy” is an attempt to anti-depress.

While drug treatment for mental illness can be healing and save lives, it can also be ineffective and unsafe for patients. Research in the field of psychoactive drugs, including those used to treat depression, is regularly tainted by the financial conflict of interests of those who benefit from the pharmaceutical industry. The Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice asserts that, “Individual and institutional financial interests may unduly influence professional judgments… Such conflicts of interest threaten the integrity of scientific investigations, the objectivity of medical education, the quality of patient care, and the public’s trust in medicine.”

For example, we know that data for drugs prescribed for depression are skewed because unfavorable results regularly don’t get published. Research findings are withheld so frequently that while certain drugs are deemed safe and effective, a more thorough review of the research found the risks outweighed the benefits for almost all antidepressants studied. “Not publishing negative results undermines evidence-based medicine and puts millions of patients at risk for using ineffective or unsafe drugs.” [4] Research published in the New England Journal of Medicine made similar findings; they assert, “Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients.

 

Conclusion: Both Sides! Now!

A more fair-minded dialogue is needed regarding the diagnosis of mental illness, in particular depression. While some are for and some against diagnosis and medical treatment, neither point of view ought to be dismissed. The diversity in people’s experience of depression as well as the situations, families, and cultures in which they live calls for a diversity of understandings and treatments. Some lives are saved by diagnosis and psychopharmaca. Some people find healing by discovering meaning in their symptoms. Some find relief and change in the healing hand of a friend or healer. And many are assisted by others’ efforts to make changes in their families, communities and cultures. And, of course, some symptoms are best address by the blending of these and other approaches.

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Are You Shadow-Shocked?

Increasingly I sense that there are two kinds of people, people who are skeptical about their own motives and people who aren’t.

The people who aren’t are the kind who, when challenged always say in so many words, “Oh no, my motivations are pure.” And you can tell that they really believe it.

I’ve called it “talkiswalkism” elsewhere. “My positive self-reporting talk is always an accurate description of my walk, my real behavior.”

I’d argue that people who can only speak positively of their own motives are shadow shocked. Like Shell Shock, traumatized by a bad experience with seeing their dark side. Post-traumatic introspection syndrome.  Experience of their own shadow or dark sides is repellant to them.

These people duck when they see their shadow like Punxsutawney Phil, the groundhog of Groundhog Day. And as with Phil, whose ducking predicts more winter, you can expect a cold response to any further challenges to them.

There are lots of reasons to duck one’s shadow or dark side.  Like all evidence of room for improvement, it can be dispiriting, immobilizing, discouraging. If you think you’re further along in life and you get evidence that you’re not, it can make you want to give up trying, or at least make you want to dismiss the evidence.

If you cringe every time you see your dark side your strongest impulse is to stop seeing your dark side.

The default for humans is to find ways around see our own dark side. Seeing other people’s dark sides, yes–that’s easy, fun, a bonding experience when people talk cattily about other people’s dark sides, present company excepted.

“Boy was Jim being a jerk the other night, right?”

But seeing our own shadow, that’s another thing.

To be able to look at your own shadow unflinchingly takes a lot of practice. The only treatment I know is desensitization therapy, see a little bit of shadow, laugh nervously, breathe, see a little more shadow, breathe—sooner or later you can get to where you can breathe seeing lots of your own shadow, including your dark side aversion to seeing your dark side (my mantra is “no matter how hard I pursue the truth about me, it will never catch me.”)

I think desensitization to one’s dark side is the most substantial benefit of long-term therapy, and of philosophy too, especially the two in combination:

Philosophers find their true perfection

Knowing the follies of humankind

By introspection.

The combination enables you to see your dark side without assuming you’re exceptionally shadowy.  We all have one, some of course have a darker side than others, but the basic habits of dark sides are pretty much the same in all of us.  Introspection and some philosophy about why we all would have dark sides enables us to feel at home in human nature.

Now you’ll notice that I said there were two kinds of people, those who can look at their dark side and those that can’t and then immediately tipped my hand that I think the kind that can are better.  The others need therapy, right?

And you can guess therefore what kind of person I’d claim to be, right?

Whether I am or not, I might be the last person to know. That’s the thing. I could claim I can look at my dark side but not really be able to. There are so many ways to not look, including claiming to look but not really looking.

You get this one from people who declare themselves receptive and even give a moment’s lip service to challenges. “I hear you, but…” and then immediately go into defense mode, or the problem is you mode or really, any distraction. Like I say, “No matter how hard I pursue the truth about me it will never catch me.”

I might also simply be suffering from “be like me syndrome.”  I’ve invested a lot of time in looking at my dark side (a side effect of over 2,000 hours of on-the-couch Freudian therapy starting at age 8) so I assume everyone should look at their dark side, right?

I could make a case why being able to see your dark side is good for us. I have elsewhere. Most of the mega-jerks this world has known are people who couldn’t doubt their own motives or see their shadow.  Every one of them thought they were on the side of truth justice and a better world.

But some of our heroes weren’t great at seeing their potential for bad motives either. Steve Jobs from what I understand, but others too.  If you’re fighting for justice against considerable opposition, you can’t afford a lot of doubt.  Steel yourself, eyes on the prize and don’t be distracted by challengers pointing out your potentially dark motives.

Which is one of the great benefits of not being able to doubt your motives.  In general you can plough through a whole lot more resistance. What you plough into as a result is another matter.

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