Thursday, September 28, 2017

An American Story of Pain

He could not have known that bishops and kings had a hand in this. That they set the stage for the paranoia, the violence, the stoicism that were handed down to him through a dozen generations since leaving Ulster. He lived like an island and felt no longing for comrades or even blood kinship. As he lived this out he was blind to its source: privation, famine, religious persecution, stern resolve. And no time for beauty and kindness. They had hidden in the woods to worship and marry. They hid and ran and changed their identities in whatever way worked. They sold their labor in order to secure escape on a ship crossing the disastrous Atlantic. This ship carried orphans without a family name, still in hiding even then. Down, down through generations scattering down, down the spine of the Appalachians, looking for a peaceful hearth on a plot of land where they might be unmolested. Only, then, to recreate their circumstances over and over with too much drink, too much violence displaced on the women, children, natives, slaves. An anger boring down into their DNA, through the bishops and kings who toyed with the planted for land, greed, and power. He did not know this until right before he died. The family story, resurrected, reverberated around him but by then he was unable to to take its full measure. Or learn. Or seek forgiveness. He passed on never knowing why he did what he did, nor how descendants carried on the legacy still. Or that the young knew the story long before he did.

Sunday, July 30, 2017

Fixing the Fixes

In the therapy business relationships are where it's at, where all the action is. Many may be searching for quick and easy fixes, and certainly the airwaves are selling this pharma-illusion, but this is clearly not where the real action is aside from its relevance in a few circumstances. Roger Greenberg (2014) has cogently articulated the many ways medications fall short or don't actually do any heaving lifting at all. He describes outcomes which are essentially based on what people believe, expect, and want to happen, oftentimes all in the absence of making any real or lasting changes in behavior or circumstances. Which is uncomfortable at best.

Real and lasting change involves discomfort and human beings, being the social creatures we are, need contact with and support from other human beings in that process. That is the true gift of psychotherapy, especially when accompanied by an accurate ear and posture toward the sufferer. I don't believe that any technological advance will ever change this reality, or if it does we will have become automatons. In this world full of strife and fear we all crave connection more than anything else, at least that has been my professional experience.

But searching for, establishing, persisting with, and paying for this connection (even if only with our time) is costly. It is an investment of monumental proportions. And so is its outcome: positive changes which stick and further, lead to other positive changes and, ultimately, more contentment and joy.

It is exactly like putting a new roof on your house as opposed to patching the leaks. When you are tempted by patches, DON'T BUY THEM, no matter what kind of window dressing or "science" is wrapped around them. Invest instead in yourself and those around you.

Thursday, June 15, 2017

A Karmic Dream

He described it as follows.

I was in an amusement park, but it was all in rubble. It looked like a bombed out town in Syria. I wandered around and marvelled at the destruction, trying to figure out what rides the remains would have been. There were no people, there was no color. Everything was gray and rocky and dusty. It was once a place of joy; now the place reminded me of what hell must be like.

I saw a place that once must have been an office, or maybe the entrance to a big ride. The roof was still intact but inside it too was in rubble. I walked in and saw my father there, cutting the hair of old men with a pair of clippers. There was a single light bulb hanging down from the ceiling, casting a dim light. The men in the shadows were tired looking, disheveled. They looked haggard, lost, and lonely. So did my father. He looked at me briefly, then went back to cutting hair. His eyes were dead. He had no regard for my presence. I understood that he was gone, not just in the physical sense, and that he would not come back. But somehow I was not sad.

I woke up thinking I was glad this was no longer in my head. Now it had coalesced and bubbled up in and out of my mind. I admitted to myself that it was an accurate representation of his life. This dream came to me two years after his death. I am moving on.

Thursday, May 25, 2017

Success or "Gradual Disintegration"?

Mental health issues may arise from a great many sources. An important source is the situation in which we find ourselves, or our total context, in particular as it interacts with a current developmental stage of life.

We often find ourselves in novel circumstances, something we have never faced before, especially when we are challenged or stressed. Major life transitions are certainly like this, like our first serious relationships, marriage, employment, having children, the loss of loved ones. And college! College is itself an extended period of incubation and growth, full of excitement and many challenges. Depending on our developmental history we are all in different stages of readiness for this enterprise.

Ideally we will be prepared, at least in some rudimentary fashion, through having had experiences which approximate the transition. Families can certainly provide for these and many do. It is also true that many do not. It is further true that, sometimes, there may be nothing that can prepare us for the stresses we face, whether in college or elsewhere. That's just the way life can be at times.

So imagine that you find yourself in an overwhelmingly stressful transition. You may learn to adapt, gaining the skills you need to adjust and succeed. You may do this through trial-and-error learning, or you may deliberately catch it early and seek more efficient forms of learning, maybe by visiting your campus counseling center or obtaining other forms of assistance. I vote for counseling!

Or worse, you may founder. There is some evidence at the both the undergraduate and graduate levels that many students experience a gradual disintegration in functioning and subsequently take a break or withdraw altogether. For some this disintegration may be due to an underlying mental illness which had not fully emerged prior to the stress. For others the symptoms are a reflection of lack of preparedness which can be remedied by focused short term interventions in therapy and other support. Data which indicate rapid equilibrium and restoration in functioning after, say, five or so therapy sessions, supports the latter conclusion. This pattern can be seen on a regular basis in campus counseling services but one rarely hears about it.

The difference between the two patterns is critical, of course. This is one reason that accessing campus counseling services is so crucial, especially in the early stages of a stressful transition. Such services can determine what type of interventions are best suited for the emerging difficulties, limit negative outcomes, and increase the probability of continued success.

Saturday, April 29, 2017

Listening to Life

Life itself tells us everything we need to know.

Through conditioning all of us bring perspectives to which we selectively attend, biases, habits of thought, and behavioral reflexes, born of the dynamics in which we developed. Many, if not most, of these probably work well at times, in terms of facilitating our needs to cope with and adapt to life's slings and arrows. This is generally why we persist in them over a long period of time.

But, inevitably, they will fail. This happens when into our lives comes novel or stressful situations we have never faced before. These may be dramatic, such as getting very sick, fired, arrested, or divorced. But mostly these are rather ordinary except that they are new to us. Facing loneliness, forming and, more importantly, maintaining new relationships, choosing a major or career, managing both freedom and responsibility, and separation from sources of support are all examples of the ordinary with which college students in particular often struggle.

Often we will turn to tried and true responding to these circumstances. If this responding matches the current situation and is effective, things will tend to go smoothly and life goes on. When the opposite is true, disruptions will occur and reflect back to us, like ripples in the pond after we cast the stone. Except that many times these ripples become waves, even the occasional tsunami. Those around us and the systems in which we live will simply let us know that what we are doing isn't working. Negative energy will return to us in the form of undesirable outcomes. A break up. Failing grades or suspensions. Conduct hearings. Rehab or jail. Rejection or isolation from others. And symptoms, plenty of symptoms. Mood, cognitive, and behavioral dis-orders are expected outcomes for failing defenses, coping styles, and habitual responding patterns.

In response to such outcomes we may set off in a search for understanding what happened. We may seek complex, erudite answers in the cosmos, or from clergy and mental health professionals themselves. A fancy explanation in the form of a diagnosis, over which we have no apparent control or responsibility can be lovely in terms of explanatory power. Don't get me wrong, this may in fact be relevant for some. But this Occam's Razor applies to all: listen to what life is telling you, and adjust accordingly.

Humans are social creatures and we all function in systems and contexts. Understanding that placing negative energy into our context, through acts of omission or commission, causes equal and opposite reactions is central to good mental health. This is a simple and enduring truth the awareness of which, if we are tuned in well, can reduce or prevent a significant amount of stress and life problems.

All we have to do is listen.

Sunday, March 26, 2017

Context Can Beat Biology

Though popular media, advertising, and Big Pharma would have you believe otherwise, evidence for the primacy of context in emotional well-being continues to pour in. Context refers to considerations of a person's entire situation, including both internal and external factors, strengths and limitations, skills and deficits, in determining both well-being and the lack thereof. We are learning more about the power of harnessing processes humans already have to overcome their life problems.

It is as if people already know this intuitively. Recent studies demonstrate that those in treatment are more likely to refuse or not complete it if it only involves drug therapy than talk therapy alone, by a factor of more than two. Authors believe this pattern occurs because participants understand the non-biological components of their concerns. It has already been widely reported that talk and drug therapy combined is better in some cases, and talk therapy alone is superior in others.

Emphasizing notions of human context and inherent strength, other authors posit that even psychotherapy should not be thought of as a cure, just as medicine should not, but rather a method of change rooted in perspective-taking and philosophy of living. Highlighting the differences among the approaches, Kev Harding states:

“The differences between the idea that ‘mental health problems’ have their roots in ‘faulty genes’ etc. to be somehow (and implausibly) ‘managed’ or ‘cured’ by psychiatric medication, CBT, or a bit of both, in contrast to the idea that such problems have their roots in a person’s life experiences, circumstances, societal expectations, and do not necessarily mean that there is something inherently ‘wrong’ with the person in distress.”

For further reference, see my previous posts concerning the developmental and contextual origins of many issues faced by college students in particular. My experience has been that, in many cases when medicines are useful, it is largely because it enables people to be more open to benefiting from new experiences and perspectives.

On the micro level of skill development, many studies have demonstrated that learning even just one new skill, such as mindfulness or anxiety reduction, can lead to dramatic improvements in a host of human life problems. In one study it was found that learning how to reduce rumination, or "boiling your cabbage twice" as the Irish proverb says, resulted in an 80% recovery rate for depression after six months. That's exciting!

It's all about the power of people, people. To a significant degree, the solutions are already inside us.

Saturday, February 18, 2017

Alternative Views on Addiction

There is much more to the addictions than the disease model might suggest. This model tends to devolve dialog into "it's in the brain" or "it's in the genes" syllogisms. End of discussion.

But other aspects of behavior influence the development of substance abuse problems. We look art two interesting set of behaviors below. These two may interact with each other in interesting ways, but that remains to be established.

In the first view, typical deficits in many adolescents are seen to lead to impulse control problems, which in turn is related to substance abuse. The review author notes that "Drug use in adolescence is often linked to later substance-abuse problems. The new study finds that key risk factors include a combination of weak working memory and cognitive processing. These deficits lead to poor impulse control." It is suggested that programs which help adolescents improve on their impulse control skills may represent the best methods to reduce future substance abuse problems.

In another view, it is hypothesized that the addictions are at their heart an inability to connect with others. Here, it is posited "...that addiction is not about the pleasurable effects of substances, it’s about the user’s inability to connect in healthy ways with other human beings. In other words, addiction is not a substance disorder, it’s a social disorder." In this way substance abuse is a vehicle of escape from social realities which have become aversive to the user. Of course this may lead to isolation which will not likely improve the situation.

When we take into consideration that alcohol abuse may be both a cause and consequence of child maltreatment, it is not difficult to surmise that such victims, who sooner or later will likely exhibit impulse control issues, are also motivated to reduce human contact and may find substances appealing for this reason. Not to mention the role that anger may have in their lives.

This view is infinitely richer, and suggestive of more complex interventions, than the disease model of addiction. Anything that is more complex is more difficult to implement and fund, and that may be the real moral of this story. But successful approaches are worth this effort.

Sunday, January 29, 2017

Strange World: Two Perplexing Trends in College Mental Health

In its most recent annual report, The Center for Collegiate Mental Health highlighted two disorienting facts from their trend data over six years:
"1. Lifetime prevalence rates of “threat-to-self” characteristics (nonsuicidal self-injury and serious suicidal ideation) increased for the sixth year in a row (page 5). This persistent trend, combined with dramatic increases in demand for mental health services documented in last year’s report, confirm that counseling centers are evaluating and managing increasing numbers of students who may also represent “threat-to-self". 
2. Despite increasing demand marked by risk, lifetime prevalence rates for prior mental health treatment remain stable for the sixth year in a row (page 4). One in two students that sought treatment has had prior counseling, one in three has taken prior medications, and one in ten has been hospitalized. The six-year stability of these trends suggests that students referred for counseling, do not have increasing rates of preexisting mental health concerns. 
4. Anxiety and depression continue to be the most common presenting concerns for college students as identified by counseling center staff (page 9). In addition, students’ self-reported distress levels for depression, generalized anxiety, and social anxiety continue to evidence slight but persistent increases each year for the past six years (page 6). Other areas of self-reported distress (academic, eating concerns, hostility, substance abuse, and family distress) have remained relatively flat or decreasing. Thus, anxiety and depression are not only the most common concerns, but students’ distress in these areas appears to be growing slowly while other areas of distress are flat or decreasing.  These findings highlight the fact that not all aspects of mental health are worsening and that it will be important to better understand the role of depression and anxiety in college students."

The latter lifetime prevalence rate data are consistent with what has been reported in epidemiological studies both in America and Canada. It strongly suggests that the cause of the increasing rates of "threat-to-self" is not due to rates of pre-existing mental health issues. The report goes on to say that "growth" in mental health concerns is actually slowing but persistent in a few areas, and flat or subsiding in others, over six years. Taken together all of this suggests that other factors are at work in terms of self harm.

Threat to self or self harm, broadly defined, is the turning inward of distress. Key questions are 1) what is causing the increase in this distress if it is not pre-existing mental health concerns, and 2) why are students focusing inwardly in manifesting their distress? Clues are available in the "list of top concerns" data from the same report (page 10). First, suicidality is ranked 18th of 44 items by counselors choosing the top concern, while self-injurious thoughts or behavior is 24th. Thus, while these appear to be increasing, they are NOT anywhere near the top-most concerns, suggesting that actual risk is low and that other concerns need more attention. Looking at those top 24 rankings then, we find that 14 of them have an external or environmental influence, such as stress, family, trauma, and relationship problems. Stress is ranked number three among all items.

A hypothesis is that something is happening to students after they arrive on campus which exceeds their ability to cope, and they are unable to articulate this in language. As previous posts have communicated, some believe it is the emergence of serious mental illness conditions that often appear in that age range (which so happens to benefit an industry). Some believe that higher education itself is too taxing and with diminishing benefit (which offers a scapegoat to the guilty). Others point to parents and families who fail to prepare their children for independence (which provides an easy target that exculpates the rest of us).

While each factor may account for some portion of the variance, I think each misses the big picture: modern life is becoming intolerably psychologically stressful. Yes I know that other generations faced dire circumstances and death and got through them with grit. There is no doubt that, at least for many, we have more resources and conveniences than ever. But that is not the point.

Today's youth do not have a clear path or ritual into independence and adulthood, and they are struggling to find meaning and define what success is for them while it seems so easily attainable by others. And the world is an increasingly confusing and frightening place. What we are seeing are reactions to an extreme form of impotence and frustration among our youth.

More on these subjects later so stay tuned.