Category Archives: Personal Reflections

Clinical Interviewing, Personal Reflections

On Psychiatric Diagnosis and Whether Donald J. Trump has a Personality Disorder

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IMG_3063Note — This is a three or four part series focusing on complexities of psychiatric diagnosis; then I ramble into an exploration of what specific psychological and interpersonal dynamics might be driving Donald Trump’s behaviors. This piece and the next two or three are a lead-up to an essay I’m doing for Slate Magazine.

Psychiatric diagnosis looks easy.

All you need is a diagnostic manual. In the U.S., you can use the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; published by the American Psychiatric Association) or the 10th edition of the International Classification of Diseases (ICD-10; published by the World Health Organization). Even easier, you can search for and find online diagnostic criteria for virtually every mental disorder. The power to diagnose is at your fingertips.

If you think your friend has panic disorder, you can type “panic disorder” into your favorite search engine, find the criteria, and confirm your suspicions. The same goes for diagnosing children. Finding the criteria for attention-deficit/hyperactivity disorder (ADHD) is simple. Of special convenience is the fact that if you look at the ADHD criteria, you’ll discover that nearly every child on the planet has ADHD. Odds are, if you look closely at the ADHD criteria, you’ll end up diagnosing yourself. I mean, who really likes waiting in lines?

Technically, you should study the different diagnostic categories and the various checklists of symptoms for each disorder, do a formal observation or interview with the person you want to diagnose, match their behaviors to the checklist, and come to your diagnostic conclusion. But we’re living in a fast-paced world where, like our president, whatever you think must be true because you thought it; never mind that you should recuse yourself from diagnosing your friends, your family, and yourself. Who has time to fact check? Besides, you can just ask, “Siri, do I have obsessive-compulsive disorder?”

Contrary to popular solipsistic fantasies and what you’ll learn from Siri, psychiatric diagnosis may look easy, but in the real world, it’s complex and sticky.

Not only are there 300 different diagnoses (and 947 pages in the DSM-5), many psychiatric conditions overlap, meaning one symptom could be associated with several different diagnoses. For example, having a depressed or irritable mood could qualify your or your romantic partner for bipolar disorder or various depressive disorders, but because bad moods are also associated with ADHD, oppositional defiant disorder, substance use disorders, and many different physical/medical conditions, you’ll need to assess for and rule out these other possible disorders. Then again, there’s the likely chance that you and your romantic partner are bugging the hell out of each other and so your depressed and irritable moods are simply a natural product of your poor judgment, incompatibility, or desperate need for couple counseling.

Sorting out diagnostic signs and symptoms is especially difficult because people will often intentionally or unintentionally minimize or exaggerate their symptoms, depending on the setting and their motivation. Think about your son. He’s a hellion at home, but when you take him to the pediatrician, you come unglued trying to tell the doctor about your hyperactive child. All the while, he sits there, hands folded like a little cherub. You leave the office with a new prescription for valium for yourself.

If you make an effort to go beyond using the diagnosis-is-easy approach, in the end, or in the middle, or somewhere in the diagnostic process you may find the symptoms have changed. You mother may have seemed bipolar and you were closing in on a diagnosis of intermittent explosive disorder for your father, but suddenly, right after you move out, their symptoms vanish. Or maybe they just aged and became more mature or maybe they got out of their miserable jobs, and consequently became less emotionally volatile? This is the nature of working with humans; as much as you’d like them to hold still for a clear snapshot, they move, their relationships change, their employment situation shifts, and you end up with what the venerable psychologist Paul Meehl might have called, a fuzzy notion, rather than diagnostic certainty. Looking back, Meehl might have added that diagnosis is also a sticky notion because, once applied, psychiatric diagnoses are difficult to remove. This is why psychiatric diagnosis is best left to trained professionals. This is also why professionals often get it wrong, and someone ends up labeled with a sticky diagnosis that follows them into the future despite new and contradictory diagnostic information.

As an example, many people and some professionals have concluded that Donald J. Trump has a mental disorder called narcissistic personality disorder (NPD). As satisfying as it might feel to diagnose Donald Trump with NPD, the NPD conclusion is erroneous on two counts. First, no one can or should diagnose Trump without conducting a diagnostic interview. Even then, diagnosing him would be difficult. As Allen Francis, Chair of the DSM-IV Task Force wrote, diagnosticians should “be patient,” because accurate psychiatric diagnosis may take five minutes, five hours, five months, or five years. In the real world of psychiatric diagnosis, accurate and useful diagnoses take much longer and are much more involved than a 5 minute armchair social media diagnosis. Competent and ethical mental health professionals always go beyond diagnostic checklists.

Now, don’t get me wrong, labeling Trump with NPD feels good and feels right. Check it out. There are many, many obvious examples of how Trump fits the NPD criteria. However, other than being fun, entertaining, and gratifying (not to mention offensive), the process and outcome of armchair social media diagnosis is neither fair nor honest.

Beyond simply matching DJT’s behaviors with the NPD diagnostic criteria, over the past two years, many articles and books have been written about Donald J. Trump’s mental health. For some odd reason, I’ve been preoccupied with reading many of these articles and books lately. Although not “fun” content, reading about DJT’s mental state was a welcome shift away from my first impulse after his election—which was to start reading about the death instinct in Freud’s Civilization and It’s Discontents. I’m having way more fun now.

For another odd reason, after reading about DJT’s mental health, I found myself fantasizing that I might have something to add to the conversation.

To be continued . . .

Counseling and Psychotherapy Theory and Practice, Parenting, Personal Reflections

Feeling Anxious? Learn the One and Only Method for Self-Regulation

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Back in 1980, one of my supervisors at Woodside Hospital in Vancouver, WA, gave me a big compliment. At the time, I was a recreational therapist in a 22-bed psychiatric hospital. In a letter of recommendation, the supervisor described me as having a special knack for translating complex psychological phenomena into concrete activities from which patients could learn. To be honest, I really had no idea what I was doing.

But I think he was onto something about me and my personality. I like to integrate, summarize, and boil down information into digestible bits. Sometimes I have to get the facts to play Twister to get otherwise incompatible perspectives to fit together. This tendency is probably why I’ve written textbooks on clinical interviewing and counseling theories.

Today, I’m tackling anxiety, anxiety reduction, and self-regulation. This feels more personal than usual, mostly because I’ve been dysregulated, more or less, since November 9, 2016.

After reading and thinking about anxiety and anxiety reduction for 30+ years, I’m strongly leaning toward the position that there’s only one, single, universal method to achieve self-regulation. The method is Mary Cover Jones’s counterconditioning. You probably already know that I think Mary Cover Jones is fabulous.

As a means of exploring this unifying method, I recently did a podcast on it with Sara Polanchek. I’ll write more later, but for now, if you’re interested, check out the podcast. It’s the latest episode (7/19/18 release date). You can listen on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

Or Libsyn: http://practicallyperfectparenting.libsyn.com/

If you do listen, please let me know what you think. That way I can continue with integration and synthesis by incorporating your thoughts into my thoughts. I’ll bet you can find many different ways to communicate with me.

If you don’t listen, no worries, I’ll just keep hanging out here in my personal echo chamber.

Clinical Interviewing, Personal Reflections

Mental Health or Mental Illness: Defining Mental Disorders

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East Rosebud

For a while, I’ve been engaged in a debate (sometimes just with myself) about the use of the term “mental illness.” [More on this at a later date]. Civil debates are good for the brain. There doesn’t have to be a winner or loser. Recently I remembered that we addressed this issue briefly in our 2017 revision (6th edition) of Clinical Interviewing. Here’s an excerpt, beginning on page 396:

Defining Mental Disorders

The concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations. From the DSM-IV-TR (American Psychiatric Association, 2000, p. xxx)

It’s often difficult to draw a clear line between mental problems and physical illness. When you become physically ill, it’s obvious that stress, lack of sleep, or mental state may be contributing factors. Other times, when experiencing psychological distress, your physical state can be making things worse (Witvliet et al., 2008).

Why Mental Disorder and not Mental Illness?

Many professionals, organizations, and media sources routinely use “mental illness” to describe diagnostic entities included in the ICD and DSM classification systems. This practice, although popular, is inconsistent with the ICD and DSM. Both manuals explicitly and intentionally use and plan to continue using the term mental disorder. From the ICD-10:

The term “disorder” is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as “disease” and “illness”. “Disorder” is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. (1992, p. 11)

The ICD and DSM systems are descriptive, atheoretical classification systems. They rely on the presence or absence of specific signs (observable indicators) and symptoms (subjective indicators) to establish diagnoses. Other than disorders in the F00-F09 ICD-10 block (e.g., F00: Dementia in Alzheimer’s disease, F01: Vascular Dementia, etc.), there is no assumption of any physical, organic, or genetic etiology among ICD mental disorders.

Consistent with the ICD and DSM, we don’t use the term mental illness in this text. We also believe mental illness to be a more problematic term than mental disorder. In fact, often we step even further away from an illness perspective and use the phrase “mental health problems” instead. However, in the end, no matter what we call them, mental disorders are fairly robust, cross-cultural concepts that can be identified and often treated effectively.

General Criteria for Mental Disorders

The DSM-5 includes a general definition of mental disorder:

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. (American Psychiatric Association, 2013, p. 20)

This definition is consistent with ICD-10-CM. Nevertheless, significant vagueness remains. If you go back and read through the DSM-5 definition of mental disorder several times, you’ll find substantial lack of clarity. There’s room for debate regarding what constitutes “a clinically significant disturbance.” Additionally, how can it be determined if human behavior “reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (p. 20)? Perhaps the clearest components of mental disorder include one of two relatively observable phenomena:

  1. Subjective distress: Individuals themselves must feel distressed.
  2. Disability in social, occupational, or other important activities: The cognitive, emotional regulation, or behavioral disturbance must cause impairment.

Over the years the DSM system has received criticism for being socially and culturally oppressive (Eriksen & Kress, 2005; Horwitz & Wakefield, 2007). Beginning in the 1960s Thomas Szasz claimed that mental illness was a myth perpetuated by the psychiatric establishment. He wrote:

Which kinds of social deviance are regarded as mental illnesses? The answer is, those that entail personal conduct not conforming to psychiatrically defined and enforced rules of mental health. If narcotics-avoidance is a rule of mental health, narcotics ingestion will be a sign of mental illness; if even-temperedness is a rule of mental health, depression and elation will be signs of mental illness; and so forth. (1970, p. xxvi)

Szasz’s point is well taken. But what’s most fascinating is that the ICD and DSM systems basically agree with Szasz. The ICD includes this statement: “Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here” (p. 11). And the DSM-5 authors wrote:

Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual . . . . (p. 20)

The ICD’s and DSM’s general definitions of mental disorder and criteria for each individual mental disorder consist of carefully studied, meticulously outlined, and politically influenced subjective judgments. Science, logic, philosophy, and politics are involved. This is an important perspective to keep in mind as we continue down the road toward clinical interviewing as a method for diagnosis and treatment planning.

Why Diagnose?

Like Szasz (1961, 1970), many of our students want to reject diagnosis. They’re critical of and cynical about diagnostic systems and believe that applying diagnoses dehumanizes clients, ignoring their individual qualities. We empathize with our students’ complaints, commiserate about problems associated with diagnosing unique individuals, and criticize inappropriate diagnostic proliferation (e.g., bipolar disorder in young people). But, in the end, we continue to value and teach diagnostic assessment strategies and procedures, justifying ourselves with both philosophical and practical arguments.

Some of the benefits of education and training in diagnosis follow:

  • Clinicians are encouraged to closely observe and monitor specific client symptoms and diagnostic indicators
  • Accurate diagnosis improves prediction of client prognosis
  • Treatments can be developed for specific diagnoses
  • Communication with other professionals and third-party payers can be more efficient
  • Research on the detection, prevention, and treatment of mental disorders is facilitated

Although we advise maintaining skepticism regarding diagnostic labels, having knowledge about mental disorders is a professional requirement.

It seems ironic, but sometimes labels are a great relief for clients. When clients experience confusing and frightening symptoms, they often feel alone and uniquely troubled. It can be a big relief to be diagnosed, to have their problems named, categorized, and defined. It can be comforting to realize that others—many others—have reacted to trauma in similar ways, experienced depression in similar ways, or developed similar irrational thoughts or problematic compulsions. Diagnosis can imply hope (Mulligan, MacCulloch, Good, & Nicholas, 2012).

 

Parenting, Personal Reflections, Writing

Everything You Already Knew About Sex (But were afraid to talk about)

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SistersI’ll never forget the night my sisters saved my life. I was 12-years-old. My sisters were babysitting me while my parents were out. They said, “Sit down, we’ve got something serious to talk about.”

I was a compliant little brother. But because my sisters enjoyed dressing me up like a girl, as I sat down, I was hoping I wouldn’t have to get all dressed up again. To my surprise, their serious topic had nothing to do with girls’ clothing and everything to do with what’s underneath girls’ clothing.

They pulled out a gigantic book. In our family, it was called the DOCTOR book; we only got it out when someone was sick. I started to worry, mostly because I wasn’t feeling sick.

They opened the book and showed me anatomically correct pictures of naked men and women. Then I started feeling sick. While looking at various body parts they explained the relationship between male and female sexual organs. I remember thinking “There’s no way this is true.” My sisters, one 17 and the other 14, suddenly looked much older and wiser. I quickly I was not the smartest person in the room (but I already knew that). They explained: “Mom says it’s Dad’s job to tell you about sex stuff. But Dad’s too shy to talk about it. So tonight, we’re telling you everything.” And they did.

At some point in their explanation that night they explained that a “rubber” was a condom and a condom was a method of birth control and that my penis could get big and send out little invisible tadpoles that could get girls pregnant. Suddenly, I understood several jokes that my fellow seventh graders had been laughing about the week before. My sisters were providing knowledge that was essential to the social life of adolescence. But maybe more than anything else, I remember them saying: “Sexual intercourse is very special. You only have sex with someone you really love.” That philosophy may not fit for everyone, but it’s worked out pretty well for me.

If you’ve got children, you should put your fears and shyness aside and directly discuss sex and sexuality with them on an ongoing basis. If you don’t, you can bet they’ll learn about sex anyway, indirectly and from other people, like their cousin Sal or a pornography website. Given this choice, most parents decide, despite their discomfort, to talk about sex with their children.

In contrast to what I got from my sisters, sex education in America is generally a crapshoot. With social media, the internet, and television’s preoccupation with sexual innuendo, it’s easy for children to absorb less-than-optimal sexual ideas. In a National Public Radio interview, the Pulitzer Prize winning poet, Andrew Hudgins spoke about his sex education from jokes:

“One of the things I talk about in the book [The Joker] is what I learned from the taboo subjects my parents never told me about: sex. So I learned about it from jokes and had to figure it out backwards. … It’s very much a hazard. And because you get a ton of misinformation, you get a ton of misogyny built into your brain at a very early age when your brain is still forming and it can cause long-term complications.” (from NPR interview, Weekend Edition, Saturday, June 8, 2013)

In contrast to Hudgins, I got lucky one evening 49 years ago. I didn’t get any misogyny built into my brain. Instead, I learned about sexuality and relationships from two people who deeply cared about me and whom I respected. I’d love to be able to clone my sisters into universal sex educators so they could magically educate all the boys in the world on how to respect women, which, in the end, is much more important than being able to accurately find a vagina in the big DOCTOR book of life.

Teaching children about sex should begin early. There are many natural opportunities for discussing sex with your children – including television, grocery store magazines, and, more often than we like, politicians who engage in questionable sexual behaviors. Other opportunities occur around ages four or five, when young children begin talking, sometimes excessively and inappropriately, about poop, pee, penises, and vaginas. Although addressing such topics with your children can be uncomfortable, you should begin this process while your children are still interested in listening to you. About 10 years later, when your children begin thinking about sex from a different perspective, they may be slightly less impressed with what you have to say.

Of course if you’d rather not deal with the issue, you can always use the approach my parents used. Just give me a call. I’ll put you in touch with my sisters.

*****************************

For more information on sex education and parenting, you can check out our Practically Perfect Parenting Podcast episode on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2 or Libsyn: http://practicallyperfectparenting.libsyn.com/

Personal Reflections, Suicide Assessment and Intervention

Bad News in Threes: Kate Spade, Anthony Bourdain, and the CDC Suicide Report

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Rainbow 2017

My mother always said, “Bad news comes in threes.” That concept, along with many of her other superstitions, never made much sense to me.

In truth, the bad news never stops. She knew that. I suppose that organizing bad news into groups of three offered hope that the suffering might soon end—at least until the next set of three bad things came round.

This week we’ve had bad news in waves, with three particular pieces distinctly linked to suicide. On Tuesday, there was fashion designer, Kate Spade. Yesterday, there was the release of a new CDC report on Suicide. And then this morning there was Anthony Bourdain.

When people like Kate Spade and Anthony Bourdain die by suicide, it’s hard not to be mystified. By all measures, both Spade and Bourdain were highly successful. They were passionate and fully alive. The dynamics that may have led them to choose death are opaque. We can’t see these dynamics. They’re not obvious.

Another thing that’s not easily seen or especially obvious is the fact that, along with Spade and Bourdain, 865 other Americans will die by suicide this week. Let that number sink in. Many of these other American suicides will be military veterans. These 865 Americans may choose suicide for reasons similar or different than Spade and Bourdain. We can’t know the deeply personal reasons why individuals choose suicide.

In honor of my mother’s desire to manage bad news in groups of three, I’ve got some other threes to share:

Three Things to Remember About Suicide

  1. As Spade and Bourdain’s deaths illustrate, suicide is unpredictable. Many respected suicidologists have thrown suicide risk factors and warning signs into the trash bin. Because we may not know if someone is suicidal, our best strategy is to treat everyone with kindness, compassion, and respect. This approach is all about connecting with others in ways that are meaningful and authentic. Then, from the context of your interpersonal connection, if you suspect or intuit that suicide is possible, ask directly in a way that normalizes suicidal thinking. You might ask something like, “It’s not unusual for people to think about suicide. Has that been true for you?”
  2. As the CDC report highlights, a person’s mental health may or may not be linked to suicide. In the CDC’s analysis, about 54% of suicides were not associated with a known mental disorder or pre-suicide warning signs. This implies that thinking about suicide or acting on suicidal impulses may be something that arises from challenging life stresses or circumstances. This information also means that you shouldn’t blame yourself for suicide deaths. We imagine suicide to be a terrible tragedy for the person who dies, but it’s also a palpable tragedy for many survivors. Of course, if you knew a person who died by suicide you deeply wish you could have known the right thing to say or do to save that person’s life. But the reality is, suicide is unpredictable, and so you and I shouldn’t beat ourselves up over not being able to effectively intervene. If you feel guilty after a suicide, talk about your feelings with someone you trust. Although it’s natural to blame yourself, there’s no point in being alone with your guilt, so please reach out for support for yourself.
  3. The deaths of Spade and Bourdain bring suicide to the front and center of our national consciousness. Although it’s good to shine a light on suicide, the deaths of Spade and Bourdain overshadow the 865 other Americans who have or will die by suicide this week. Many of these Americans will not have sought help. The irony of not seeking help is that there are several excellent talk-therapies that specifically target suicide risk. These therapies can be highly effective. Hotlines are a fine first step and medications might help, but the interpersonal connection that comes with evidence-based talk therapies, is profoundly important to positive outcomes. Effective help is available. Let’s bring the evidence-based talk therapies front and center in our national consciousness also.

Three Evidence-Based Therapies

Here are links to the three top evidence-based therapies for suicide.

Dialectical Behavior Therapy (DBT): https://www.amazon.com/DBT%C2%AE-Skills-Training-Manual-Second/dp/1462516998/ref=sr_1_1?s=books&ie=UTF8&qid=1528498109&sr=1-1&keywords=linehan+suicide

Collaborative Assessment and Management of Suicide (CAMS): https://www.amazon.com/Managing-Suicidal-Risk-Second-Collaborative/dp/146252690X/ref=sr_1_1?s=books&ie=UTF8&qid=1528498077&sr=1-1&keywords=jobes

Cognitive Therapy for Suicide: https://www.amazon.com/Cognitive-Therapy-Suicidal-Patients-Applications/dp/1433804077/ref=sr_1_4?s=books&ie=UTF8&qid=1528497986&sr=1-4&keywords=cognitive+therapy+suicide

Three More Resources

The CDC Report, although depressing, includes excellent information. You can read it here: https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_cid=mm6722a1_w  You can also listen to or read an NPR interview with the report’s lead author, Deborah Stone, here: https://www.npr.org/sections/health-shots/2018/06/07/617897261/cdc-u-s-suicide-rates-have-climbed-dramatically

A while back I wrote an Op-Ed piece for the Missoulian newspaper. This Op-Ed emphasized core factors or dimensions that often drive suicidal behavior. Reading the article can give you a better understanding of suicide dynamics and could help you help others, but in no way will it make you capable of successfully preventing suicide amongst all of your family and friends. This article is available through the Missoulian: https://missoulian.com/news/opinion/columnists/suicide-prevention-ignore-the-math/article_ce3c7f1e-ab86-587e-9505-310cc00b3355.html

In January I had a suicide assessment and intervention article published in the Journal of Health Service Psychology. This article is a good resource for professionals who work with suicidal clients. It’s an easy read and might also be of interest to non-professionals seeking to understand more about how professionals work with suicidal people. Conversations About Suicide by JSF 2018

I wish you all a weekend of connection and healing.

Parenting, Personal Reflections

Self-Regulation is Central

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Scarecrow

Self-regulation is central to nearly everything in life. I suppose maybe that’s why Dr. Sara Polanchek and I have been ruminating on it so much in our Practically Perfect Parenting Podcast series. In fact, the podcast that became available today is more general and less parent-focused than is usual. Again, that’s because self-regulation or self-control in the fact of outside forces or stressors is so important for everyone.

To read my more general self-regulation blogpost, click here: https://johnsommersflanagan.com/2018/06/04/the-secret-self-regulation-cure-seriously-this-time/

To listen to the podcast on iTunes, click here: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

To listen on Libsysn, click here: http://practicallyperfectparenting.libsyn.com/

And finally, here’s a description of the podcast that’s live today!

The Secret Self-Regulation Cure (Seriously, this time)

For this Practically Perfect Parenting Podcast you should just let yourself relax, let go of all expectations, and tune in. You can even practice being bored, because one part of the secret to self-regulation is that it’s all about embracing your boringness (Spoiler alert, Sara gets bored at the end). Another way of putting this, is that the deep secret to self-regulation (which John shares in this episode) is to repeatedly focus on one comforting thing that is—or becomes—boring (for you science types, that means focusing in on one comforting stimulus). Another big part of the secret to self-regulation is mindful acceptance. Of course, you probably know that mindful acceptance is from Buddhist philosophy, but the concrete application of mindful acceptance involves accepting the fact that you will always get distracted and won’t ever be able to meditate or use progressive muscle relaxation perfectly. You can only strive to be imperfectly mindful (and you shouldn’t even strive to hard for that).

If you make it through this podcast episode without falling asleep, then you might be able to answer one of the following questions:

  1. According to Herbert Benson, What are the four parts of the “relaxation response.”
  2. What’s the problem with counting sheep as a method for dealing with insomnia?
  3. What was the spiritual mantra that John shared?

And if you can answer one of these questions and be the first person to post it on our Facebook page, then you will win something—something in addition to having that warm, positive feeling of having been the first person to post the answer.

Here’s the link to our Podcast Facebook Page: https://www.facebook.com/PracticallyPerfectParenting/?hc_ref=ARRyCtUkbbKwI1usTfQpgCtCAHB3Pi4EVR3fikiq3gd5A-C07BjG7mY7Lqtel9x2jiA&fref=nf

 

 

Counseling and Psychotherapy Theory and Practice, Parenting, Personal Reflections

The Secret Self-Regulation Cure (Seriously this time)

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The Road“I’m in suspense,” Sara said. “I’ve been in suspense since the last time we recorded, because John said he had this big secret and I don’t know what it is.”

Partly Sara was lying. She wasn’t in much suspense, mostly because the “last time we recorded” had been only five minutes earlier. But, as I’m sure you realize, capturing and magnifying in-the-moment excitement is the sort of behavior toward which we Hollywood podcasting stars are inclined.

Sara stayed enthusiastic. When I told her that I thought every self-regulation and anxiety reduction technique on the planet all boiled down to a single method that Mary Cover Jones developed in 1924, she said things like, “That’s exciting!” and “I love Mary Cover Jones.”

[Side note] If you end up needing a podcasting co-host, be sure to find someone like Sara who will express enthusiasm even when you’re talking about boring intellectual stuff. [End of side note.]

Mary Cover Jones was the first researcher to employ counterconditioning with humans (although she rarely gets the credit she deserves—but that’s another story). Counterconditioning involves the pairing a desirable (pleasant or comforting) stimulus with a stimulus that usually causes anxiety or dysregulation. Over time, with repeated pairing, the pleasant feelings linked with the desirable stimulus are substituted for the anxiety response. Eventually, the person who has experienced counterconditioning can more comfortably face the undesirable and previously anxiety-provoking stimulus.

My belief is that counterconditioning is the first, best, and only approach to self-regulation and anxiety reduction. Put another way, I’d say, “If it works for self-regulation, then what you’re doing is counterconditioning—even if you call it something else.”

I know that’s a radical statement. Rather than defend my belief and philosophy, let me move on and describe how you can begin using counterconditioning to make your life better.

Let’s say your goal is for you to experience more calmness and relaxation and less agitation and anxiety. That’s reasonable. According to Herbert Benson of Harvard University, you need four things to elicit the relaxation response.

  1. A quiet place
  2. A comfortable position
  3. A mental device
  4. A passive attitude

Benson was studying meditation way back in the early 1970s. Okay. I know I’m digging up lots of old moldy stuff from the past. But take a deep breath and stay with me.

Let’s say you’re able to find a quiet place and a comfortable position. If you’re a parent, that might be tough. However, even if you find it for 12 minutes as you lie in bed, waiting for sleep, that’s a start. And really, all you need is a start, because once you get going, you don’t really even need the quiet place and comfortable position. On airplanes, I use this all the time and it’s not quiet and I’m not physically comfortable.

The next question that most people ask is: “What’s a mental device?” or, “Is that something I have to strap on my head?”

A mental device is a mental point of focus. In Benson’s time and in transcendental meditation, the popular word for it was “Mantra,” but Benson’s research showed that it can be almost anything. One mental device (that’s actually physical) is deep breathing. Another one is to sit comfortably and to think (or chant) the word OM. Benson also found that simple words, like the numbers “one” or “nine” also were effective. But, as I mentioned on the podcast, you can use other words, as long as they are—or can become—comforting. For example, I know people who use the following words:

  1. I am here
  2. Here I am
  3. Peace
  4. Shalom
  5. Banana

For those of you with religious leanings, you might want to use a specific prayer as your mental device. For those of you who are more visually inclined, you could use a mental image as your mental device. For those of you who are physically-oriented, you could use progressive muscle relaxation or body scanning.

The point is that all you need is a point . . . of focus.

Now comes the hard part. Because we’re all human and therefore, imperfect, no matter how compelling or comforting or soothing your mental device might be, you won’t be able to focus on it perfectly. You will become distracted. At some point (and for me it’s usually very early in the process), you’ll find your mind wandering. Instead of focusing on your prayer, you’ll suddenly realize that you’re thinking about a recent movie you saw or a painful social interaction you had earlier in the day or your mind will drift toward a future social situation that you’re dreading.

What’s the solution to the wandering mind?

Well, one thing that’s not the solution is to try harder.

Instead, what Benson meant by a “passive attitude” is that we need to gently accept our mental wanderings and distractions. More commonly, the words we use for Benson’s passive attitude are “Mindful acceptance.” In other words, we accept in the moment of distraction and every moment of distraction, that we are humans who naturally become distracted. And then, after the noticing and after the acceptance, we bring ourselves back to the moment and to our chosen mental device.

On the podcast, Sara asked, “What if, as I try to focus on my mental device, I notice that all the while I have an inner voice talking to me in the background?”

What an excellent question! The first answer is, of course, mindful acceptance. For example, when you notice the inner voice, you might say to yourself, I notice my mind is chattering at me in the background as I focus on my mental device. Then, without judging yourself, you return to your mental device. A second option is for you to find a more engaging or more soothing mental device. Perhaps, you need two mental devices at once? For example, that might include a soft, silky blanket to touch, along with your “I am here” mantra.

As Mary Cover Jones illustrated over 90 years ago, the counterconditioning process is a powerful tool for anxiety reduction and self-regulation. I happen to think that it’s the only tool for anxiety reduction and self-regulation. Whether you agree with me or not isn’t important; either way, don’t let anything I’ve written here get in the way of you identifying and using your own cherished mental (or physical) device. At first, it might not work. It will never work perfectly. But, like Charles Shulz was thinking when he created Linus’s special blanket, life is way better when you live it with a comforting counterconditioning stimulus.

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For more information about Mary Cover Jones, you can go here: https://johnsommersflanagan.com/2011/11/25/a-black-friday-tribute-to-mary-cover-jones-and-her-evidence-based-cookies/

Or here: https://johnsommersflanagan.com/2017/07/17/brain-science-may-be-shiny-but-exposure-therapy-is-pure-gold/

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As I write this (6/4/18), the podcast isn’t quite up yet . . . but will be soon!

To listen to The Secret Self-Regulation Cure on iTunes, go here: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

To listen to The Secret Self-Regulation Cure on Libsyn, go here: http://practicallyperfectparenting.libsyn.com/

To check out our podcast Facebook page, go here: https://www.facebook.com/PracticallyPerfectParenting/

Multicultural, Personal Reflections

It’s Not Unusual: John’s Weekend Reflections

6 Comments

john-rapA stranger posted a comment on my blog today. As Tom Jones might say, “It’s not unusual” for my blog to stimulate reader commentary. After all, I’m expressing my opinion, distributing professional information, and often I specifically ask for reader feedback.

Mostly I get positive feedback. Occasionally, I touch a nerve with someone and get pushback or criticism. What’s most interesting to me is that the nerves I touch are nearly always nerves related to White privilege or feminism. I suppose that’s not unusual either.

Today’s comment started with, “Wow. All u do is wafle here. . .” and went on to provide a rambling critique of White privilege (I think). Three thoughts on this: First, to find my several year-old White privilege blog post requires significant effort and searching. Second, with the advent of spellcheck, typically it’s very hard for your computer to let you misspell “waffle” as “wafle.” Third, the critique, as is not unusual, didn’t seem to have much to do with the content of my blog post. Instead, the commenter was clearly focusing in on his own personal issues and history and not so much on what I had written.

The next part of all is also not unusual. In response, I felt disappointment, hurt, and defensiveness. To be perfectly honest, I wanted to counterpoint or counterpunch my commenter. I managed to stop myself. Instead, I labeled his comment as spam and moved on.

Upon reflection, my “spamming” his comment was probably passive-aggressive. And, it was (and is) clear that I haven’t moved on. Funny how criticism has a way of hanging on long after the party has ended and everyone should go home.

In conclusion, here’s the sort of thing I wish I’d written . . .

“Hello beloved fellow human. I’m grateful that you took the time to read my blog and make a comment. Thank you for that. Based on your comment, I think you and I probably disagree on this topic. Rather than arguing and trying to convince you that I’m right and you’re wrong (which likely wouldn’t work anyway), I want to say that I respect your right to a perspective and opinion that’s different from mine. I’m sure we’ve lived very different lives and so it’s not unusual that we would disagree on White privilege. Although I feel defensive about what I wrote, I can also feel a part of myself that’s way down deep and not defensive. That part of me wants to reach out and say ‘Hey. No big deal that we disagree. It wasn’t my intent to write something that offended you. I wish you health and happiness. I wish us a better and deeper mutual understanding. Wherever you feel hurt or pain, I wish you healing. I hear your disagreement with me and, in the future, although I know I won’t be perfect, I will try to be more sensitive and compassionate in what I write.’

If you like, you can read the offending blog post here: https://johnsommersflanagan.com/2012/09/14/a-white-male-psychologist-reflects-on-white-privilege/

Have a fantastic Saturday night.

John SF

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

Memories of Memorial Day: How to Use Memory Re-consolidation to Cope with Pain from the Past

4 Comments

Green Shadow II

Back in the 1970s, I remember singing the lyrics to, The Way We Were, along with Barbra Streisand. Using my best falsetto, Barbra and I crooned, “Memories, light the corners of my mind.”

These lyrics aren’t technically correct. But then Barbra and the song’s lyricists, Alan and Marilyn Bergman, didn’t have access to modern brain scans. Based on neuroscience research, it would have been more accurate for Barbra and I to sing, “Memories, light the center of my mind.”

Memories live deep within the brain. If you could magically poke your index finger down through the top center of your skull, you still couldn’t quite reach your brain’s memory structures, the hippocampus and amygdala.

Memories are a fascinating electrical, molecular, cellular, and inter-structural phenomenon. I won’t be providing scientific details about memory, because then I’d have to write something about how the interaction of glucocorticoids and noradrenaline in the basolateral region of the amygdala can modulate the strength of memories in the hippocampus and other brain areas . . . and by then our fascination with memory would doubtless give way to boredom and sleepiness.

Speaking of sleepiness, it’s metaphorically accurate to say that most of our memories typically just lay around dozing in their hippocampal bed until awakened. Not surprisingly, some memories are lighter sleepers than others; they can be easily awakened. Sometimes, when sleeping memories are rudely awakened (triggered) they tend to be rather grumpy and unpleasant.

Here are three examples:

Say you’re creeping around on Facebook. You see an old high school photo from 25 years ago. The visual stimulus of the photo is a memory trigger; several related images and narratives pop into your mind. These images and narratives aren’t grumpy or unpleasant. Instead, you feel warmly nostalgic. This is an example of a visual trigger that activates a mildly pleasant set of associated memories.

In contrast, if you’re a veteran who has experienced war trauma and you hear firecrackers on the 4th of July, your consciousness may flood with vivid, multisensory memories. These memories could link to deep emotional pain. This is an example of an auditory trigger that awakens or activates disturbing memories—memories that you might prefer to put back to sleep.

Now, think of the smell of coffee in the morning. For me, the scent of coffee is neutral. No clear memories are activated. But, when coffee smells are combined with the aroma of bacon on the griddle, I have instant flashbacks to my Grandma Lucy making breakfast. This is an olfactory stimulus triggering a pleasant memory. I see my grandma’s grey hair, pulled back with bobby pins. I can see my own small hands touching and feeling the textured floral pattern on her white milk glass china as I wait for breakfast, watching her. I hear the pop of bacon sizzling. I can imagine the pain I might feel if I get too close to grandma’s griddle. I instantly know the past and future of this memory. First, Grandma Lucy peeled the bacon apart, dangling each piece before laying them on the griddle. Later, she’ll save the bacon grease, for another purpose. She was like that. Another emotion emerges. I feel sad. I miss her.

In honor of memory science, it’s important to note that each of the preceding memories may be more or less historically accurate. Even more important is the likelihood that these memories, like all memories, have changed, shifted, and evolved over time.

How can memories change? Isn’t it true that humans have an experience and then store a record of it in their brain, ready for later retrieval? Not exactly.

As it turns out, new memories are more fluid than solid. Following a memorable experience, memories stay unstable for somewhere between a few minutes and a few hours. New memories are in flux and shaped or degraded by additional new experiences that immediately follow. More remarkable is the fact that, even after storage, every time memories are pulled out (or retrieved) they return to an unstable or vulnerable state, until they re-stabilize or reconsolidate. And when they reconsolidate (a process that involves cellular protein synthesis), they can include new, different, or less information. This is how and why memories change over time.

For many Americans, Memorial Day is an intentional memory day. For example, yesterday there were flowers, speeches, and flag waving. Yesterday, you were probably in the company of family, possibly kneeling at a gravesite, perhaps celebrating the life of someone whom you loved and lost.

Memorial Day is a memory trigger. It’s a time set aside to honor the lives of men and women who died in service of our country. It’s natural and good to engage in this honoring ritual. People also honor non-military family members with flowers and graveside visits. But, amidst the celebrations, as is often the case, the emotional side of life gets short shrift. Typically, we celebrate and move on, despite the fact that it’s equally natural and good to honor the grief that we feel in response to Memorial Day celebratory rituals.

It might have been the 21 gun salute or the color of the flowers or the taste of the potato salad or the smell of your uncle’s cologne. Whatever the case, yesterday you probably had old memories awaken and stroll past you in an internal memory parade. Some of these memories may have been neutral. Others may have been pleasant. Still others, felt angry, sad, guilty, or lonely.

But memories are open to change, and that fact begs for intentionality. What I mean is that we should all have a plan for Memorial Day (and then a plan for Memorial Night). Not only do we need plans for how to celebrate, we need plans for dealing with the raw emotions that Memorial Day can trigger.

I wish I could offer up a simple method for helping you to deal effectively with Memorial Day memory activation and reconsolidation. But you (and everyone) are a unique entity with layers of fantastic idiosyncrasy. Nevertheless, here’s a quick glimpse into the emerging science of memory reconsolidation.

In one research study, participants were exposed to negative emotional memories from watching a trauma film. The next day, these memories were re-activated using a trauma-photo from the film. Then, after a 10 minute-break some participants played a game of Tetris, while others didn’t. The results: Over the next seven days, the participants who played Tetris after having traumatic memories re-activated, experienced significantly fewer intrusive trauma-related memories. The implications? Maybe the Memorial Night solution is to establish a Tetris-playing ritual.

But painful memories are complex and unique. What works for one person, might not work for another. As Drexler and Wolf (authors of a 2018 scholarly review) were inspired to write, “Indeed, when the activation of selective L-type voltage-gated calcium channels or GluN2B-containing NMDA receptors in the hippocampus was prevented before retrieval, thus blocking memory destabilization . . . the interfering air puff had no effect” (p. 15). Reading this led me to conclude that reading more of Drexler and Wolf’s article might serve as another possible memory disrupting intervention to employ during the reconsolidation period. I’m guessing, if you’ve made it to this point in this blog, that you’re inclined to agree.

From a practical perspective, it’s good to know that, generally, memory reconsolidation can take up to six hours. And so, in addition to Tetris and reading intellectual research papers, there are other reasonable strategies you can use to facilitate healthy memory reconsolidation, not just on Memorial Day (or Night), but any time of the year—as long as you’re within the six hour memory consolidation window.

  • Talk with a trusted friend or counselor about the emotions you’re experiencing. Even better, don’t just talk about your emotional pain, but also talk about and focus on the strengths you have for coping with your challenging emotions.
  • Engage in a physically strenuous activity. This could involve some sort of strenuous physical activity like cycling, running, yoga, or weight-lifting.
  • Ritual is good. This could involve a culturally appropriate spiritual activity like going to a sweat lodge or attending a religious service.
  • Writing is a common and effective method for expressing emotions. In particular, writing about your loss in ways that are meaningful to you can be therapeutic.
  • There may be no better way to deal with problematic emotions than engaging in positive helping behavior. Alfred Adler called this social interest. When you’re triggered, consider ways in which you can shift the spotlight away from yourself and toward fostering wellness in others.

Memorial Day is an intentional memory day. We created it and we celebrate it. But you can have other, self-created memory days. And what we know about memory and the disturbing emotions that can accompany memories, is that they present us with an opportunity. Some researchers call this an opportunity for “updating.” Recognizing this opportunity and intentionally engaging in healthy and soothing behaviors when difficult memories are activated is good guidance. This might be Tetris. It might even involve singing along with Barbra Streisand in your best falsetto. The point is that we have power, albeit limited, to update our activated memories . . . and so I wish you the best in finding intentional and healthy ways to soften your painful memories. It’s the honorable thing to do.