Category Archives: Writing

Suicide Myths — Part Two

From M 2019 Spring

This is part two of my “Four Suicide Myths” blog post. If you read part one, you probably noticed that it ended abruptly. Apparently, that’s how I do two-part blog posts. Thinking back, I should have added something like, “end of part one.” 

And so, as an introduction, here’s the beginning of part two . . .

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another—even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.” Additionally, the rates of suicidal thinking among high school and college students is so high (estimates of 20-40% annual incidence) that it’s more appropriate to label suicidal thoughts as common, rather than a sign of deviance or illness.

Edwin Shneidman—the American “Father” of suicidology—denied a relationship between suicide and so-called mental illness in the 1973 Encyclopedia Britannica, stating succinctly:

“Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality (although . . . it has often been so treated in Western and other cultures).”

A recent report from the U.S. Centers for Disease Control (CDC) supported Shneidman’s perspective. The CDC noted that 54% of individuals who died by suicide did not have a documented mental disorder. Keep in mind that the CDC wasn’t focusing on people who think about or attempt suicide; their study focused only on individuals who died by suicide. If most individuals who die by suicide don’t have a mental disorder, it’s even more unlikely that people who think about suicide (but don’t act on their thoughts), meet diagnostic criteria for a mental disorder.  As one of my mentors used to say, “Having the thought of suicide is not dangerous and is not the problem.”

Truth #2: Suicidal thoughts are not—in and of themselves—a sign of illness. Instead, suicidal thoughts arise naturally, especially during times of excruciating distress.

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

In 1995, renowned suicidologist, Robert Litman wrote:

At present it is impossible to predict accurately any person’s suicide. Sophisticated statistical models . . . and experienced clinical judgments are equally unsuccessful. When I am asked why one depressed and suicidal patient commits suicide while nine other equally depressed and equally suicidal patients do not, I answer, “I don’t know.” (p. 135)

Litman’s comments remain true today. Part of the problem stems from the fact that suicide is what is referred to as a low base rate event. When something occurs at a low base rate, it becomes mathematically very difficult to predict. Suicide is a prime example of a low base rate event. According to the CDC, in 2017, only about 14 of every 100,000 citizens died by suicide.

Imagine you’re at the Neyland football stadium at the University of Tennessee. The stadium is filled with 100,000 fans. Your job is to figure out which 14 of the 100,000 fans will die by suicide over the next 365 days.

A good first step would be to ask everyone in the stadium the question that many suicide prevention specialists ask, “Have you been thinking about suicide?” Assuming the usual base rates and assuming that every one of the 100,000 fans answer you honestly, you might rule out 85,000 people (because they say they haven’t been thinking about suicide) and ask them to leave the stadium. Now you’re down to identifying which 14 of 15,000 will die by suicide.

For your next step you decide to do a quick screen for the diagnosis of clinical depression. Let’s say you’re highly efficient, taking only 20 minutes to screen and diagnose each of the 15,000 remaining fans. Only 50% of the 15,000 fans meet the diagnostic criteria for clinical depression.

At this point, you’ve reduced your population to 7,500 University of Tennessee fans, all of whom are depressed and thinking about suicide. How will you accurately identify the 14 fans who will die by suicide? Mostly, based on mathematics and statistics, you won’t. Every effort to do this in the past has failed. Your best bet might be to provide aggressive psychological treatment for the remaining 7,500 people. However, many of the fans will refuse treatment, including some of whom will later die by suicide. Further, as the year goes by, you’ll discover that several of the 85,000 fans who denied having suicidal thoughts, and whom you immediately ruled out as low risk, will confound your efforts at prediction and die by suicide.

To gain a broader perspective, imagine there are 3,270 stadiums across the U.S., each with 100,000 people, and each with 14 individuals who will die by suicide over the next year. All this points to the magnitude of the problem. Most professionals who try to predict and prevent suicide realize that, at best, they will help some of the people some of the time.

Truth #4: Although there’s always the chance that future research will enable us to predict suicide, decades of scientific research doesn’t support suicide as a predictable event. Even if you know all the salient suicide predictors and warning signs, odds are, in the vast majority of cases, you won’t be able to efficiently predict or prevent suicide attempts or suicide deaths.

Myth #4: Suicide prevention and intervention should focus on eliminating suicidal thoughts.

Logical analysis implies that if suicidal thoughts within an individual are eliminated, then suicide will be prevented. Why then, do the most knowledgeable psychotherapists in the U.S. advise against directly targeting suicidal thoughts in psychotherapy? The first reason is because most people who think about suicide never make a suicide attempt. But that’s only the tip of the iceberg.

After his son died by suicide, Rick Warren, a famous pastor and author, created a Youtube video titled, “Rick Warren’s Message for Those Considering Suicide.” The video summary reads, “If you have ever struggled with depression or suicide, Pastor Rick has a message for you. The pain you are experiencing will not last forever. There is hope!”

Although over 1,000 viewers clicked on the “thumbs up” sign for the video, there were 535 comments; these comments mostly pushed back on Pastor Warren’s well-intended message. Examples included:

  • Are you kidding me??? You’ve clearly never been suicidal or really depressed.
  • To say “Suicide is a permanent solution to a temporary problem” is like saying: “You couldn’t possibly have suffered long enough, even if you’ve suffered your entire life from many, many issues.”
  • This is extremely disheartening. With all due respect. Pastor, you just don’t get it.

Pastor Rick isn’t alone in not getting it. Most of us don’t really get the excruciating distress, deep self-hatred, and chronic shame linked to suicidal thoughts and impulses. And because we don’t get it, most of us try to use rational persuasion to encourage individuals with suicidal thoughts to regain hope and embrace life. Unfortunately, a nearly universal phenomenon called psychological reactance helps explain why rational persuasion—even when well-intended—rarely makes for an effective intervention.

While working with chronically suicidal patients for over two decades, Dr. Marsha Linehan of the University of Washington made an important discovery: when psychotherapists try to get their patients to stop thinking about suicide, the opposite usually happens—the patients become more suicidal.

Linehan’s discovery has played out in my clinical practice. Nearly every time I’ve actively pushed clients to stop thinking about suicide—using various psychological ploys and techniques—my efforts have backfired.

Truth #4: Most individuals who struggle with thoughts of suicide resist outside efforts to make them stop thinking about suicide. Using direct persuasion to convince people they should cheer up, have hope, and embrace life is rarely effective.

Starting Over

Individuals who are suicidal are complex, unique, and in deep distress. Judging them as ill is unhelpful. Believing that we can successfully predict and prevent suicide borders on delusional. Direct persuasion usually backfires. Letting go of the four common suicide myths might make you feel nervous. At least they provided guidance for action, right? But just like having the female on top to prevent pregnancy, clinging to unhelpful myths won’t, in the end, be effective. How do we start over? Where do we go from here?

All solutions—or at least most of them—begin with a clear understanding of the problem. As someone who has worked directly with suicidal individuals for decades, there’s no better person to start us on the journey toward a deeper understanding of suicide than Dr. Marsha Linehan.

Dr. Linehan is the developer of dialectical behavior therapy (DBT for short). DBT is widely hailed as the most effective evidence-based approach for working with chronically suicidal patients. To help her students at the University of Washington better understand the dynamics of suicide, Dr. Linehan begins her teaching with this story:

The suicidal person [is] trapped in a small, dark room with no windows and high walls (in my mind always with stark white walls reaching very, very high). The room is excruciatingly painful. The person searches for a door out to a life worth living but, alas, cannot find it. Scratching and clawing on the walls does no good. Screaming and banging brings no help. Falling to the floor and trying to shut down and feel nothing gives no relief. Praying to God and all the saints one knows brings no salvation. The only door out the individual can find is the door to death. The task of the therapist in this situation, as I always tell my clients also, is to somehow find a way to get into the room with the person, to see the person’s world from his or her point of view; to get inside the person, so to speak, and then together search again for that door to life that the therapist knows must be there.

Efforts to understand someone else’s reality are destined to fall short. You can’t always get it right, but that’s okay, because empathy is more about being with and feeling with others, than it is about perfectly understanding them. Trying to understand the inner world of others is an act of courage and compassion. Thus, our next step is to suspend judgment and begin our descent into that small, dark room with no windows.

The Brain-Based Truth of Donald Trump’s Social Dominance

Snowy Sunset

Although everyone is arguing with everyone else about everything—especially everything involving presidential politics, no one argues about whether Donald Trump can work a room, work up an audience, and dominate a news cycle. Love or hate him, Trump has a special talent.

But what is that talent? How can it be that despite clear evidence of Trump lying at unprecedented rates, despite the small blue wave that swept the House of Representatives this past November, and despite substantial evidence that his policies are not benefiting rural Americans, Trump’s approval ratings continue to hover at around 40%. Given his flirtation with the Russians, his legal problems with the Department of Justice and in the Southern District of New York, and his incessant outrageous and vulgar tweeting, why don’t his approval ratings dip even lower?

Perhaps even more puzzling is the apparent inability or unwillingness of previously powerful republicans to push back on Trump’s wanton disregard for family values and morality. Many of Trumps tweets are, at best, rated PG-13. The fact that Googling “bullshit” and “circle jerk” takes us to commentaries about Trump’s tweets is a testimony to his ubiquitous disrespect for whatever moral codes republicans have retreated behind.

Never mind the well-documented porn star payments, “shithole” references, and stories about bullets dipped in pig’s blood. Unless they’re still commenting on Obama, the Clintons, or other targets designed to distract from rational argument, the collective chorus of outrage among republican politicians is no louder than you’d expect from a band of Buddhists practicing mindful acceptance at a silent retreat.

Sure, Mitt Romney and a few others have occasionally (and carefully) expressed their sickened feelings. And although Bill Kristol and other #neverTrumpers have held forth—even purchasing political advertisings to counter Trump rhetoric—to date, no current republican office-holder has publicly confronted Trump and provided an alternative leadership narrative. What’s up with the formerly assertive republican leaders? Whether we’re watching blank looks from Chris Christie, John Kelly, or Rod Rosenstein, republican power brokers appear frightened, intimidated, and only a meek shadow of their former selves.

What’s the best explanation for Trump’s stable approval ratings and the continued shriveling of republican leadership? You might be inclined to consider favorable economic indicators, or the Fox News phenomenon, or some other rational explanation. But I’m leaning a different direction—toward a theory to explain the irrational.

Like all dangerous populist politicians, Trump is a master manipulator. He can bend minds like psychics bend spoons. Although many—including my father—refer to him as a run-of-the-mill con man, Trump is much more than that. Trump is no expert on the art of the deal; but he’s a wizard at the art of mass hypnosis.

Among others, two Canadian academics, Drs. Erik Woody and Henry Szechtman, have written about how mass hypnosis works. They say it involves the activation of a particular evolutionarily-important part of the brain. They’ve labeled this neural network in the brain as the “security motivation system.” Essentially, the security motivation system is an ancient part of the brain that scans for “hints, inklings, whiffs, and foreshadowings” of danger. The problem, as Woody and Szechtman put it, is that contemporary human brains are now connected to the internet, and the internet is filled with perpetual news, Facebook forwards, Russian bot activity, and political messages. Much of this instant information has hints and whiffs of danger and those hints and whiffs activate the security motivation system. The louder the call of dark, scary, danger, the more activated our collective security motivation systems become. And what do our collectively activated security motivational systems want? Action! Specifically, action leading to safety. All this can direct us to embrace politicians who offer big actions that will hypothetically protect us from danger. Woody and Szectman wrote: “. . . support for politicians promoting bold action [like building a big, impenetrable border wall] is itself an action . . . which may help” de-activate our heightened security motivation.

In contrast to Reagan’s message of the late 1970s and early 1980s, Trump’s message has been consistently about doom, gloom, and danger. His speech at the 2016 Republican National Convention was a bleak frightening portrait of America. But, in contrast to Trump’s portrait of America as under attack from Mexican rapists, Muslim terrorists, and international commerce, he simultaneously promised (and continues to promise) to make America great again with big, albeit unrealistic and unfounded, actions.

For a substantial minority of Americans, Trump is a charismatic speaker. He ramps up crowds to an emotional fever-pitch. He combines extremes. On the one hand, America is under attack from Mexicans, Muslims, and Democrats. On the other hand, he—and only he—can offer a future filled with beauty, safety, and financial success. As he speaks, he sometimes riffs like a hypnotist employing a specific hypnotic induction procedure called the “confusion technique.” When he employs this strategy, Trump’s words barely make sense. He offers a rhythmic narrative absent any real content. Take this example from the 2016 campaign trail:

You are going to be so proud of your country. Because we’re gonna turn it around, and we’re gonna start winning again! We’re gonna win so much! We’re going to win at every level. We’re going to win economically. We’re going to win with the economy. We’re gonna win with military. We’re gonna win with healthcare and for our veterans. We’re gonna win every single facet.

We’re gonna win so much, you may even get tired of winning. And you’ll say, “Please, please. It’s too much winning. We can’t take it anymore. Mr. President, it’s too much.” And I’ll say, “No, it isn’t!”

We have to keep winning. We have to win more! We’re gonna win more. We’re gonna win so much.

Ashley Feinberg of Gawker, described this verbal dispatch from Trump as: “His best Howard Dean impression if Howard Dean had been given a whole lot of cocaine and also a thesaurus with just the word “winning” followed by the word “winning” again in progressively larger fonts.” Not surprisingly, Woody and Szechtman described it differently, noting nuanced differences between the oral and written word:

Through repetition, this type of communication stays “on message,” almost to the point of caricature. More importantly, it presents no line of argument or supporting material whatever that would call for higher thought. Such communication, which can be effective in person, is similarly effective when replayed on media as video [or audio]. By contrast, it becomes ineffective in print, where its paucity of intellectual content is painfully obvious. (p. 14)

Most observers agree, Trump is best when on the stump. When it comes to governing or foreign policy or role-modeling moral behavior, Trump is less effective. On the stump Trump uses other hypnotic methods, beyond the previously mentioned confusion technique. He continually pounds away messages about current dissatisfaction, combined with an orientation to the future. Under him, future life will always be better, more beautiful, a Shangri-La for the masses. He uses the words “believe me” and “trust me” like a mantra. Even though nearly every rational person in the U.S. knows they should quickly run away whenever a salesperson (or con-man) says “trust me” Trump’s hypnotic reverie has weakened the rational mind to the point where the words believe me and trust me actually work. As Roger Cohen opined in the New York Times,

Tolstoy wrote of “epidemic suggestion” to describe those moments when humanity seems to be gripped by a mass hypnosis that no force can counter. . . . We find ourselves in such a moment.

But there is a countering force. There always has been. And there always will be.

Let’s go back to Woody and Szechtman, and their ideas about the brain’s security motivation system.

When activated, the security motivation system directs humans toward actions that enhance safety. When looking for safety, nearly always, humans follow their evolutionary noses. And where do their evolutionary noses point . . . toward the person with the most social dominance.

Think about it. Who can keep us safe? Then, think about Trump’s hulking figure looming in the background as Hillary Clinton speaks in one of the televised debates. Then, think of what he has (wealth and property) and think of what he offers in his hollow narratives (winning, beauty, and safety, so much winning).

Republican politicians are cowed like never before. They can’t match Trump’s verbal skills and hypnotic persona. They can’t match his wealth and connections. And republicans have historically been motivated by fear. Trump’s presence activates their security motivation systems. On their own, most White, male republicans fear immigration. On their own, most White, male republicans are drawn to wealth and power. For them, Trump stokes their fears and activates their security motivation system in a way that goes back to primitive human thinking: “Save yourself” . . . is the irresistible unconscious motive that weakens republicans. Open conflict with Trump is too dangerous. Alone, individual republicans don’t have the verbal or financial prowess to compete with Trump. So, they slink into the background and do what frightened people have done since the beginning of time—they follow a socially dominant and powerful leader.

The answer to the problem of Trump is simple, but not easy.

There are two roads to countering a socially dominant, hypnotically adept bully. Both roads necessarily include an alternative socially dominant discourse. How to get there? Republicans, if they can find their courage, might band together to push back against Trump. This would be risky. And the outcome is dicey.

The other road is to latch our trailer to an alternative socially dominant political figure. The hazard here is we could end up jumping from the socially dominant frying pan into the socially dominant fire. Consequently, we need to be very careful when selecting the socially forceful leader who can take on Trump and win. Perhaps of greatest importance, along with powerful messaging, to ensure safety of all Americans, our new leader needs to have two characteristics that Trump lacks and that make Trump dangerous. We need a leader who can be a team player (and not just deputize family members) and we need a leader who is able to experience and express compassion.

Methods for resisting and awakening from a hypnotic trance exist. They begin as all things begin, with awareness. Now is the time to wake up. Listen closely as I count backward from five to one. When I get to the number one, you’ll awaken, you’ll stretch, look around, and realize that finding an alternative socially dominant and yet compassionate leader is urgent.

5

4

3

2

1

You can wake up now. If you stay asleep, you face a greater danger. If you stay asleep, you may act in ways that are incompatible with your deep values. If you stay asleep, you may need forgiveness, because although you will act, you . . . will . . . know . . . not . . . what . . . you . . . do.

The End of Mental Illness, Part I

Irrigation Sunrise

For years I’ve planned to write a scintillating review of the words and phrases I now, as a wise and mature adult, refuse to use. The “c-word” (expelled in 1976) and “r-word,” (out forever in 1980), and “n-word” (never used) are notable, but they’re old and tired targets that most self-respecting people in the 21th century have also banished.

BTW, I got rid of tireless in 1988 (who doesn’t get tired, especially after the birth of a child, an all-nighter, or a long day’s work?). On a related note, I got rid of countless in the early 1980s, when, while studying statistics, it became obvious to me that everything was countable, unless you got too tired or too lazy to do the counting. But, even then it didn’t make much sense to just stop counting or to lose track and suddenly declare something countless. More than anything else, the word countless struck me as lazy. I would go with the lazy explanation for countless were it not for the fact that I also eliminated lazy from my vocabulary about 15 years ago when I read about Alfred Adler’s description of people who are lazy as not lazy, but instead people whose goals are beyond their reach and consequently, they experience discouragement (and not laziness).

More recently, I’ve grown weary of “the new brain-science” (how can it be that the media continues to refer to science from the 1990s as perpetually “new” but somehow the pleats in my pants have become so “old-fashioned” that I can no longer wear them in public?). On a related note, neurocounseling and neuropsychotherapy would be on my list for potential banishment, but because they’re new terms that people invented (along with polyvagal), purely for marketing purposes, they can’t be banished, because quite conveniently, I refuse to acknowledge their existence.

All this silly ranting about words makes me sound like a crank—even to myself. But as I get older, I find that worries over sounding like a crank are, in fact, more motivating than worrisome. Indeed, I’m embracing my intellectually snooty crankiness as evidence that I’m fully addressing the crisis inherent in Erik Erikson’s seventh psychosocial developmental stage: Generativity vs. Stagnation. Yes, that’s right, instead of stagnating, I’m cranking my generativity up to a level commensurate with my age.

In contrast to all these aforementioned banished or unacknowledged words, most people (who are otherwise reasonably intelligent) continue to use the term mental illness. As a consequence, the words mental illness have now risen to the coveted #1 spot on my billboard of eliminated words.

My preoccupation with avoiding term mental illness isn’t a news flash, as my University of Montana students would happily attest. For well over a decade, I’ve been explaining to students that I don’t use the term mental illness, and warn them, with what little roguish power I can muster, that perhaps when handing in their various papers throughout the semester, they also, at least for the time being and so as to not irritate their paper-grader, ought to follow my lead.

In my social life, whenever mental illness comes up in conversation, I like to cleverly state, “I never use the term mental illness unless I’m using it to explain why I never use the term mental illness.” This repartee typically piques the interest (or ire) of my conversational cohort, usually stimulating a question like, “Why don’t you ever use the term mental illness?”

“Wow. Thanks.” I say. “I thought you’d never ask.”

Three main cornerstones form the foundation for why I’ve made a solemn oath to stop privileging the words mental illness. But first, a tangential example.

This morning, once again, I’m awake at 3:30am, despite my plan to sleep until 7:00am. I know this awakening experience very well; I also know the label for this experience is insomnia, or, more specifically, terminal insomnia, or more casually known as, early morning awakening.

After this particular early morning awakening, I briefly engaged in meditative breathing until my thoughts crowded out the meditation. Having thoughts bubble up and crowd out meditative breathing is probably a common phenomenon, because neurotic thoughts, spiritual thoughts, existential thoughts, and nearly any thoughts at all, are nearly always far more interesting than meditative breathing.

A favorite statement among existentialists is that humans are meaning makers. As with many things existential, the appropriate response is something my teenage clients have modeled for me, “Well, duh.” Channeling my ever-present inner-teen, I want to respond to my inner-existentialist with a pithy retort like, “Yeah. Of course. Humans are meaning makers. Maybe we should talk about something even more obvious, like, we all die.”

What I find fascinating about the existential claim that humans are meaning makers is that existentialists always say it with gravity and amazement, as if being a meaning-maker is a profoundly good thing.

But, like life, meaning-making is not all good, and sometimes, not good at all. As I lay in bed along with my early morning awakening, it’s nearly impossible not to begin wondering about the meaning of the dream that woke me up (there was a broken anatomical bust of Henry David Thoreau in a small ocean-side creek at Arch Cape, Oregon); even more engaging however, is the so-called lived experience of terminal insomnia, and so my middle-of-the-night dream interpretation gets pushed aside for a more pressing question. “What’s the meaning of my regular waking in the middle of the night?” My brain, without consent, calls out this question, in an all-natural and completely unhelpful lived meaning-making experience. The explanations parade through my hippocampus: Could my awakening be purely physiological? Could it be that I missed my daily caffeine curfew by 30 minutes? Perhaps this is the natural consequence. But if so, why would I awaken now, after falling asleep as my head hit the pillow and sleeping for 4½ hours, instead of having a more easily explained experience of initial insomnia.

Of course, the most common explanation for early morning awakening is neurochemically filed in my brain and easily accessible. Without effort, I recall that terminal insomnia is a common symptom of clinical depression. I’ve known that for about 40 years. Now, by 3:45am, the various competing theories have completely crowded out my breathing meditation and will settle for nothing less than my full attention.

Is my terminal insomnia simply a product of the half-life of caffeine, or a full-bladder, or primary insomnia? Or is it something even more malignant, a biological indicator of clinical depression? Do I have a mental disorder? Although that might be the case, after briefly depressing myself with the contemplation of being depressed, I also begin refuting that hypothesis. My memory of taking an online “depression” test emerges, along with my score in the mild-to-moderate depression range. I might have believed the online questionnaire result, had it not been conveniently placed on the website of a pharmaceutical company and had it not culminated in the message, “Your score indicates you may be experiencing clinical depression. Check with your doctor. Lexapro may be right for you?”

Given that I’m absolutely certain that Lexapro isn’t right for me, the pattern analysis and search for deeper meaning breaks down here. I am a meaning-maker. I woke up at 3:30am. Now it’s 4am and I’m still awake. So what? It happens. When it does, I like to get up and write. It’s productive time. My stunning meaning-making conclusion is my usual conclusion: believing that I have a mental disorder is unproductive; in contrast, believing that I’m creatively inspired to write at 3:30am is vastly preferable and consistent with what Henry David Thoreau would want me to do in this moment.

What does all this have to do with eliminating the term mental illness from the human vocabulary?

Mental Illness Lacks a Suitable Professional Definition

Mental illness is a term without a professional or scientific foundation. Even the American Psychiatric Association doesn’t use mental illness in its latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The World Health Organization doesn’t use it either. I pointed out this fun fact while attending a public journalism lecture at the University of Montana. I asked the journalist-speaker why she used “mental illness” when the American Psychiatric Association and World Health Organization don’t use it. Initially taken aback, she quickly recovered, explaining that she and other journalists were trying to put mental health problems on par with physical health problems. That’s not a bad rationale. Mostly I want mental and physical health parity too, but what I don’t want is an assumption that all mental health problems are physical illnesses and therefore require medical treatments. Besides, whenever people make up (or embrace) non-professional and scientifically unfounded terminology to further their goals, their goals begin to seem more personal and political and less pure. In the end, I don’t think it’s right to make up words to negatively classify a group of fellow humans.

A side note: The American Psychiatric Association and World Health Organization are not left-leaning bleeding hearts; they would happily use mental illness if they felt it justified. Back in 2000, the authors of the 4th edition of the Diagnostic and Statistical Manual explained their reasoning:

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 behavior associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here.

Broadly, my first reason for refusing to use the term mental illness is that it’s not used in the definitive publications that define mental disorders. It’s too broad and consequently, unhelpful. If mental illness isn’t good enough for the American Psychiatric Association and the World Health Organization, it’s not good enough for me.

Mental Illness is Too Judgmental

When asked about diverse sexualities, Pope Francis summarized my second reason for not using the term mental illness. He famously responded, “Who am I to judge?” I love this message and believe it’s a good guide for most things in life. Who am I (or anyone) to judge (or label) someone as having a mental illness?

You might answer this question by recognizing that I’m a mental health professional and therefore empowered to judge whether someone has a mental disorder; I’m empowered to apply specific mental disorder labels (after an adequate assessment). Sure, that’s all true. But I also have a duty to be helpful; although the communication of a diagnostic label might be helpful for professional discourse, insurance reimbursement, and scientific research, I don’t see how it’s helpful to categorize a whole group of individuals as “the mentally ill.” Hippocrates founded medical science. His first rule was “Do no harm.” As fun and entertaining as diagnosing other people and myself may be, I’ve come to the conclusion that doing so is often more harmful and limiting than good.

Think about it this way. Would it be any LESS helpful for us to delete the words “the mentally ill” and replace them with “people with mental health issues?” I think not. But you can decide what fits for you.

To the extent that it’s helpful to individual clients or patients, I’m perfectly fine with, after an adequate collaborative assessment process, diagnosing individuals with specific mental disorders. I believe that process, when done well, can help. What I’m against is using a broad-brush to label a large group of fellow humans in a way that can be used for oppression and marginalization. Why not just say that everyone has mental health problems and that some people have bigger and harder to deal with mental health problems. As Carl Jung used to say, “We’re all in the soup together.”

Mental Illness Resists De-stigmatization

Mental illness and its proxies, mental disease and brain disease, are inherently, deeply, and irretrievably stigmatizing. I know several different national and local organizations that are explicitly dedicated to de-stigmatizing mental illness. My problems with this is that the words mental illness are already so saturated with negative meaning that they resist de-stigmatization. The words mental illness instantly and systematically shrink the chance for therapeutic change and positive human transmorgrification.

If you look back in time, you’ll find that mental illness was created by people who typically have a political or personal interest in labeling and placing individuals into a less-than, worse-than, not-as-good-as, category. The terminology of brain disease and brain-disabling conditions are even worse. What I’m wishing for are kinder, gentler, and less stigmatizing words to describe the natural human struggle with psychological, emotional, and behavioral problems. If you’ve got some, please send them my way. I need help in my tireless efforts to let go of my crankiness and embrace hope, especially when I wake up in the middle of the night.

 

Top Blogs for 2018

JSF Dance Party

Reviewing the past is a bit easier than predicting the future; so despite my love predicting what will happen tomorrow, today’s blog is about yesterday.

Last year was rough. Nearly everyone agrees on that, although I suspect that finding consensus on who to blame for last year’s roughness would make fodder for unpleasant argument rather than agreement.

In the midst of all this disagreement, I decided to see which of my blogs garnered the most interest. That’s sort of like picking out blog posts that were agreeable reads.

I recognize that this info might only be of interest to me. Then again, this is a blog and blogs are traditionally about whatever interests the blogger. Sorry about that. There’s no peer review. Apparently I submitted this post to myself and it passed my rigorous editorial review.

First, a look way back to late 2011 when this blog started with what one of my favorite topics: the amazing Mary Cover Jones. https://johnsommersflanagan.com/2011/11/25/a-black-friday-tribute-to-mary-cover-jones-and-her-evidence-based-cookies/

Back then, in 2011, I had a total of 1,522 blog “hits” with the top blog being a very short “26 Years with Rita” message. https://johnsommersflanagan.com/2011/12/30/26-years-with-rita/

In 2012, the first full year of JSF blogging, there were 15,486 hits, with the favorite new 1,167 hit post being “Two Sample Mental Status Examination Reports.”

Fast forward to 2018. Overall there were 156,811 hits, with the hottest post–by a landslide with 62,647 hits being. . . drum roll: “Two Sample Mental Status Examination Reports.”  https://johnsommersflanagan.com/2012/08/10/two-sample-mental-status-examination-reports/

The second most popular post of 2018 was:

The wildly popular 2015 post (with 14, five star likes) “Constructive vs. Social Constructionism: What’s the Difference?” and 11,691 hits. https://johnsommersflanagan.com/2015/12/05/constructivism-vs-social-constructionism-whats-the-difference/

The top three new posts from 2018 were:

#1: “Bad News in Threes” https://johnsommersflanagan.com/2018/06/08/bad-news-in-threes-kate-spade-anthony-bourdain-and-the-cdc-suicide-report/

#2: “The Diagnostic Clinical Interview” https://johnsommersflanagan.com/2018/02/27/the-diagnostic-clinical-interview-tips-and-strategies/

#3: “New Journal Article” https://johnsommersflanagan.com/2018/03/09/new-journal-article-conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/

Okay. That’s enough self-reflection. Soon and next, I’ll be posting my 2018 New Year’s resolution. Here’s to hoping that happens soon.

And for now, before we run out of January. . .

Happy New Year!

 

 

Predicting the Future of Psychotherapy and Counseling

Eta Cow Pi 1979

Ever since my sisters and I experimented with our Ouija board back in the 1960s (and possibly before), I’ve been fascinated with prediction. It seems, in retrospect, I should have been able to predict that, in 1985, I would decide to do a dissertation on personality and prediction.

The results were stunning. My discovery? Human behavior is notoriously difficult to predict. Although, to be honest, because hundreds of previous researchers had already made this remarkable discovery, it’s probably more appropriate to call it a re-discovery.

Slamming into the prediction is difficult reality hasn’t stopped me from loving prediction. Not even close. But that’s predictable too. Most people ignore reality; instead we prefer to fool ourselves into believing our own idiosyncratic magical thoughts and wishes. And so even though I incessantly brag about my ability to predict the future, I secretly recognize the truth; most predictions, similar to my annual March Madness picks, are mostly wrong, most of the time.

But the end of 2018 is near. And you probably know what that means.

It means people become more predictable. That makes this particular moment in time (late December) an unparalleled opportunity to accurately predict the future. On that note, I offer you my late 2018 and early 2019 predictions:

1. Right around December 24, families from around the world will gather together with love in their hearts. Many of these families will simultaneously experience both love and dread, partly because there will be predictable conflict around current politics and past family dynamics. But hey, that’s love.

2. Toward the end of 2018 and the beginning of 2019, the media will be preoccupied with “the best of 2018” and “predictions for 2019.” Will Mueller and Trump meet at a D.C. Starbucks for an amiable chat about whether to trade a witch hunt for a presidential resignation? Will Rudy be one of the top “Baby names” for 2019? Will White Nationalists suddenly discover (or rediscover) that Jesus was a Jewish person who loved diversity? All that and much more is coming your way.

3. And this, according to leading astrologists, “Capricorn rules the governmental structures of society: politics, church, monarchy, big corporations, monetary system, and macroeconomics.” Well. That’s obvious. What’s less obvious is that the pesky presence of Uranus and Pluto means there will be continued government instability; on the other hand, Jupiter is on it’s way, which signals a potential calming of emotional turbulence, as well as new prospects for romantic love. I should note that every year the astrological forecasts are the same: Romantic love may be in your future.

4. Rita and John SF will publish a short, new article on the future of psychotherapy and counseling. Wait. That already happened. Our fancy new article about the future was just published in the Psychotherapy Bulletin. You should know that, in this article, we don’t say anything about astrology, Ouija boards, or politics. However, we do construct a future scenario of what psychotherapy and counseling will be like in the year 2068!

I know this article isn’t as exciting as predicting romantic love in your future, but if you go to the link below and scroll down to page 7, you can read about the future of psychotherapy in an article with the fancy title: “Recursive and emerging themes in psychotherapy: Past, present, and future.” Here’s the link:

https://societyforpsychotherapy.org/wp-content/uploads/2018/12/2018-Psychotherapy-Bulletin-Volume-53-Number-4.pdf

And here’s the official citation: Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Recursive and emerging themes in psychotherapy: Past, present, and future. Psychotherapy Bulletin, 53(4), 7-12.

One more prediction: March Madness is coming . . . and this year, I’m more certain than ever, my bracket will be perfect.

My Closing Argument: Take a Breath, Check Your Moral Compass, and Vote for Checks and Balances in Government

California Street FootbridgeTrust me.

As the election closes in, I’ve been obsessed with perusing the literature on mass hypnosis. Trust me happens to be a rather common phrase among stage hypnotists and used car salespeople.

Then, this morning an unusual word popped into my brain.

Demagogue

Believe me, really, I thought of demagogue first thing this morning. Funny coincidence, did you know that Donald Trump used the words, “Believe me” 40 times in the 2016 presidential debates?

Here’s what Wikipedia says about Demagogue:

A demagogue (from Greek δημαγωγός, a popular leader, a leader of a mob, from δῆμος, people, populace, the commons + ἀγωγός leading, leader) or rabble-rouser is a leader in a democracy who gains popularity by exploiting prejudice and ignorance among the common people, whipping up the passions of the crowd and shutting down reasoned deliberation. Demagogues overturn established customs of political conduct, or promise or threaten to do so.

I can’t help but wonder, maybe every century or so, a natural-born demagogue comes along. It’s possible.

You already know I’m referring to Donald Trump. He is, unarguably, a talented, master manipulator. We can all agree on that. Go ahead and match up Mr. Trump with the preceding definition of demagogue. See what you think. You’ll see a match like you’ve never seen before.

Tomorrow, the democrats will mostly vote for democrats and the republicans will mostly vote for republicans. The question, for those in the middle, is whether you believe and trust that Mr. Trump is employing his vast skills of manipulation for the good of America. I doubt it, but maybe that’s just me.

My Montana connections tell me that the Trump played “Sympathy for the Devil” to crank up the crowd at his October 18 Missoula rally. The lyrics begin, “Please allow me to introduce myself, I’m a man of wealth and taste.” You can find the rest of the words online. But just in case you don’t have time, I’ll share this: when Mick Jagger sings the lines, “Just as every cop is a criminal, and all the sinners saints. As heads is tails . . .” it gets hard to break free of the song’s powerful grip. But at the same time, somewhere, down deep, it’s also hard to imagine that Mr. Trump is looking out for the welfare of the average American citizen.

No question, Mr. Trump is fantastic at conjuring up fear, division, and hate. He’s also a master at giving his listeners permission to think and act on their least morally upright and most unhealthy thoughts and emotions. Believe me on this too. After all, this is the guy who, at one of his rallies, said, “I’d like to punch him in the face.”

Often I’ve heard Trump supporters say, “I like him because he says what everyone is thinking.” The problem is that although Mr. Trump’s extreme and judgmental statements may resonate with his audience, embracing a philosophy where acting on or sharing all of our thoughts is encouraged is nearly always a very bad idea. In fact, I think it might be the opposite—along with shooting refugees who throw rocks—of what Jesus might recommend.

The truth is (and you should trust me on this because I’m a psychologist), some thoughts (and some emotions) are simply not ready for prime time. Convincing listeners (as Mr. Trump does) to follow their coarse, uncensored thinking toward action is a common magic trick of someone who’s goal is to produce a mass trance or hypnotic state.

He might as well be telling people, “Trust your thoughts. and trust me. You know in your heart and mind there are many things to fear, but I will keep you safe. I know your thoughts, your thoughts and my words are as one, bring them together and all will be well. Trust me, I will keep you safe. And you will keep me safe. Because you feel anger and fear and because I’ve so helpfully pointed out the enemy, we know what we need to do. Maybe some of you 2nd amendment supporters will take care of it for me. We share common fears and anger and thoughts and actions and we can move forward together and you can let me take care of the rest of what’s important. Trust me. Trust me to do that for you. I can do it better and bigger than anyone else has ever even thought of doing it.”

The big question is, how to break the demagogue’s hypnotic spell?

Unfortunately, the big answer is . . . it’s very difficult.

Step 1: Hang on tight to reason and rational analysis. A hypnotic state requires suspending rational thought, therefore, it’s essential that messages from the demagogue not be accepted without critical analysis. Seek input from alternative viewpoints. Don’t just trust me. Don’t just watch MSNBC and Fox News. Find content from the middle . . . and then fact check that too.

Step 2: Get out of the heightened and focused state of arousal. Hypnotic trances are states involving hyper-focus. If you’re feeling activated all the time, take time to meditate, reflect, walk around the block, and talk to your neighbor about life and death and health (instead of politics). The truth is that you don’t “need” the demagogue on either end of the political continuum. What you need is balance.

Step 3: Listen for the “Trust me” card. Right now, in this state of questionable news and Russian bots, it’s tough to determine who to trust. If you’re feeling that, then get out your favorite moral guidelines—it doesn’t matter whether your favorite moral guidelines include the Dalai Lama or the Sermon on the Mount or the Eightfold Path or the Ten Commandments or the Koran. Take your moral guide and then place what Trump is saying right next to it. Is Trump saying something consistent with what’s in your guide? Does your moral guide say anything about holding children in cages? Or does it say something like “Let the little children come to me.”

This brings me to my closing argument.

Now is a good time to stop and take a breath. Break free from the aroused state of hyper-focus. Consult alternative views.

If you do, you may recognize that most democrats are not members of an angry mob. You may also recognize that most republicans are not White supremacists. Democrats, republicans, independents, (and yes, even libertarians) are your neighbors. Love them.

Now is a good time to shake yourself free from someone (anyone) who tells you what you should fear, how you should think, and for whom you should vote. After shaking yourself free, embrace your moral guide.

If you need a more obvious voting tip, consider voting for a balance of power. Right now, we need the checks and the balances to do what they do—to provide checks and balances so one person cannot wield too much power. This is especially true when that one person keeps repeating the words, “Trust me,” because . . . and you know this in your heart . . . that’s never a good sign.

 

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

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.

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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/