psychology

28
NOV
2014

Fear of Mental Illness

The fear behind mental illness reflects the nature of fear itself: We fear what we don’t know. We can never truly know what is happening inside the mind of another person. We as people follow fixed rules most of the time. Drive through an intersection when the light is green. Wear some amount of clothing outdoors. Don’t cross the double yellow line. So many rules.

When rules are broken, it is jarring to us as bystanders. Perhaps that rule breaker is innovative. Perhaps that rule breaker is a genius. Or perhaps that rule breaker is sick. The more bizarre the behavior, as in something so unorthodox that we cannot construct a rationale to make the behavior make sense, the scarier it is. That person no longer fits the parameters of normal, and thus cannot be understood. Except they can be understood. Once the parameters are broadened, and we understand what is happening inside the mind of a “crazy” person, then they become just as human as anyone.

The typical example is a psychotic man. They may do “strange” or bizarre things. People are afraid of them. They may mumble to themselves all day long, or talk to people that aren’t there. They might run around naked. They might hide in unusual places. These activities don’t seem “rational” by traditional standards. We can’t understand it, and the easiest label is “crazy.” By categorizing these people as crazy, we know they’re not us. And yet with that comes stigma, because there is still no understanding in that label.

The way to destigmatize these conditions is not just to educate the public that these are people with illnesses, but to take it a step further and understand the process that led to them doing this.

An individual with psychosis (schizophrenia, for example) is having a break from reality. That is a definition for psychosis. This might involve hearing things that aren’t there (auditory hallucinations), having paranoia or bizarre thoughts (such as that aliens will be imbuing them with special powers). There are commonly occurring forms of psychosis, and people with psychotic symptoms often fit into one of these categories.

How does this happen? The short answer is it’s a brain malfunction, and they are thinking things that are fundamentally disconnected from reality. Some paranoid beliefs or delusions might pop into their heads. This is like what happens in a dream, when you know something without having any idea why you know it.

If you could imagine hearing a voice that no one else hears which whispers in your ear, making you question everyone and everything you trust, then you might start to understand the difficulties of someone with psychosis. I myself can only imagine, having never lived with it myself.

So this brain malfunction leads to this false information, until they don’t know what’s true and what isn’t. Within this world of misinformation, though, they’re acting as best they can. If the voice is telling them they are in danger, they might strike out at anyone approaching them. This is not because they’re evil, but to protect themselves. I once had a patient who stripped off his clothes because his voice told him it would help him outrun the devil. He believed it. It’s often hard, even if they know it’s not true, to completely discount this false information they are getting. Even worse than our attempts to filter mass media messages about what we should buy or think, the false information in someone with psychosis is coming from their own brains. It’s hard to learn to NOT trust yourself. That’s why they need our help and understanding.  When we can understand what’s happening, then it’s easier to remember they are people.

Psychosis feels especially scary since there appears to be a level of unpredictability, and thus dangerousness. Research has never shown psychotic individuals to be more violent than the general population. But we’ll get to more on understanding the nature of violence in an upcoming post.

25
NOV
2014

Positive Psychology, Lindsay Doran, and Story

Many months ago I attended a lecture by Lindsay Doran on Psychology as an approach to understanding story. It was hosted by the Blacklist.  For anyone interested, her Ted Talk covers much of the same material.

Ms. Doran is a studio executive that has helped in the development of a number of films, including recently The Lego Movie. She also has a fondness for Positive Psychology. For those not familiar, the wiki page is actually pretty good on the subject. In short, it’s an approach to human psychology that focuses on the positive side of functioning, such as how to become optimistic, or what helps someone thrive rather than removing a problem or deficit.

I believe this is a valuable approach to understanding the human condition, and adds a necessary perspective to a world very preoccupied with pathology and problems. Dr. Martin Seligman is one of the most influential leaders in Positive Psychology, authoring such books as “Learned Optimism,” and “Flourish.” In a world so focused on tragedy all the time, turning our attention to developing the good things makes complete sense to me.

Doran went on to reference Seligman’s core components of well-being, namely PERMA:
Positive Emotion – Simply, about feeling good.
Engagement – Being absorbed in a process or activity.
Relationships – Feeling connected and involved with others
Meaning – Finding purposeful existence
Accomplishment – Achievement as a form of success

Seligman identifies these as the components of having a fulfilled life. Doran believes they are the key to what makes certain movies successful.

Doran even uses these ideas (PERMA) as a lens to identify what makes films inspiring or uplifting. She further draws conclusions about the movie industry going too dark, and that just as positive psychology redirected therapy towards the positive, lighthearted films without tragedy (like Airplane, Young Frankenstein) are fun for fun’s sake. She believes there should be more of these lighthearted fun comedies that help us to vicariously just have a joyful experience.

I agree with much of her message, though I believe she might be missing some points.

Regarding PERMA, Doran references an audience researcher who stated that he knew that people don’t really care about accomplishments. So even though we can be fixated on an achievement appearing to be the entire point of a story, we only care about it when it is tied to other things in the life of the character. So the A of PERMA seems less important.

Positive emotions obviously have their own point, and I would agree that lighthearted films serve a great purpose. Laughing feels good. Sometimes we just feel like a comedy for ninety minutes.

On the other hand, positive emotions on their own lack context. Sometimes what makes comedy so wonderful is that it is “comic relief,” as in relief from heavier topics. A comedic movie is really our comic relief from the heaviness of everyday life.

Movies serve a greater purpose than simply to entertain or distract. They serve a purpose in reflecting on the world, and in helping us gain perspective on how to live. Doran herself states that one of the purposes of movies is to answer the question of how we should live.

It is in that question that I believe Doran loses focus. She emphasizes the Positive Emotion of PERMA, while not sufficiently emphasizing the Meaning. I think she nails it with the importance of relationships, and has a direct point that women want to watch movies about relationships, and that men can only handle the relationships indirectly. Accomplishment in movies only feel good when it’s shared with someone.

This focus though on accomplishment and relationships, as well as on the positive, misses the reason that the industry has turned dark. We suffer. People feel a sense of suffering every day, and they are looking for some way to understand that. They are looking for meaning from it. And in the absence of meaning, they at least want to not feel alone in it. They want resonance, and portraying a dark theme that matches what they feel about the world resonates with them.

I posit the idea of suffering and sacrifice as being important values. In writing we set up stakes for protagonists, and often put them through hell to earn their accomplishment. That protagonist suffers and sacrifices, and what they do with that suffering and sacrifice gives meaning.

In that way it is the transformation of negative into positive that we want. We want ways to get through our own suffering, whether that be light movies (respite), or darker movies finding meaning (transforms suffering into something useful). Dark movies can masquerade as jaded, when really they may be vicarious relationship movies, where we can feel connected to someone who has suffered the way we’ve suffered. Which comes back to the idea of not wanting to feel alone. We connect to a character. We don’t want them to die because we want to stay connected to them.

Of course I agree with the point made by many (including Doran) that our fascination with pathology and problems, with what’s “wrong” can miss the larger picture. That process can even result in getting stuck in bad emotions, such as wallowing. Yet a focus on the Positive Emotions of positive psychology seems to neglect the real human suffering that occurs.

We become whole not through avoiding the negative but through owning it and transforming it.

Doran pulls many references from the AFI list of top 100 films to explore her hypothesis.

I’d like to look at a different movie, that of Cast Away.

At the surface it’s a story about survival. Chuck Noland (Tom Hanks) gets deserted on an island, away from the love of his life. He suffers. He learns to survive. He becomes so lonely he makes a relationship with a volleyball to have a friend. He builds himself a boat and gets away. We feel for him throughout. It’s primal. We see him cling to the last remnants of civilization in a beautiful butterfly on a box. He gets home, and he loses again. The love of his life has married someone else.

I love this movie. It was a massive success in the US and internationally. It doesn’t have many positive emotions at all. He loses his fiancee. He doesn’t accomplish anything but survival. His relationships are almost nil. He loses his entire identity. So it should be depressing. And yet there’s a transformative hope built into the film. We watch him suffer, and he finds a way out of it. There’s a lovely monologue of him talking about his loneliness and despair, and how he just remembers to keep breathing. A message for us all.

Finally he delivers this box that had kept him inspired. He meets a woman and we have a glimpse of hope. Maybe he was meant to meet her all along. Or maybe that’s my interpretation of it.

It’s a beautiful story of survival.

Viktor Frankl pioneered his own approach to therapy long before Seligman, which focused on meaning. I recommend everyone should read his book Man’s Search for Meaning. It’s a quick read. He was a psychiatrist who survived the concentration camps. At the time the wisdom was that when men have enough taken away from them, they’ll revert to animals. His experience was that people could be incredibly kind, and that those who survived had a reason to live. They found meaning and purpose in their suffering, even if it was just to survive to fulfill their purpose.

Now I don’t want to pretend that suffering, sacrifice, and transforming it into meaning is the key to what makes all movies powerful. Doran has clearly broke some great conceptual ground in thinking about films with a lens other than traditional formulas.  But the Meaning component seems underemphasized by Doran.  I heard many that night say that it was a transformational experience for them, yet in the vein that I hear so many emphasize “positive thinking” as a solution to the parts of themselves they dislike.

When we overvalue any one side, we miss the whole picture.

08
JUN
2014

Your Partnership is a Fantasy

Yes, I’m being dramatic and the title probably borders on clickbait. And yet it’s true. When I refer to partnership, I mean the idea that two people join equally at all times, make decisions equally in all things, and that no one ever dominates. It’s a beautiful utopian idea, post-modern gender roles, where neither “partner” does more than the other. It just doesn’t exist in reality. For the purposes of illustration, I write about roles here in a heterosexual male/female relationship, though this is all easily applicable to same-sex couples.

Perhaps there are moments when two people are in absolute sync, thinking and functioning as one, and do things at the same time. But that’s something else, rather than a partnership.

A partnership doesn’t involve two people “equally” making decisions. To illustrate how a partnership really works, let’s look at the image we hold (or maybe just I hold) of the 1950’s stereotyped household. The husband earns money via his job, the wife takes care of the home. In this model, the man is authoritative, the wife somewhat submissive. Really this somewhat suppressive dynamic existed through a lot of history, even in hunter/gatherer and child rearing roles. It was functional. It served its purpose. For a time, both sides knew their place in the dynamic. In modern society though we have higher standards for a relationship. It becomes uncomfortable to be stuck in a single dynamic permanently.

In reality there is always someone dominant, or someone taking the lead in a situation.

This person is the more active member of the dynamic. Watzlawick talked about this role as the “one-up.” The complementary role would be the “one-down,” or passive role in a relationship.

The giver and the taker. The giver and the receiver. The leader and the follower. The dominant and submissive. The talker and the listener. The caregiver and the sick one. The rescuer and the vulnerable. The leader and the participant. I could go on for quite a while about how these dynamics help us to have purpose, and how we may stumble upon these in our youth. Maybe we began this with our parents or someone else, and then get pulled emotionally into them again and again in other relationships. They become comfortable for us. We know how to function in them. It’s a functional dynamic, in that it works.

In a healthy relationship, though, one person will not be the active or dominant person in the relationship all the time, in all areas. There has to be switching, ways for people to have time in both the active and passive roles.

In a conversation, for example, there could be a designated talker and listener. That’s a functional dynamic. It can work for a while. Eventually there needs to be a switch, though. The listener needs to have time to speak. That’s what makes it a real conversation and not a monologue. That’s what makes it a healthy relationship.

So here lies the distinction between a functional dynamic and healthy partnership. A functional dynamic involves two people taking their two sides, the one-up and one-down in some area. Both people know their place and can engage in that. They work well together in this single situation. It’s functional in that they cooperate to get things done. If this is fixed and pervasive, though, then it becomes unhealthy.

What if there was literally a dominant and submissive role at play here. The “wife” who manages the house goes shopping and she has to get approval for every little thing she buys at the store. What kind of eggs. Whether to buy milk or not. Everything. While this seems to continue the stable dynamic of her being submissive, its pervasiveness could be stifling to the wife. It might be equally be exhausting the husband, to have to make every decision for her. She has to have some room for freedom. She has to have an area where she can be active and in the “one-up” role.

So a healthy relationship often has designated areas of responsibility. Separate areas where each person is the more active member, and their partner becomes passive in this area. And then there’s role reversal. This is a particularly healthy strategy for a partnership, when both have some investment in an area and want to participate actively. It’s simply to take turns, as in a conversation. In the first instance the husband takes the lead, in the second the wife takes the lead.

An easy way to illustrate this whole process is in sex. While it’s beautifully (or tantalizingly) portrayed in movies that when two people have sex they’re enmeshed, they both feel all the pleasure at seemingly the same time, and they climax simultaneously, reality is much more clunky. In a heterosexual relationship, if the man orgasms first, the woman may never achieve an orgasm. This is a stable dynamic (meaning some people do this for years), with one side basically taking and the other side giving. It leaves the woman unsatisfied. He may even be oblivious to this. An alternative could be making sure that the woman orgasms first, and then the man. They take turns, to make sure both receives what they want. Now of course this requires each person to be willing to take their turn “being selfish.” With oral sex this is even clearer. One person receives and the other gives. The receiver is allowed to be selfish during that period, knowing that the roles will be reversed in the future.

Now let me add one additional layer. No dynamic is ever fully one or the other, but can have both sides co-existing. The man giving oral sex to his female partner is giving rather than receiving, but can take satisfaction in the process of giving, in causing pleasure in his partner. The partner who is receiving may feel guilty about receiving, about being “selfish” and just feeling pleasure for what it is. The receiving partner can know though that while they are receiving, they are serving their giving partner by allowing their giving partner to feel good about giving. Giving can feel good all on its own. We’ve all met people who are seemingly selfless in a relationship. That can be nice for a time, but ultimately a source of burnout if it isn’t reciprocated.

Because in truth a single dynamic never serves all the sides of someone. A dynamic can be stable, for a time. But if there is never any changeover, it will become fixed and thus prone to break should any outside pressures get involved. What happens if the active gets in an accident? If the passive member of the relationship has never had to be active ever, they might fall apart. We want to encourage opportunities to experience both sides.

The more we’re stuck in only one dynamic, and unable to try out reversing roles in some contexts, the more fragile the relationship. This is usually not about subverting or taking advantage of the other person. Not usually. As long as the needs of both individuals get met, and the roles are not especially rigid.

So having a “healthy partnership” really involves some agreed upon designated responsibilities for each, where each person is the more active in that area, and there are times set aside for taking turns in other cooperative areas. When full agreement has to occur in an area of conflict, it’s important both sides can feel they’ve had a turn at the active role. Both people have had the opportunity to talk and have the other side listen.

The dysfunctional alternatives not mentioned are when both sides try to be active (or dominant). This leads to a continual escalation to try to assert authority. It becomes a competition, rather than a partnership. Or just as bad no one makes a decision or takes an active role, and the couple is paralyzed by inactivity.

Keep an eye out for this in your relationships with friends, family, and even professional relationships. How could the partnership be shifted to make sure everyone feels like they have had their equal time and roles in the relationship? Is your partner uncomfortable taking the other position in an area? Might they secretly like to take turns in something? Just more food for thought about relationships.

21
OCT
2013

Resetting the Bar

I’m not a fan of competition. It brings out the worst in people, while trying to bring out the best. So of course I have difficulty understanding athletes using steroids or doping just to win a contest. These drugs have possible health consequences after all. For the athlete, I’m sure they believe it’s about achievement and maximized potential, but it’s driven by trying to be better than the other guy. The bar is set by another person.

With that drive they are willing to do “whatever it takes.” Train more. Work harder. We as spectators encourage it and set up an environment that doesn’t reward holding back. Those that hold back anything that might enhance their performance don’t last too long in competitive sports. Once someone else becomes the standard to be matched or exceeded, they determine the bar for “normal.” Anything less is unacceptable.

In society we have a name for functioning below the level of “normal.” We call it impairment. As a psychiatrist I am supposed to intervene when someone has a mental impairment. Physicians usually define normal as the range of functioning of the average person in society. Not having enough energy to get regular activities done is an impairment. As society pushes people to pursue one’s “full potential,” expectations shift up for “normal.” People view normal by unnaturally high standards, and feel disappointment if they don’t meet it. Performance enhancement becomes common, normal, and expected.

When I was twenty-two years old, I did my job with five hours sleep and little to eat. That was normal then. Now in my thirties I need three cups of coffee to get the same amount of work done if I’m sleep deprived. I view it as necessary and justified since the work needs to get done. It’s normal. In medicine we’ve trained ourselves to maximize functioning without sleep, because it’s expected of us.

While it’s possible that my medical training has skewed my view of athletes, college students don’t seem to find performance-enhancing drugs in athletes acceptable either. Last year, in a study in the journal Psychology of Addictive Behaviors, authors Dodge et al., found that college students viewed such athletes as “cheaters.” These same college students, though, believed it was all right to abuse stimulant medications (not prescribed) to do better academically. They did not consider that misuse of stimulants to be cheating. The more they themselves had abused stimulants, the more judgmental they felt about athletes. Stimulant abuse is rampant in colleges, with students attempting to enhance their academic performance. If their classmates are using them and scoring better on tests, the bar is raised, and a new “normal” is set.

I routinely have patients who come to me asking if they have ADHD. More of the time they insist that they have it. They insist because they’re sure they have attention problems. Or because they tried their friend’s Adderall and were “able to focus so much better.” In their minds, improvement on a drug must indicate a diagnosis and thus an explanation for the difficulties. I even have parents of patients who presume that the lack of A’s must indicate ADHD and insist on my prescribing stimulants. Two hundred years ago people weren’t expected to sit in a chair for eight hours a day. Today we have a diagnostic construct of ADHD. Now this isn’t to say to that ADHD doesn’t exist, as we have all seen children who really struggle with this condition.  But perhaps thinking about our expectations reveals the slippery slope that leads to overdiagnosis.

As we’ve stumbled upon many ways to “enhance” functioning, to maximize what we can do with our bodies and minds, the bar shifted on normal. We expect people to perform at that new level. If they can’t, it must indicate a deficit. Such a progression leads to less and less tolerance for any impairment, distress, or problem. In the end, this is really about performance at all costs, masked in the pretense of “treatment.” In 2008 a group of eminent scientists published a commentary in the journal Nature, calling for regulation to allow “cognitive enhancers,” namely open use of stimulants to improve brain function in the average person. Implicit in their argument is a goal to “call a spade a spade.” In that argument, people use drugs to do better at tasks, so let’s call it what it is. I reserve an opinion on the matter.

It’s easy to have perspective on something we ourselves are not doing. Once we have incorporated it into our routine, we develop rationale to justify it. I can understand how the college student thinks “athletes shouldn’t use drugs to win at sports, but keep your hands off my Adderall.” Personally I believe students shouldn’t use ADHD drugs they aren’t prescribed to do better on tests. It’s wrong for them to misuse drugs just to be able to take tests.

Just don’t take away my coffee. I need my coffee.

10
OCT
2013

On Balance in Relationships.

This isn’t just about balance.  Or how to stay connected.  Though it serves all of that.

I touched on this just a little bit in my post about burnout, but I want to get into Balance in Relationships.

We’re asked to care.  We’re asked to do something.  We’re asked to invest time and energy.  This is usually about a person.  Sometimes it could be a project.

John was a military vet.  He didn’t have to be.  He could have been my childhood friend, or a guy I made friends with in a coffee shop.  In this case I met him where I was his doctor, and he was my patient.  I sit down with him in clinic, and I see a long list of “problems,” from medical issues to PTSD and many notes about “personality” issues.

Two seconds after I sit down, he pulls out his own list, but these are things he wants from me.  Medication refills?  Easy enough.  Help with disability?  Let’s investigate.  Call his landlord and advocate for him to keep his apartment after causing problems?  Maybe I’ll help.  Call his parole office?  Hmm.  Prescribe him medical marijuana?  Well…

It isn’t long in this interaction before I start disconnecting emotionally.  It’s natural to want him to leave, because he is putting all the burden on me to fix his life.  To a tiny degree I understand that, as it’s supposed to be my role to “help” him with many of his problems.

So let’s say I spend a couple extra hours trying to help him with everything he asks.  At the next visit he comes back with new issues, and this time he wants me to write a letter for court saying he has PTSD and that he shouldn’t be held accountable for some things he’s done.

Now let’s pretend that John has other issues.  Maybe he’s an alcoholic, and my repeated pleas to get sober haven’t helped.  Or he’s my brother (I don’t have a brother) and asks me to loan him money for the tenth time.

All of these situations feel emotionally taxing on me, and a common response is to disconnect.  I feel tired pouring more energy into a situation that isn’t changing, and I want to just stop. Maybe at best I keep going through the motions.  For those in a role where we’re supposed to stay emotionally connected to people (such as healthcare), it’s helpful to not get apathetic.

So I happened upon two simple philosophies that have helped me to stay balanced, particularly when stressed.

1.  Don’t work harder than the other person.

As sad as it sounds, this is their problem, not yours.  If they’re bringing the issue to you, they need to be willing to meet you halfway.  Now halfway might be different for each person, but the idea of effort is what’s important.  If you find yourself over-investing, doing more or all of the work, that is a recipe for burnout.  Once you’re pouring yourself into something, if it fails, you feel jaded.  You then want to withdraw and not try again.

There’s a much longer discussion that can be had about how to get someone to invest.  Another time.  Here, though, not working harder than the other person can often feel like pulling back.  And if we pull back too much emotionally we can end up apathetic, not caring at all.  So then comes the other side of the coin –

2.  Cultivate a feeling of Detached Compassion.

I want to hammer both words in there.  DETACHED.  Meaning disconnected from the outcome.  Aim high, but don’t set up your emotional payoff on the win.  COMPASSION.  Meaning you still care about the person.  Stay connected to the person, but disconnected from the outcome.

Especially since a lot of the time people don’t want things fixed, they want someone present for them.

As you pay more and more attention to this balance of effort, investment, and connection, you’re really cultivating mindfulness.  Mindfulness (which needs its own posts), which I’ll simply define here as awareness, without reacting.

30
SEP
2013

How to Not Burn Out

“I just can’t do it anymore.”

People burnout everywhere, in every field. They burn out professionally. They burn out in taking care of others. I live in Los Angeles and I can understand how just driving a car can burn someone out in this level of traffic.

No one plans to burn out. Maybe they do have a little awareness that they’re going down that road, though.

We have a level of control over where we place our attention, as well as our effort. If you’re worried you’re burning out, consider preventing it.

There’s two parts, I believe, to preventing burnout.

For the first, I’d like to borrow from a simple model I first heard from Dr. Christine Moutier (a psychiatrist and former supervisor of mine at UCSD), modified a bit here. Imagine a gas tank. It’s feeding an engine. That engine is you. If the engine shuts down, you shut down.

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This gas tank has a leak in it. It’s losing gas. Gas is pouring out. Eventually if we do nothing, the tank will be empty. When it’s empty, the engine stops. It doesn’t run anymore. The engine burns out.

We don’t want the engine to stop, so we need to fill the tank. It has to be filled faster than it’s losing gas. In life we each have our strategies to fill the tank. Sleep. Food. Socializing. Rest. Sex. Yoga. Watching TV. Meditation. Talking to people.  Exercise. Make a note of your ways to fill the tank, and note what others do, since one way might not be enough. One way might not be able to fill it fast enough.  It’s for your own well-being.

On the other side, look at the size of the hole that gas is leaking out of. This is the effort we put out into the world. We can try to narrow the hole, to hold back. That may be effective, to a degree. If done too much, it leads to apathy. The hole can’t ever be completely plugged up, in a normal life.

It’s not a particularly complex model, I’ll give you. Yet really smart people neglect themselves all the time. They think their tank will never run out, as if there’s a secret reservoir somewhere. Running on empty hurts the engine. So the first step is to keep the tank filled.

The second part of not burning out is to Not Overextend. We all have projects we’re asked to be involved in, whether that be something at work or even fixing up something in the house. Or maybe it’s arranging an event for family or friends. Presuming this is not a startup business that is your idea, ask yourself – how much am I putting into this? How much are the other people putting into it?

Here’s the key: If you’ve been asked to do this project by someone else, and you decide to invest a lot of time/energy in it, make sure the other person is as invested in it as you.  The plan, the approach, and if possible, the energy/time.  If you’re thinking up a lot of aspects of it, make sure the other person agrees along the way, or has as much skin in the game.

Let’s say I’m asked by my wife to plan a party for our friends. I put a lot of time into planning and arranging it, and then my wife tells me she doesn’t like what I did. I devoted hundreds of hours into the project, she devoted none. My response to any criticism she might have is anger and wanting to quit and disconnect. I would feel burned out. Such is the way when only one party in a group does most of the work, and the other critiques or doesn’t support it.

Now in many situations the division of labor is unavoidable. One side will do more work than the other. Chances have to be taken. When they are done with open eyes, though, the disappointment may be less.We can clarify the point, then, that the other party needs to buy into the plan at least. Don’t overdo it expecting the other party to be wowed by the amount of time you’ve put into it. What if they aren’t? You may end up apathetic and withdrawn. Check in with them frequently, to get their buy-in on the approach, so they won’t be surprised, and you won’t be surprised. And finally, try to discern endeavors that might not be worth the investment.

23
SEP
2013

In Brief for Those New to Therapy

If you ask ten different therapists what it is they do, you’ll get twenty answers. A therapist talks. A therapist listens. Using the term “therapy” implies only one thing, so for those who don’t know what therapy is, it’s hard to get a grasp on it. It’s even harder to understand that there’s many types of therapy.

So let me begin with a comparison to religion. Religion is similar to therapy, in that they both have belief systems. Therapy is usually based more on research and evidence, though, rather than faith. Trying to pretend that there is one “religion” doesn’t help to define what religion is, or to understand the different religions. Nor does understanding Catholicism tell you much about Buddhism. Understanding Catholicism does of course give you a frame of reference to understand other religions, but its minutiae don’t tell you about the minutiae of other religions.

I’ve studied and trained in a number of different psychotherapies. Psychodynamic, Gestalt, CBT, DBT, hypnotherapies, brief strategic therapy. Within that there are others such as supportive and insight oriented therapy. Maybe some of these are better fits for you as a patient than others. That’s fodder for a longer post, discussing what to expect from each therapy style. I’ll get to it. In the meantime I hope the idea can be seeded that no one therapy is absolute, and that change can come about in many different ways.

Let’s get to some myths and misunderstandings about therapy. Therapy isn’t simple. And it isn’t just listening or support. Or at least it shouldn’t be. It’s idealized from those outside. As if a little support is all that’s needed. As if people go to therapy to vent or complain about others, and somehow they come out “fixed.” That’s never how it works. Real therapy is more than that, and should be more than that.

Therapy is about change. This can be changing how you feel or think or function in life. It usually comes about through working with a therapist. A relationship is formed. Usually trust develops. This alone can help some people change.

Beyond this there are a number of strategies and theoretical systems. There’s simply talking about whatever comes to mind, developing a relationship with the therapist that can reflect other relationships, recognizing and changing thoughts to change feelings, changing behaviors or exercises that alter the way you feel. It can be about changing patterns in life.

Sometimes therapy feels good. Sometimes it involves a lot of effort. Both can be important.

There is not only one way to do therapy. Many therapists will become dogmatic about their approach, as if their way is the only way. I would again draw the comparison to religion. Many therapists become invested in the approach they learned first, just as many people stick with the religion in which they were raised. They may even push the belief that their approach is better proven than others. Other people wander and explore various approaches, for better or worse. The skinny on this is that different therapy styles may be a better fit for you as the patient (aka client or receiver of therapy). If you don’t feel like you’re making progress through therapy, perhaps it is a bad fit with the therapist or the style being used. Also it is possible that you’re not feeling a good fit because that which is being stirred up in therapy (bad feelings, annoyances, etc.), may be exactly what needs to be worked on in therapy.

Being told exactly what you want to hear is usually not that helpful in therapy. If that is all you want (to vent and be agreed with), then I’d suggest that therapy may not give you what you’re looking for.

Oh, don’t get me wrong. You may find someone to agree with you and allow you to vent the whole time. That alone may not lead to the change you want in your life, though.

19
SEP
2013

Psychotic vs. Psychopathic

They aren’t the same. Going back to at least Hitchcock (one of my faves), who brought the muddy term “psycho” into the public psyche, conflated the definitions as if all are violent, and all “crazy” is crazy.

I’m sure there are briefer answers out there for those wondering what’s the difference between psychotic and psychopathic. And even though SRSLY made it into the OED because of its widespread use, lay inaccurate uses of the term psychotic will likely not.

Briefly in discussing how we got here, the words are interchanged because they sound alike, and are used commonly to describe someone “out of control,” often in an unpredictable or dangerous way.  In a way that is accurate for both.

Psychotic refers to someone who has detached from reality in a severe way that the common person would believe they are ill. Common examples of psychotic disorders include schizophrenia, schizoaffective (kind of schizophrenia and bipolar in one). People with psychosis can have hallucinations (hearing or seeing things that aren’t there), delusions (believing things that are known to be false or fantastical, like aliens are controlling their mind through a chip), paranoia (belief others might be following or trying to hurt them), magical thinking (believing they have special powers or could control things that they cannot), or ideas of reference (believing TV or commercials has special messages inlaid just for them personally). Now there are some mimics for any of these, so a single symptom shouldn’t be taken as proof of a condition, but instead the whole picture examined by a professional. Even then many professionals can get it wrong. We do the best with the information we have available.

People with psychotic disorders seem scary because their break from reality can make them unpredictable. Research evidence is quite mixed as to whether they are more dangerous than anyone else. Aside from some individuals who make headlines in terrible ways, on average they probably are not more dangerous than anyone else.

Psychopathic refers to someone without a conscience, who exists on a spectrum from your con man (self-involved, uses others for own benefit, not prone to violence) to the serial killer (predatory, gets aroused by hurting people physically or causing suffering). Psychopaths are scary because they seemingly have no limits to what they might do, including hurting others, just for their own benefit or enjoyment. If you want a bit more detailed discussion about psychopaths, see my posting here regarding Walter White and Breaking Bad.

Is it possible for someone to be BOTH psychotic and psychopathic? Unfortunately, it is. That raises all kinds of other topics, and I’ll leave that for my fictional writing.

Is being a psychopath a mental illness? That is an area of debate, both between mental health professionals, and between government/social services individuals and mental health professionals. Attributing it to an illness lessens the idea of culpability and choice, and directs thinking towards treatment and rehabilitation (of which there is little evidence that much works, though there are some small projects out there that might). Not attributing it to a mental illness or even acknowledging the lack of treatment options means the intervention of choice is containment (usually in prison), which raises all kinds of larger questions – should it be the crime that leads to containment? Can professionals feasibly identify psychopaths and identify those who can’t improve? A lot of controversy has arisen regarding the overuse of the PCL-R (a tool used to measure psychopathy), and that misidentified people might be incarcerated indefinitely. The UK has had an interesting experiment with all of this, with the government wanting psychiatrists to treat dangerous individuals with personality disorders. The psychiatrists didn’t want to do it, so the government forced the issue, creating their own name of DSPD (Dangerous and Severe Personality Disorder), and mandating that psychiatrists intervene. It’s an interesting social experiment, and continues to raise questions and controversy.

16
SEP
2013

Portraying Mental Illness in Story

Mental illness as a term gets thrown around a lot. It’s used by politicians as a scapegoat for problems or a target for funding. It’s sought by individuals to find meaning to their experience, or sometimes a justification for their difficulties. It’s a thing, talked about like any other disease. And yet the term is a lumping of many conditions under a single term, as if all mental illnesses are the same. They are not, but we talk about them that way and “let the experts sort it out.” I get that. At the same time it maintains the mystique and stigma behind mental illness. Because that is what the average person fears – the unknown. By keeping it labeled as one thing, whether that be to ostracize, excuse, or empathize, without educating the public more, we continue to leave it as a large unknown. So the stigma continues.

Media portrayals of mental illness usually fall into one of three categories:

1. Spectacle

2. Educational

3. As a relatable factor to human struggle and suffering

"Crazy" blonde girl.

The first reason clearly stands out as the most popular use of mental illness in the media. I can’t count the number of characters nowadays in movies and TV who are given mental illnesses primarily for the purpose of making them “different” or interesting. This misses the boat though, particularly when added to secondary characters or even worse, villains. The spectacle of the mentally ill involves the “crazy person,” usually meaning dangerous or unpredictable, which can be used for plot turns or as an explanation for the odd character. “He’s just nuts, man.” No one is “just nuts.” We miss the truth when we oversimplify.

Of course spectacle is the purpose of much of film and television. It’s entertainment. It serves its purpose in our lives. Using mental illness to have the “crazy guy” in a group of friends just becomes cliché, though. It isn’t that entertaining, anymore. And in the world of political correctness, it’s offensive.

Any good writer will not hold back from offending now and then, sometime more than that, all for the purpose of telling a good story. I don’t hold back, and others shouldn’t if it truly enhances the story. Adding in a mental illness just to add a character quirk can lessen the story, though. If the intention is to make the person more interesting, but is done only as a spectacle, where it doesn’t serve the larger story, then it hurts rather than helps.

I’m watching “The Bridge” right now, an FX TV show where one of the leads, Sonya Cross, appears to have Aspergers. In examining the story, it isn’t clear at first what the purpose is to the story of her having Aspergers. It isn’t a story about Aspergers. It does contrast well with the “normal guy” of her partner, detective Ruiz, who fits a different cliché of a cop. That may enhance the story as it makes her behavior and his more noticeable (by contrast), but there has not yet been revealed how her having these particular characteristics, with difficulty in social engagement, makes the serial killer stories more powerful. It may raise some obstacles against her pursuing the killer(s) as efficiently as possible, but that more extends the story rather than enhancing it.

Robert Mckee talks about this a bit in his book Story, when he describes the difference between characterization and character. Characterization are the demographics of an individual – their height, weight, job, clothing, background. That isn’t their character, and for the most part that isn’t what makes a story good. Whether it’s an accountant or a lawyer lying to the district attorney doesn’t matter as much as we might think. Character is revealed through the choices people make, with decisions under pressure revealing their deeper nature. Mental illness as a characterization doesn’t enhance a story. If it is left as that, as window dressing, then it’s a missed opportunity.

educational blocks

The second reason, that of educational, isn’t particularly useful in stories, either. I view it as the antithesis of spectacle. In fact, it’s usually boring. Royal Pains did some groundbreaking work from a health advocacy role by portraying a depressed person, and having that person receive ECT. It was shown realistically, with the usual anesthesia and care involved. Much of the episode centered around the stigma and one character fighting to keep the other from receiving ECT. When the ECT session was finally performed, all that was spoken was – “gee, you’re right, it really is a great thing.” It felt boring and didactic. While I appreciate the writers choosing not to further the cliché and inaccurate stereotype of ECT (e.g. Cuckoo’s Nest), it didn’t work as well as it could have as it wasn’t delivered in a way that enhanced the story. It became a story about stigma, which isn’t what the show is really about. Educational approaches require an investment from the viewer, and always risks losing them if it feels like just conveying information, similar to exposition in story. Exposition slows down a story. Education slows the story, and risks losing the audience. Even documentaries have a story structure to them to keep the audience invested.

Educational portrayals follow the rationale that “if we can increase awareness, that will solve the problem.” I disagree. Creating understanding and empathy is more important, and that comes not through the conveying of information, but through feeling a personal connection to another person, even if fictional. It is here that the true benefits of portraying mental health in media lies.

ideas

The third reason is as a relatable factor to human struggle and suffering. Mental illness is not a foreign entity. It is not like cancer, or something that “someone else” gets. Well, sometimes it is. In reality it’s usually a more extreme version of issues everyone struggles with. This is the avenue not only to make a character likable to the audience, but to make the path of that character relatable relevant to the path of the audience. Many people struggle with depression at some point in the life. Even more have lesser bouts of depression that they muddle through. Telling a story about someone with a worse depression could help the viewer, while also just being a compelling story. While psychotic disorders don’t seem relatable, more people than you’d imagine have an episode in their life where they feel like they’re “losing their mind.” These conditions are interesting because they are the extremes of human experience. The keyword is human. Understanding how to take what has been traditionally spectacle, and reveal the authentic human side of it that is relevant to everyone not only makes for good story, but indirectly helps with the stigma. Just as Orange is the New Black didn’t take the approach of a political campaign saying “women are marginalized in media.” Instead they told good stories about women, that made them empathetic and broke the mold on prior clichés.

So I encourage my fellow writers (as I remind myself) to think beyond cliché, spectacle, and even educating when it comes to portraying mental illness in story. Let mental illness be a window into humans, and let that enhance the story as a whole. Otherwise, the portrayal isn’t serving anyone.

03
SEP
2013

10 Life Lessons from a Psychiatrist

I run into the same issues everywhere, from patients, co-workers, and friends. People are stuck, and not sure how to “un-stuck” themselves.

I’ve noticed some basic rules on how to live a more fulfilled life, to make life easier, and make you more effective.

Consider them like guideposts if you feel off track. Some may be obvious. Others, maybe not so much.

It’s not about knowing them.  It’s about where you put your attention and effort.

1. Be Polite

I’m not suggesting to be fake or disingenuous. Instead find the way to being kind to others. And if kindness can’t be found, then at least be civil.

You may get what you want by being rude, angry, or demanding. The squeaky wheel does get the grease. In the process, though, you’ll burn the bridge with the person you’re getting it from. They won’t respect you, and given the choice they wouldn’t help you in an accident. I’ve worked with plenty of people that steamroll over others to get what they want. A lot of the time they still get what they want, but no one likes them.

If people like you, they’re more likely to want to help. Create allies, and start by being nice to people. Especially when you have no reason to be nice to them.

2. Be Flexible

I’m not talking about doing yoga backbends. This isn’t about physical health.

This is the holy grail in functioning in life, IMHO. The way to mental health is to develop flexibility, being able to function in a variety of situations, to find appreciation wherever you are, to be a leader when a leader is needed and a follower when that is needed. And to find enjoyment in every role. To be able to see multiple sides of every issue, and appreciate the opinions of everyone. Even if you disagree with it. Even if its hateful, to be able to understand what led to that person having that opinion.

See #10 for more on this.

3. Pick Your Battles

Stand up for yourself when you can, and when it will help. Assert yourself to make positive changes, but not just to exert your will on others. Don’t let yourself be trodden down by others, but be smart about it. If it’s important to finally stand up to your boss, do you have a backup plan?

People have variable lengths to their fuses. Some will let themselves be beaten down their whole life, never speaking up for what they want or believe. Others snap violently at the tiniest provocation. Neither approach works to get your needs met. Think ahead and plan the next three steps after you stand up for yourself, and plan how to weather the worst possible consequences.

4. Be Open to New Data

Medicine has few certainties. During medical school the lesson was: “Twenty years from now, 50% of what we know is fact will be wrong.” In a field of explosive egos and paternalistically telling others how to live their lives, it’s hard to be able to admit fault. It’s absolutely necessary though.

I could be wrong about everything here. I know I don’t know anything for certain. Anyone that says they do is wrong. This is more than being humble. New information could arrive at any point, and if we choose to selectively ignore that information because it’s a blow to our ego to change our minds, then we’re living in a delusional world. We’re ignoring reality.

I very rarely get all the information on someone’s background to be able to even make a definite diagnosis. I get pieces, and I put together the best picture from that information. If new information comes in, I have to revise that picture.

Think about your own philosophy on life. Any one thing you take for granted. Would you be willing to admit you’re wrong if some new information came in that didn’t fit? Most likely you’d want to discredit it, unless it came from someone you trusted.

The better stance is to be open to any credible information, and to recognize any belief or idea is only as good as the data it is based on. This is also the way of science, usually. At least when politics aren’t involved.

5. Paradox is the answer to many puzzles

I could give a thousand examples of this. You get more by giving. When in the black hole of desire and want, feel better through focusing on gratitude. Strength comes through vulnerability not hardening the walls. Fears are broken through experiencing the fear, rather than numbing it. Giving is the best way to get people interested. You have to stop chasing a dream to get it to stop running away.

We are creatures of habit. We do things because they worked in some way, at some point in the past. So we keep trying to do them, stuck in the hammer-nail paradigm all the time. We do what we do because our approach makes sense. It fits common sense.

Sometimes what we intuitively do is very effective. But sometimes it doesn’t work at all. Conventional wisdom tells us to “fight harder” and do more of it.

If you’re stuck on a problem, consider trying the thing that doesn’t make sense. Oppose your intuition. Trying to keep things from getting worse sometimes just makes the problem last longer. We do it because common sense dictates that things would be worse if we did anything else.

When desperate for love, we’re in a place of want. We desire. We feel empty, as though there’s nothing to give. We want someone else to fill us with love. Yet giving without expectation may be the very thing that results in getting what you want.

You just have to accept the worst outcome as a possibility. Some of those worst outcomes may not be acceptable, no matter what. I can’t speak to the specifics in your life. Just think of these as guideposts. There are whole schools of psychotherapy (lesser known) devoted to this approach.

6. Growth (or change) Requires a Degree of Risk, But Not Pain

There’s always risk in doing something new. Because it’s new and unfamiliar. The pain that’s expected comes from fighting change, from swimming upstream against the current, from holding onto the past. In order to change it means letting go of something, even if only as the sole way of doing something.

Weigh the risks and benefits, and make a choice to try something different.

7. Your Heart Will Keep Ticking

Even if it feels like the end of the world. Even if you feel like your soul is dying. You will probably survive. The pain will pass, like a wave. And you will survive. Don’t give up just because the wave is rising, or because it’s scary. Fear won’t kill you (unless you have a heart condition).

In that vein, I always appreciated this quote:
“I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.”
― Frank Herbert, Dune

8. Balance is a Process, Not a State

No one is perfect. No one is at bliss twenty-four hours a day. Marketing (including by self-help marketers) sell you the idea of perfection. Or balance. Or happiness. Or Mindfulness. In truth that is not a maintainable state.

Stand on one foot. Even if you aren’t falling over, that’s because opposing muscles are working simultaneously. Balance isn’t about one thing only. It’s about finding the right amount of two things that might oppose each other, so you don’t fall over.

Find the balance between apathy and overinvestment. Being totally absorbed in anything is a recipe for burnout. In relationships or projects. Apathy isn’t living, but shielding yourself from any future risk, because it doesn’t seem worth it. Life is best lived in-between, in a state of mindfulness.

9. Everybody is Doing the Best They Can with the Tools They Have

Just sometimes their tools aren’t good enough. If that’s you, get more tools. Try new stuff. Shrugging your shoulders that you are the way you are doesn’t leave much of a path for your story.

If it’s someone else that is pushing your buttons, find some compassion. Whatever they’re doing, no matter how annoying, has served a purpose for them. They’re using what they believe is the best tools they have, even if it makes no sense to you.

10. Problems in Relationships Can Often Be Fixed by Trying Different Positions

Get your mind out of the gutter. I’m not talking about that.

Think about where you find yourself, in relationship to others. First, second, third positions.

First position (I) is looking at it through your own eyes. Some people literally cannot think for themselves, but are constantly caught in the needs of others.  They’re disconnected from their own needs and always put others first.

Second position (you), is about empathy and being able to imagine yourself as another person. Why they do what they do, and how they feel how they feel. Understanding that helps to understand how to deal with another person.

Third position (outside) is looking at the group from the outside, detached, and seeing the big picture. Seeing that when I push, he pushes back, which I might not be able to appreciate from the first or second positions. Each of these is like a muscle. Which of yours is underdeveloped?  Which is overdeveloped?

——

Now of course there’s lessons #11 – 20. But those will wait for another post.

Share this if you think it might benefit someone you know.

12
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