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The Value of “Having Your Head Examined”

Psychotherapy

PsychotherapyThe profession of psychotherapy has been around for over 100 years, with less formal versions of personal consultation going back to biblical times.  So why is it that the voluntary seeking of psychotherapy can be such a polarizing issue?   

Skeptics of psychotherapy cast doubts on the effectiveness of “talk” to change anything in a substantive manner.  Human beings are talkative creatures, so what is so special about talking to a psychotherapist rather than to a hairdresser, bar tender, cab driver, or next-door neighbor?  “If all therapists do is talk, then I can get that anywhere, and for a lot less than $150 per hour!”  

But talking is only one part of the picture.  An even more significant aspect of psychotherapy is the therapist’s capacity to hear what is being said—not just with words, but also in a larger implicit sense—hearing the meaning of a person’s truth.

Some advocates of psychotherapy might argue that it has changed their lives, saved their marriages, or even freed them from a life of abuse.  

What does seem clear to me though is that many people are afraid of psychotherapy.  Considering how therapists get portrayed in movies or the embarrassing presentation of media psychologists, there seems to be good reason to fear them.  I am often asked if psychotherapists are motivated by their own deep-seated issues and if they are as “crazy” as the people that they portend to treat?  My answer is simply . . . of course!  Being human is, in itself, a crazy proposition.  We live in an artificial world of our own invention by rules we make up, and we kill ourselves needlessly in wars, with drugs, on highways, in airplanes, and sometimes for pleasure.  There is good reason to think humans are crazy!

Yes, we do good things too, and we invented science and ethics and laws.  But while it is easy to be seduced into exalting the remarkable advances produced by the human race, our fellow (nonhuman) creatures may have a profoundly different opinion of us—if we could only hear them speak!  Humans have one foot in a virtual world of seemingly limitless creativity that seems wonderful, if not artificial, and the other in a biological reality, with specific needs and limitations.  People need to be nurtured, for instance, by another person who will validate their existence and uniqueness.  (Think about how painful it can feel to be ignored, or have your feelings and thoughts dismissed and devalued).  

Perhaps the most valuable contribution made by the profession of psychotherapy has been to create an industry designed to help persons retain their connection to their humanity.  In spite of all we have invented, we remain fragile living organisms, clinging to each other for survival—a reminder that there is no substitute for real human contact.  

With dozens of forms of psychotherapy to choose from, what they all have in common is that they provide a private, protected space, where the challenge of being alive can be acknowledged and supported by another who respects and listens to the struggle for sanity.

A good resource for clinicians for more information on the complexities of the therapeutic relationship is the course Psychodynamics of the Therapeutic Relationship.

A Commentary on the State of Mental Illness in Contemporary Society

Psychiatric MedicationPsychiatric Medication

Television advertising for psychiatric medications seems to have become as regular as commercials for automobiles, miracle cookware, or cosmetics. We are shown beautiful young men and women enjoying their friends and family, as we are also told that they have major depressions, bipolar moods, insomnia, and other potentially debilitating conditions.

Certainly these ads help de-stigmatize mental illness by showing that anyone can suffer from psychiatric problems. They present an optimistic view of successful treatment, a healthy productive life, and the assurance of better living through chemistry. Appropriately, they provide the legal disclaimers that these medications might cause some side effects and are potentially life threatening, but the likelihood is probably small and the image of a potential cure is obviously seductive.

The Motivation Behind Psychiatric Medication Ads

But also consider what else may be motivating these ads. These are not products that anyone can go out and buy like a car, a non-stick pan, or anti-wrinkle cream. These are products carefully controlled by the FDA to be dispensed only by licensed medical providers with an expertise in psychiatric disorders.

The target audience is presumably people who are suffering from serious mental health complications and/or their family members. If the intent of the advertisers were to help people seek psychiatric care, they would be promoting clinics, counseling centers, healthy lifestyle choices, and sources of information, as seen in public service announcements. Instead, they are targeting a vulnerable population with an implied promise of a cure that is not really supported by scientific research.

This is not to say that psychiatric medications are not helpful–they clearly are.  But they are not curative. The ads promote the theory that psychiatric disorders have been proven to be medical illnesses, which is not exactly true. The ads further assert that the cause of these conditions is specifically known and that these medications will correct the imbalance or deficiency the person is plagued with—also not exactly true!

In my 30+ years as a clinical psychologist I have seem many patients benefit from the use of medications, but I have never seen a patient cured by medication.  The combination of medication, psychotherapy, and lifestyle change has the best likelihood of helping people survive and thrive, so why isn’t that being made more explicit?

What Are Psychiatric Medication Ads Really Promoting?

I believe that the subtext to psychiatric medication ads is the promoting of helplessness and dependency in the public. That is, the ads promote the position of the patient as defective, damaged, or victimized.

There is no question that people are biological creatures constituted by a remarkably complex physiology and neuroanatomy. People are also creative, imaginative, and intelligent creatures who experience life with a remarkable capacity for change and adaptation. Everything we do or think or feel is accompanied by changes in our physiology, biochemistry, and neuroanatomy, but that does not mean that these processes determine us. Rather, biological processes are descriptions of how we function.

An increase in neurotransmitter levels may enhance a mood, whether by ingesting a medication, or by engaging in meditative or pleasurable activities. The causal relationship between biochemistry and mental states goes in both directions. By taking active roles in improving their lives, people can foster a healing that extends to the deepest levels of their physical existence.

To equate the effects of a medication with the definition of a mental experience would be like saying that a headache is caused by an aspirin deficiency. The aspirin can help, but its absence is not the reason for the headache any more than lowered serotonin level is the reason for depression.  For those people who may have a genetic, or otherwise inborn tendency toward a depressive way of being, medications may prove to be a godsend. These people will also greatly benefit from being helped to reconsider how they manage their lives, relate to others, and pursue their dreams.

Our Potential In the World

Mental illness may be an inevitable consequence of the human endeavor to redesign nature into a world that is safe, fair, and rewarding. We cannot eliminate the reality of nature’s forces or its occasional cruelty and tragedy. As humans, we face the disappointments of elusive ideals and the limitations of our ability to control our destiny. We must also consider the extent to which the world we have created for ourselves may be responsible for eliciting what we call mental illness. We are not the world, only participants in it who have a potential to think, choose, and survive with the help of others.

Mindfulness meditation practices and psychotherapy provide alternatives that can improve well-being, without diverting attention from the individual’s role in defining his or her life’s journey.

To find online courses for continuing professional development in psychoanalysis and other areas of psychology, see our list of courses on promoting diversity, modern systems theory, psychodynamics, mindfulness, and more.

Are We Over Diagnosing Children With Mental Illnesses?

 

Over Diagnosing Children

Overdiagnosing ChildrenI once read an article by Jordan Smoller called, “The Etiology and Treatment of Childhood.”[1] It was a satirical article that described childhood as a mental disorder. He noted that childhood is congenital, is characterized by temporary dwarfism, is marked by emotional instability and immaturity, and that children have knowledge deficits and legume anorexia. Mercifully, most children recover from this condition over time.

While clearly the article was meant as a spoof on the Diagnostic and Statistical Manual of Mental Disorders (DSM), the standard reference guide for mental health providers in the U.S., the implications of this article are quite serious.  Children are being diagnosed with mental illnesses at an alarming rate and being medicated for those conditions with increasing regularity.

Over Diagnosing of Attention Deficit/Hyperactivity Disorder

Consider the case of Attention Deficit/Hyperactivity Disorder. This is a condition where a child is unable to constrain his/her behavior to the requirements of a given social context. We are not talking about criminal or psychopathic behavior, but rather the inability to sit still in a classroom, restaurant, doctor’s office, or other such environment where conformity is expected.

Fifty years ago this condition was called Minimal Brain Dysfunction (for extreme cases) and was thought to be the result of a mild form of brain compromise that was not explicitly evident but could be assumed. The term fell into disrepute when parents resisted having their children stigmatized as damaged goods.

Then, sometime in the 1980’s, the atmosphere changed and the former stigma became, for some parents, an embraced diagnosis of ADD (then called Attention Deficit Disorder, with hyperactivity as a sub-type).

Why the change? ADD was classified as a learning disability that entitled children to special accommodations in the classroom and on standardized tests. Not only were schools required by federal law to provide preferential seating in the classroom, but the students could also have less, or no, homework, extra time on exams, less rigorous exam standards, and counseling and tutoring services (also subsidized by federal funds).

I am not suggesting that all children and parents took unfair advantage of the system. Many children needed these services and greatly benefitted from them. Some students also received these services in order to give them a competitive advantage for college placements.

I am not faulting parents for trying to get what they can to make their child’s life better and their future more promising. In fact, as a psychologist, my profession has profited greatly from this boon, as have college guidance counselors, and educational therapists. No one has profited more, however, than the pharmaceutical industry, which supplies medications to enhance focus, concentration, and task performance.  In my view, the issue of ADHD is only the beginning of a much larger problem—the pathologizing of children.

Over the past few decades we have seen enormous rises in the diagnosis of autistic spectrum disorders, bipolar disorders, depression, and obsessive-compulsive disorders in children and adolescents. It is possible that the mental health of this population is deteriorating at an epidemic rate. It is also possible that children are being dangerously over-diagnosed. Note also, that the rates of diagnosis are unique to the U.S. and disproportionately represented in middle and upper-middle class families.[2]

What Can Parents Do If They Think Their Child’s Behavior Is Questioned?

So what can be done?

First, parents need to step back and question the basis for a child’s diagnosis. If a child’s behavior is being called “pathological,” what is the normal standard for a child of the same age and sex? Nowhere in the DSM is there a guide for determining at what point a child’s restlessness, for instance, exceeds normal standards. The diagnostic criteria instead say “often.” Not how often, or too often, just “often.”

Second, parents and doctors need to consider the context of the child’s life. If the parents are divorced and the child lives alternatively in either home, how might that stress affect concentration and attention? Or how interesting is the classroom for the child?  Maybe a different teacher or school would be a better fit for the child.

Third, how much sleep is the child getting each night? Half of the children I have assessed for “inattentiveness” were sleep deprived. The child may be going to bed at 8:00, but may be on a smartphone, iPad, or computer until late in the evening. Furthermore, a sleep-deprived child may be depressed or anxious, not necessarily “suffering” from ADHD.

Fourth, doctors, psychologists, and teachers often base their diagnosis on checklists. This can be a somewhat useful starting point, but is irresponsible as a stand-alone assessment. No checklist is a substitute for knowing the person of the child. Consider that chest pain could be a heart attack or it could be indigestion! A restless, inattentive child may be lonely, sad, afraid, etc. While these conflicts and challenges are difficult and distressing, they are not necessarily signs of mental illness.

Finally, if there is a reasonable suspicion of some mental health issue, a competent specialist should be involved to thoroughly assess the child, the family, and the surrounding circumstances.  What diagnoses have been explored, evaluated, and ruled out? A range of possible interventions should be considered, with priority given to those that are the safest, least invasive, and most likely to be helpful. A child’s mental health is not the place to shop for bargains or quick fixes.

 I constantly remind my graduate students that diagnosis is more about the person than the illness and that children are people, not disorders.

Professionals who want to learn more about psychoanalysis, developing an analytic mindset, and more topics for continuing education in mental health counseling, see a list of our online courses.

[1] Published in the book by G. Ellenbogen (1982), Oral Sadism and the Vegetarian Personality, a collection of satirical psychological articles.

[2] Hastings Center, Washington, D.C. (2008) found a 20% increase in prescriptions for behavioral drugs between 2000 and 2003 and a 73% increase in prescriptions for antipsychotic drugs between 2001 and 2005.

Thinking Like a Psychologist

Psychotherapy and Epistemology: Learning How to Think

Psychotherapy and EpistemologyPsychotherapy and epistemology–what do they have to do with each other?  Philosophy refers to how knowing happens as epistemology.  I would argue that addressing the process of knowing is at least as important for training psychotherapists as considering what is known.  Let me explain…

When I supervise graduate students who are training to be psychotherapists, I find the most challenging task is to teach them to think like a psychologist.  How does a psychologist think?  Or, more accurately, how do I think a psychologist should think? 

To me, the purpose of clinical psychology is to help mitigate human suffering to whatever degree we can.  In order to pursue that purpose, the psychologist has to understand the uniqueness of each patient’s suffering.  The patient is a person with whom we have a therapeutic responsibility and a person whom we are obligated to know and respect.

Knowing someone, especially someone who is a virtual stranger, such as a psychotherapy patient, is a formidable task.  We do not know someone by getting a list of facts.  Name, birthdate, place of birth, occupation, history of illnesses—these are all lists of categorical data, but they are not knowing.  We can only know someone by relating to them over time in a relationship.

In a relationship, we know someone by how we feel with them, what fantasies they stimulate in us, or how they communicate beyond words.  Being with another person allows us to become part of their (and our) creative process.  The key here is process…an ongoing interaction.

We are much better served by using verbs to describe relationships than by using nouns.  In fact, I would assert that mental disorders and pathologies are best understood as verbs as well.

Suppose, for a moment, that you wanted to get to know Vincent Van Gough.  Since he is dead, you couldn’t set up an appointment.  But you could read books about him, see a movie about him, or sit with a few dozen of his paintings and relate to them for a while.  I would suggest that, as a psychologist, you could get to know him very well from sitting with the paintings.  In fact, I would suspect that the books and the movie would be dangerously misinforming.  One does not need to be a trained art historian or critic to understand Van Gough from his paintings.  One needs to be able to be transformed by the perceptions and sensations created by the colors, swirls, and patterns.  The question you might have is whether these transformations are true and valid.  My answer is that they are as true and valid as one ever gets.  There is no ultimate truth to Van Gough any more than there is to you or me.

What is true is what we negotiate from our experience with one another.  And these truths are transient and evolving.  The truths we learn about someone are the products of our relationship.

In part, what we know is made up. We invent knowledge from information that is generated by our biological processes.  But it is not as if we just make it all up; rather we create information at a basic biological level that then gets transformed by complexes or networks of other biological processes that produce still more variations of information.  At some point, the product of these processes becomes a mental phenomenon that we refer to as thinking.  We link our thoughts together in patterns that are self-supporting and that afford us a sense of certainty or knowing.

In fact, much of everyday anxiety is caused by a lack of certainty or doubt that interferes with knowing.  Ask an anxious person why they worry and they can often tell you that they know that it doesn’t make sense, but that they “can’t help it.” Why not?  The thinking disrupts the links in the patterns of knowing and disrupts the certainty.  The result is to question what is known or to be anxious.

“What if…,” we think?  There are no limits to what we can imagine, but there are limits to what can be true.  Just because it can be thought doesn’t mean that the thought is true, but try to convince a worrier of that!  The dominance of our basic subjective position, our narcissism, can lead us to feel compelled to account for any thought as important simply because we thought it.

I doubt that most of us ever consider the epistemology with which we know.  We might be aware of certain beliefs or values and we might be aware of political or scientific theories that seem more right to us than others, but I doubt that we regularly consider the extent to which our knowledge is the product of a system for knowing.  We are most likely to entertain a challenge to our knowledge only as a last resort.

Even the onset of mental illness is not sufficient to cause us to rethink what we know.  I tell my graduate students that a patient’s psychopathology is the person’s best effort at staying sane.  A person is apt to make themselves crazy before they will lose their sense of certainty.  In fact, psychotics are quite certain about their delusions and hallucinations; it is we neurotics who worry and fret about what is true.

What is true, in any meaningful way to a person’s life, is always a subjective truth—what we “know to be true.”  This is a truth rooted in our sense of self—our being.  Scientific facts, religious truths, or mathematical proofs are only true to us when they have been incorporated into our being and embraced as our own.

Obviously, we have gone through quite an array of truths over the course of human history that were all touted as the unequivocal truths of their time.  Where did the Greek and Roman gods go?  They died when they didn’t have people to believe in them.  Why do we know that the Earth revolves around the Sun and not the other way around?  Because the mathematics for the former is much more simple and elegant.  Why do people go mad?  Because of abusive childhoods, biochemical imbalances, predisposing genetics, or socio-political persecution?  We are still struggling with that one!

Science is an epistemology, but only one of many.  The key to survival in nature is adaptability and diversity; likewise, the key to psychological survival is in adaptive and diverse epistemologies to help us learn to appreciate and respect the complexity of nature.

I am not arguing against science or for any particular epistemology for that matter.  Instead, I am hoping to inspire the reader to consider the basis and presuppositions that comprise one’s system for knowing.

Having spent nearly my entire life in education, either as a student or as a teacher, I am quite aware that we are rarely, if ever, taught how to think, but rather what to think.  I am also just as aware that what people benefit from most readily in psychotherapy is being emancipated from truths that are pathogenic and paralyzing.  These “truths,” however they may have been derived, can be redefined, diminished, or discarded for the sake of a person’s future mental health, but not without considerable resistance from that person’s loyalty to the “known.”

I welcome your thoughts.

~ Michael J. Gerson, PhD

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