Sunday, January 24, 2010

Dream Interpretation in the Clinical Setting

Attaching meaning to dream content via psychoanalytic approaches has taken a back seat to short term, behavioral and cognitive therapy in the past three decades. Those clinicians still practicing psychoanalysis still try to find significance in interpreted symbols derived from the dream narrative. They attach meaning of these representations to the client's past in order to help them become more aware of how they were affected by significant events during their upbringing. This is of course a big ball of yarn to untangle and warrants a lengthy course of treatment.

Although extremely qualitative and subjective, I do believe dream interpretation can be part of a repertoire for cognitive therapist. Since we are concerned with how thoughts effect motivation, the representations and underlying messages in dreams can lend to us understanding how profound thinking in the dream state affects our cognition and in turn our day to day behavior. A growing body of literature supports the continuity hypothesis of dreams from sleep to waking reality. The continuity hypothesis suggest that the content of dreams is not remote from the waking reality, but, rather, portrays the most prominent feelings, interests and concerns of the individual.

Call it the subconscious, the inner mind, suppressed thinking or subliminal thought, we all must acknowledge that there is this highly active yet less than apparent process that dualistic-ally parallels our conscious state. When we have an opportunity to digest the storyline and details of a dream, we are given a chance to gain insight into the significant events and relationships in our lives. Often these are realized as symbols and metaphors. So while the meaning may be obfuscated and coded, the insight and honesty are of value once these representations are untangled.

Some of these symbols are universal, others are not. For instance, the house is often symbolic of the body and the condition and constitution of the home points towards the health and well being of the body and mind. If we dream of a home with a dwindling fire in the hearth, this may be universally symbolic of a weak heart. Bats in the belfry? Toys in the attic? You get my point.

Sometimes dream symbols are very individualized. For instance, if someone was bucked or kicked by a horse at a young age, the horse may symbolize danger of the threat of personal injury. To others, the horse may symbolize freedom, mobility or virility. Our personal experiences shape the meaning of the symbol and the context in which it is used in the dream further shapes its significance.

Years ago, I had a dream about a romantic interest and myself. We were in a rowboat, sitting side by side. My partner was rowing and I was oar-less. The symbolic interpretation I had was that she was in control (held the oar) of the relationship. The metaphor was the boat (relationship) going around in circles. The dream was affirming my feelings that this romance was going nowhere, although consciously at the time I may have not wanted to admit it to myself.

So I would argue in the conscious state we cloak some pretty obvious things. It could be due to defensiveness or denial, or it could be that we are so caught up with the bustle of everyday life that we are denied the opportunity to really analyze some important social phenomena and our emotional reactions to them. In having clients relate their dreams in the past, I have helped them extract buried and difficult to resource fears. Often these fears are irrational or exaggerated and this opens a dialogue conducive to altering some unhealthy thought processes and schema that are affecting the client's functioning and well-being. Using this form of dream interpretation in the cognitive setting may open some doors in terms of treatment that would otherwise be left unaddressed. It has found a place in my therapeutic repertoire.

Next: A look at Mindfulness Cognitive Therapy

Wednesday, November 18, 2009

The Informed Psychotherpist's Advice is Free

Hello to my minute minions. I have been away from blogging for awhile and am checking in. The reasons for my leave of absence are numerous. I have been taking time to develop online, real time counseling service at (link is to the right on this page). I have also had a number of personal affairs to address, some good, some rather challenging, so I have been emphasizing some self-care. I have also been really busy in my private practice, the volume of sessions has increased and taking up more of my time (of which I am very grateful).

And then there is the fact that I have not got any requests for advice from this site recently . It is somewhat puzzling to me why people pay for my advice on liveperson and in my practice, but there are a limited requests for advice here. I have taken some time to give deliberate answers to those that have wrote, with varying feedback and expressions of gratitude from the letter writers.

So I will be returning soon one way or the other. If I get a letter requesting advice I will promptly give my two cents worth. Otherwise, with the weather turning cold, my outdoor tennis, bicycling and hiking will be coming to a slow crawl and I will have more blogging time on my hands.

In the meantime, there is a year's worth of blogging on this thread so take some time to catch up on some of my archives if you'd like. I still continue to get several hits for certain sites, of particular popularity are the writings on adolescent slang, body symmetry, antidepressants and suicidal ideation, and open marriage.

I will be returning with something of meaningful content soon and thank you for your interest.


Tuesday, August 11, 2009

Life During Wartime: When There is No "Post" to PTSD

We are amazingly resilient as human beings. But at some point you just have to ask how much can one person take? I received this letter and was amazed by its length and detail. I had to condense it a bit in terms of practicality. But this woman has experienced a constant barrage of trauma her entire life. It continues on and on to present day. She has made some mistakes in judgment to be sure, but also some smart moves too. And yet her psychic pain seems to never end

There is a gender bias in the diagnosis of Post Traumatic Stress Disorder. When men go to war and suffer exposure to near death experiences and mutilation, we call it PTSD. Women are frequently given the diagnosis of Borderline Personality Disorder when they are exposed to the same. In the males case, we point to some external source as the cause. With women we blame some internal mechanism, we blame the victim and this is simply unfair and an example of gender bias.

So I am going to make an attempt to help this woman sort things out. There are no easy answers here.

Hello, I found your post on Craigslist and I believe that I was meant to find it today as I am looking up from the bottom of a hole and can barely see the light. I fell like I am already in my grave and each day another pile of dirt falls down on me. My story is a long one, so bear with me.
I was born to two drug addicted parents in the early 70's. My father tried to clean up his life and enrolled in the service. My mother was overwhelmed with my daily care neglect is not even a harsh enough word. When my Grandmother found me, I was covered in bed sores and very ill. She immediately sought custody. My Father dropped out of the service and became involved. He resumed his previous habits and my earliest memories of being with him are full of drugs, porn. I was molested more than once by his druggie friends. I grew up in bars. My Grandma tried but she had issues of her own being a severely abused wife.
At age 5 my father married my birth mother's cousin. She had grown up in an orphanage, having been abandoned by her own mother, and she was abusive and inappropriate with me regarding boundaries. She would discuss their sex life with me, and walked around nude. They put my room in the cellar, unfinished and not heated. I basically took care of myself from a very early age. My Father would disappear for days at a time. She would drag me out at 3 in the morning to go look for him, once trying to run him over in the street.
Around this time I was molested by a teacher at my school. I loved the attention that he gave me, and as long as I felt like he cared about me, it was ok. This began a pattern of male “attention” throughout my teenage years. My dad's marriage fell apart when he got a teenager pregnant. I was completely ignored by him at this point.. I walked several miles each day to spend time with my Grandma, my only rock. I began to abuse drugs and alcohol myself. My Dad reacted by getting really strict and I resented his control. His response was either whipping me or grounding me for long periods. I became isolated and depressed. I attempted suicide and was hospitalized in a psych ward.
My mom tried to reenter my life. But she was inconsistent in keeping plans at best. Her motives were always selfish in design, a con to get me to babysit her druggie friend’s kids or some other scam. The visits often ended with me in some horrible neighborhood, abandoned by her and vulnerable to being rolled and you guessed it, sexually abused.

At this point in my life I found some stability. I found a boyfriend, started working. Doing a little traveling. I enroll in college down south I moved into campus housing. One night a friend of one of my dorm mates forced his way into my room and raped me. I just became numb at this point. I moved back home and in with my boyfriend. We went on to have a child together. A daughter. I could never bond with her because I imagined myself at her age always. The baby that was not wanted or loved, the years of abuse and neglect suffered at the hands of my family, and others. The depression was deep, but I fought to stay on top as best I could. Eventually the boyfriend and I break up, I meet someone new and we have a child together. During this time I had developed severe social anxiety, was very suicidal and a weight of pure terror and dread settled on my shoulders. The only place that I had ever felt safe and not judged was with my first love, so we moved in together and got married. Now, there is an odd quirk about my personality...I have a fear of being the one to care for another being, like I don't trust myself to nurture or be able to hold it all together. For instance, I crave the companionship of a dog and have attempted to adopt several. However, once I am alone with the creature this awful dread rises up in me and I feel as if the animal is a horrific parasite feeding off of my energy and making demands of my time etc. I have sometimes (to my great shame) felt this way about my children as well, and any affection just gives me the heebie jeebies. With the dogs, the only thing that relieves my anxiety is getting it out of my space as quickly as possible, often in less than an hour after I bring it home. It makes me feel like such a bad person to do this to a helpless creature, and this is something that I would like to resolve.
As a side note, I did apply for disability and was told that my case was the fastest to ever be approved, literally within a matter of just a few months. At this point I am living with my first love, raising the two older kids and seeing my youngest child every weekend and as often as I can. The relationship with my first love is unstable and I had never been able to truly get close to him. I have some intimacy issues : ) but when I picture him out of my life it is a horrible feeling, like I will be absolutely alone in this world. I am trying like hell to make a family and be "normal". Then the bottom drops out of my life again. He leaves me for a close friend. Can you imagine? I could not even trust the two people that I loved the most to be decent human beings. Oddly enough, after that I proceeded to have two of the happiest years of my life! I found peace in my heart, it took awhile but I learned forgiveness. I still have not spoken to my friend since the day. I was afraid that I would snap and hurt her very badly. Remember, that is how I dealt with life's little problems. Uncontrollable anger. I learned that at Daddy's knee. I rose above all that and took great pride in my home, in my kids and in myself. I met someone and we began dating. I enrolled in nursing school and got into honors classes! I was walking on a cloud. But not for long. A month after school started I began having fainting spells. I was diagnosed with narcolepsy and had my driving privileges revoked. I had to quit school. I lost my grant and now owed the government money. I could not do fun things with my beautiful kids. A new boyfriend stuck by me, however, and I continued to thrive. He made sure that I got to see my youngest son, and took us all over to do fun things.
Well, about a year and a half later black mold was discovered in my home and we were told to move immediately. I had no money and nowhere to go. I felt that familiar feeling of the floor dropping out from underneath me. Panic rising... I moved into the basement of my boyfriend's mother's home and we made plans to get a place together. Oh, but nothing ever can just be easy. Then I found out that I was pregnant. Now, my youngest son was born with birth defects and I was told to never attempt to have more children. My state of mind worsened. That feeling that I get about the dogs began to creep in on me, like I just have to get away from it. I am in full blown panic and terror mode. The father wants this baby. He has been patient but it is wearing thin. I cry all day, I do not feel happy to be in this situation. I am suicidal. I have no stability. I told my Doctor and received a prescription for Zoloft but I am afraid to take it. I can't see the good in this even though I know there is some. But I feel like I already had a family and that was ruined by my ex. How can I go on to have another family?

Ms H

Hi Ms H

I can see you have had a challenging life. I generally tell clients they have to play the cards they are dealt, but this seems like a very unfair proposition for you. I admire your resiliency.

Although seemingly chaotic, I will try to make some sense of your life and mental state. There are a few repeating thinking errors on your part. You readily identify them, but do to your past trauma and experience, have difficulty "unlearning" them. These patterns run deep in your psyche.

1.Uncontrollable Anger: you state you learned this from your father, but it is also an expression of frustration because you can seemingly never find any continuity and stability; your depression eventually boils over and turns outward as angst.

2. Fear of Nurturing: the failures of your parents manifests itself in your own reluctance to care for others, and this is conflicted by a strong drive you have to care for others (i.e. nursing), perhaps as a need to "fix' family legacy of past generations and your own perceived failures.

3. Need for Help: you have been betrayed by so many that trust is an issues and when someone reaches out, you fear being double-crossed. So the most sincere gesture from others you interpret with suspicion.

4. Unreasonable Need to Please Others (particularly your current partner): You forcibly gave "all of you," in your youth and beyond and this created issues of personal boundaries. If you gave control of your body to so many in the past and they were still displeased, what else could you possibly give them so they would be satisfied? It seems like a no win situation for you.

I am thinking the meds are worth a try. I am sure you read my previous post about co-therapy (pharmacological and talk). A good therapist will examine these cognitive errors and the Zoloft will give you a chance to tone down your emotions enough to sort things out with him/her.

best of luck to you

Thursday, July 16, 2009

Suicidal Ideation and SSRI's

In this letter the writer expresses concern regarding her sister's welfare. She worries that the SSRI antidepressant she is taking is putting her sister at risk for self-harm or otherwise interfering with her quality of life. Some concerns are raised here and some myths are dispelled.


Back when I was in the worst part of my depression/anxiety/panic disorder, I was prescribed heavy doses of Zoloft and Buspar (maximum allowable amounts). While on the meds I felt nothing, I mean literally nothing-not happy, not sad, not anything. Which I suppose was better than the depression/panic/anxiety. However, there was a feeling I had--and my sister who recently began going through the end stages of menopause (at only 46 years old) and who was also prescribed Zoloft for at least a year has also recently experienced. That is something I call "passive suicidal feelings". Not wanting to actually take action to end your life, not actively looking for ways to do it either, just a feeling of "well if a bus hit me and killed me, that would be okay" (but again, not looking for that bus, just hoping a random act would happen).

Is that normal or is it something that the medical field has heard of? I thought I was unique/unusual many years ago but my sister recently reported those same feelings and happened to be taking the same meds so it made me think there's got to be a connection (either medically or by family?)



According to the DSM-IV, passive suicidal ideation is the lowest form and least lethal of suicidal conditions on a wide spectrum of intent. Although there is no immediate compulsion to act out these self-destructive feelings, it is reason for concern because it could easily advance into more active forms of suicide and interfere with her overall happiness and satisfaction.

There is valid widespread study supporting the association between SSRI (e.g Zoloft) class medications and suicidal preoccupation. In referencing the Journal of Family Medicine, this risk is greatest in the 1st 9 days of trial. The cause is thought to be from general agitation and akethesia, a general feeling of internal turmoil and unrest. This side effect is more generally found in typical antipsychotic medications, less in atypical antipsychotic medications and to a much lesser extent in SSRI's. But it does rarely occur. Despite this phenomena, a study by Kahn (2000), reveals less risk of suicide for subjects on SSRI's than those taking a placebo or no medication at all.

A common characteristic of depression is inhibition, the repression of uncomfortable thought and a reluctance to take action. When this symptom is lifted due to the change in brain chemistry at the beginning of an SSRI trial, thoughts of self-harm and worthlessness that were once repressed may surface into conscious thought. So varying forms of SI sometimes arise early in the trial of the medication. When the veil of depression is temporarily lifted, a reassessment of self generally occurs and if negative thoughts of self are allowed to flourish, they may not subside as the medication trial continues.

During the trial of the SSRI, the full efficacy of the drug can be realized in 10-14 days. This is a time of great opportunity for the client. With a general lessening of the feelings of psychogenic pain and dread, comes an opportunity to step back from the shroud of depression and identify the root cause of the thoughts and feelings that have contributed to the depression.

This is why it is so important to engage in talk therapy at this point. Several studies point to the importance of combination therapy in treating depression (for instance see Glass, JAMA. 2004;292:807-820, 861-863). The combination of cognitive-behavioral talk therapy and an SSRI medication have been consistently found to be more effective than the sole use of either intervention. The therapist can identify long held negative schema and thinking errors the client has held and assist in challenging and refuting them and help the client replace them with more measured, healthier and positive thought.

In the case of your sister, the onset of menopause may be of minor consideration. Doctors frequently prescribe antidepressants as an off-label treatment for menopause. The more recently developed SNRI's (serotonin and norepinephrine reuptake inhibitors) have got allot of attention in treating menopausal symptoms. Along with serotonin, norepinephrine reuptake is also inhibited. Norepinephrine is a neurotransmitter and stress hormone that also effects the way the body responds to and regulates temperature. It has been found helpful in regulating both mood and minimizing "hot flashes."

So perhaps a reevaluation of the prescribed antidepressant is necessary. More so, the question to be asked is has your sister ever received CB talk therapy in conjunction with the medication? If so, did she connect with the therapist and follow through with the treatment? The opportunity to examine her inner thoughts that were initially the cause for the depression and eliminate them still exist. She should seek out a therapist, one that fits her personality and disposition.

Wednesday, July 15, 2009

A Comment About Letters and Comments

I have been writing this blog for about 9 months now. I have received some interesting letters. Many are concise and right to the point. Some are a bit rambling and I have to sift through and glean information in order to give a relevant answer. Others are so brief I have to be somewhat hypothetical in my stance and opinion.

I have promised to publish or answer all the letters written and up to this point I have kept that pledge. I have published them as written as I find this to be the most helpful and honest method in which to respond to these inquiries. However, if a letter contains vulgarity I retain the right not to publish it on my page and if it is rude or condescending I reserve the right not to answer or publish it.

The same goes for comments. I have received a few that are constructive in their criticism and I appreciate that. Some have recognized my unique approach to a topic and I humbly and graciously accept the recognition. Others have used the comments as a forum to be vile, obscene and insulting. Disparaging remarks have been made about everything from my writing style to my profile pic. Nothing constructive mind you, just rude and acidic. It is easy to make these comments from afar, assuming the person lacks the courage to make them face to face or with even a return address to be held responsible for what they said. I have no editing function with the comments, so I either publish them or I don't. If they are rude, vulgar or intentionally insulting I have to delete them in their entirety.

Some commenters appear to have difficulty knowing the difference between opinion and fact. When I state something as fact, it is generally backed by overall conventional wisdom or it is well documented by study. One of the intentions of this blog is to create controversy and stimulate dialogue via the comments section. This way people can respond with their opinion in hopefully a mutually respectful way. In doing so, it is helpful to appreciate when I am being subjective and relating my opinion to the overall advice and discourse of the writing.

For instance, a few have stated that I view relationships in a rigid and archaic way. On the contrary, I have stated several times on this blog that people can mutually define a relationship however they want to. So when I state an opinion as regards parameters in a relationship, this relates to my own personal beliefs as to how I behave and act in a relationship. It is not intended to be a dictate or written in stone. So the pretense that their should be fairness and justice in a relationship, that what is good for one is good for the other, is based on conventional wisdom. The declaration that one should not give out a phone number to an available member of the opposite sex because it would risk hurting their partner is opinion. I would invite an intelligent reader to know the difference and digest that comment in the context of the entire article and blog.

Other nasty comments and emails have revolved around the use of the title "doctor," in this blog when I lack that qualification. There is a disclaimer in this thread wherein I state "I am not a real doctor, but I do have a Master's Degree......" In the 80's and 90's there was a popular show on NPR called Ask Dr. Science, in which an almost identical disclaimer was used. If this method of disclosure was good enough for an entity as prestigious as National Public Radio, it is good enough for me.

This blog, for me serves several purposes. One is to create a quick reference for my psychotherapy clients as regards common treatment techniques for their review. Some articles are also dually published on one of my contract employer's website. Another purpose is to try to stimulate a dialogue as regards maintaining a healthy romantic relationship and a well-adjusted self. And I readily accept opinions about these issues that are submitted in a civil and mature manner. The truly obnoxious and belligerent reader can just move on (its the left click on your mouse).

Wednesday, July 8, 2009

Reunited? A look at Unalienable Maternal Rights

I enjoyed receiving this email because it broaches a topic most of us can identify with. The writer yearns to reconnect with children she birthed, then during a troubled time in her life, relinquished parental rights. I do appreciated her concise writing and I will also try to get right on topic. The correspondence is printed as written, excepting the name which was changed to guarantee confidentiality.

I Have a question and I will try to make it the short version.

Back in 1995 my ex-husband, well we were married at the time, turned our two daughters over to the state claiming he could not take car of them. When he did this I was in jail for a bounced check. He had no reason for doing this as the kids were not in his care at the time, a friend of mine had them. After fighting with the state of Tennessee for over a year, I lost and my rights were terminated and they were adopted out.

Recently i have found out where they are and who adopted them. They are 15 and 14. I'm at a loss at what I should do now. I fear them rejecting me. Should I contact their adoptive parents and talk to them to see if they were ever told that they were adopted? I don't want to disrupt their lives but at the same time I long to be reunited with my girls, there has never been a day that has gone by that I haven't missed them. I need for them to know that. What should I do? Any advice would be greatly appreciated.

Thank you


There is this blood tie at issue here. It is greater than any law on the books. Karin's desire to be a part of the life of her children in some way is understandable. At some point in her life, during her troubled young adulthood, she vowed to try to loose her emotional investment of these children. Now she has found that is an impossible thing to do.

So in considering reuniting with the children, the 1st consideration is their welfare. We must weigh the benefits of being exposed to their past versus the simple family life they enjoy at this moment. They are of an age, however, when the discussion of their past may not be detrimental. It is my experience that adopted children should at some point know the truth about their blood ties. The timing becomes important as to when the information is exposed to them, at a time when they are emotionally and intellectually ready to handle the complexities of this issue.

So when are they ready to be exposed to this juggernaut from their past? I would say simply when they begin asking well-formulated questions about their birth rights and family linage. As they reach adolescence and begin to self-actuate, they will at some point see some inconsistencies in the notion that their adopted parents are biological parents. Differences in appearance, physical constitution and inconsistencies between the marital history of the adopted parents and their births are a few examples. So when the children are ready to ask concise and elaborate questions about their past, they are usually emotionally prepared to get honest answers.

Another reason it is important for them to eventually know who their biological parents are is it is a viable part of their medical history. The family genotype has become more and more important information in terms of medical treatment and prevention. Illnesses that are passed on from generation to generation can be addressed proactively and are a vital resource in keeping these children healthy.

So contacting the adoptive parents is a harmless first step in your attempt to be in some way a part of these children's lives. Approach this contact with humility and respect, as you realize the AP hold all the cards legally. If they think it is too early for you to have contact, you must respect this. But the communication will hopefully give you some insight into their development and at worst you will have greater knowledge of how they have reached milestones and the piece of mind that they are well taken care of and provided for and are moving through developmental milestones toward adulthood.

Keep in mind that knowledge of their adoption opens a Pandora's Box. For instance, they will also want to know about their paternal father and if alive his circumstances may not be as good as yours. If they are unable to find or contact him to get answers, this will be cause for anxiety and stress. There are many other issues about their past they will be curious about and you may be uncomfortable revealing this information to them or not be informed yourself of the answers.

So once again, the emphasis is on the emotional and physical well being of these children. If you and the AP can reach a mutual agreement with this in mind and set aside all selfish motives, a beneficial outcome is guaranteed.

Thursday, June 4, 2009

Obsessive-Compulsive Disorder Part 2: Breaking the Behavior Chain

In part one I discussed the need to diminish the connection between the strongly linked obsessive thought and the compulsory action. These elements of OCD and the strong bond between them are the essence of the client's discomfort. So addressing each element and their connection is the strategy to be deployed in treating the illness.

Refuting the irrational thoughts that solidify the obsession should be the first step taken in treating OCD. Pointing out the false beliefs that the repetitive behavior will significantly advance the client's well-being is one approach. Another is too point out how the wasted time dwelling on these thoughts interferes with other significant events in the person's life. These tenets will help motivate the client to take on the arduous task of breaking the association between the thought and the behavior.

When the compulsion to act is so overwhelming that something has to be done, the therapist should point out alternate behavior that approximates the compulsion to act. For instance, the use of alcohol wipes for hand washers vs going to the rest room and running their hands under the sink with soap and drying their hands. It saves time, satisfies the urge, is generally more socially acceptable and and is one gradual step that moves the client away from the fixed thought and action.

The last step should entail a technique that helps break the overall behavior chain. Systemic desensitization or graduated exposure therapy has been proven the most successful in treating OCD. With this technique a client is taught relaxation techniques (see my 3 part blog treating anxiety) to be used to quell anxiety when client is experiencing discomfort from not performing the desired act. A hierarchy of fears is created and one step at a time the client tries to distance the time between the obsessive thought and the compulsive action. Gradual exposure to the negative stimuli (i.e. germs and sweat on hands) is enacted while the client utilizes the newly mastered SRT to battle the associated anxiety.

The technique of flooding has also been proven successful in treating OCD. In this case, the client is exposed to the negative stimulus is a superficial and dramatic manner. A hand washer, for instance, may be asked to soil his hands with dirt for an extended period of time. This technique has been found more successful when used in tandem with an SSRI medicine.

The treatment of OCD is best approached as a method to break up the repetitive antecedents, behaviors and consequences that are linked together to form the unwanted repetitive thoughts and actions. The hope is that in time the strong urge to act on these thoughts will fade away, and the chain will be broken. The client can then live a normal, happier life, free of the distracting thoughts and the encumbering actions.

Tuesday, May 5, 2009

The Curse of Kalimba: "Reach Out and Torch Someone"

This letter comes from a young lady who is having difficulty with her boyfiend. Her discovery of text messages on her significant other's phone has lead to dissension in their relationship. Letter is printed as written, excepting the name.

um well i keep finding text messages that i dont like. this girl that likes and is messing with his friend has texted him and said things like "where r u", "are you coming" "just us" now his phone doesnt show the sent messages so i dont know what he said to her. but when i asked he said that he is not cheating and all those kind of text were when his friend was there. and im not sure what to believe. it has cause multiple arguements. i just dont know what to believe anymore.


The new technologies of communication are a wonderful advancement when used for good purpose. It also becomes an opportunity for predatory and exploitative behavior. Text messaging was designed to be a convenience that allowed us to send messages at times when we are not available for oral communication. It has unfortunately been used for dishonest means and is constantly generating excess "drama" in relationships. The "thumb harp" as I call it is frequently the center of attention when couples present for counseling. Here are some of the aspects of the technology that help fuel disagreements in marriage and committed relationships:

1. Its covert nature, the ability to send messages in private, allows and even encourages someone to to reach outside their own morals and values as regards commitment.

2. Its covert nature, the ability to send messages in private, allows and even encourages someone to to say something they normally would not over the phone or in person. It is an impersonal medium often used to say very personal things. One client told me her boyfriend said "I love you," for the first time over text. That guy needs to get a pair (not of ipod headphones either).

3. Because there is no tone or inflection of voice as in when talking by phone or in person, it is harder to decipher meaning, especially with emotional content. This can also be manipulated by the sender, who wants to keep you off guard by sending a message that can be interpreted multiple ways, to keep the receiver off guard or "played." For instance, "do you really want to see me?," Could be said in an enthusiastic or sarcastic tone. It is up to the listener to interpret meaning which could later be denied by the sender. Text messaging was invented to convey information, not emotion.

The constant use of text, email or instant message to address important and intimate meaning is, pardon me, just chicken-shit. Linguist and media theorists call this "parasocial" behavior. These are people who believe that constant virtual or digital correspondence is more than just pretend intimacy. It is shallow and lacks real meaning.

4. There is the matter of digital evidence being left behind. Just ask Kuame Kilpatrick. This can also be manipulated by the owner of the phone. Purposefully leaving an easily recoverable message for their partner to uncover to create turmoil or draw attention to themselves. I know it is immature and tactless, but it does happen.

As it pertains to Tara, she has bits and pieces of a conversation and only one half of a two way communication. If her partner is in a committed relationship with someone he really has no business giving his number out to another available female, unless it is related to his work. If his friend wants to text this woman, he can get his own phone. If this friend already has a phone, Tara's SO's explanation for the messages is pretty lame.

If these discovered messages are creating that much tension as to threaten the relationship, perhaps you should both consider canceling the text service for awhile. It may be an inconvenience, but it would be worth it if it made for a healthier relationship.

Discussing the meaning of this commitment might also be helpful. Mutually agree on what exclusivity means in terms of interacting with others who might propose a threat to your union, with both of sticking to it.

Direct, honest and "centered" communication is the key to any relationship, but especially romantic ones. When implemented, the couple can survive the most chaotic and unsettling challenges, even those facilitated by the thumbs.

Sunday, April 19, 2009

Obsessive-Compulsive Disorder Part One: The Do Do Do, The Da Da Da

OCD is a very common diagnosis. It is extremely debilitating and interferes profoundly with relationships, accomplishments and personal happiness. It manifests itself with 2 profound elements. First is the obsessive, irrational thought. There is a perceived danger in the personal environment and it is magnified in the mind to the point that one can think of nothing else. These repetitive thoughts are cause for a compulsion to do something about that perceived danger and to act on removing or altering the magnitude of that danger and alleviating fear. When the urge to perform that task is insurmountable, it creates tremendous discomfort and interferes with important daily functions that must be performed to maintain one's well-being. These urges can be categorized into types. Some frequent recognized categories are Washers (obsessed with cleanliness), Checkers (consistently check on things they associate with danger), Counters (seek order, evenness and symmetry), Sinners (believe there will be severe consequences for a past action and seek to undue it), and Hoarders (take survivalist behavior to an irrational extreme).

OCD is commonly co morbid with other diagnoses. It is frequently diagnosed with depression and the inability to satisfy the compulsion feeds into the other hopeless feelings that fuel a low mood. It is also associated with other mood disorders, such as Bipolar and PTSD. In the case of ADHD, attention enhancing medicines are often cause for people to form "loops of thought," and a repetition of ideas that often lead to repetitive actions. Pharmacologically treated ADHD can often help manifest compulsive behavior as a side effect. Psychiatrists will commonly address this effect by prescribing an SSRI/antidepressant along with the attention enhancing drug. This patchwork approach is limited in its effectiveness.

Treatment of this illness focuses on interrupting the chain of thoughts and behavior associated with the idea and the action. It is generally conceded that the compulsive thoughts will exist at some level, but the OCD client can find ways to diminish the intensity of that thought and seek secondary cognitions and behaviors that diminish the urge to wash, go back, doubt or stack up. What helps reinforce the intensity of the obsession and compulsion is that it is positively reinforced. The hand washer does not catch the disease after repeated washing and the checker does not have his house broken into. The therapist is effective in supporting and validating the client's fears initially, but diminishing the intensity of those fears and helping the client find less intrusive behaviors to satisfy his now less intense fears. The hope is to find a new and viable chain of behavior. The compulsion to "do" will become the more comfortable, socially acceptable and less debilitating "da." Once the client is able to experience the contingency between the tone-downed thought and the less-profound action, this will be reinforced to the point that the old extreme thoughts and behaviors will fade away.

I am optimistically simplifying the course of treatment as described above. Alternative behaviors that are satisfying to the client are difficult to find and require allot of probing and problem solving with the therapist. OCD behaviors are often ingrained over a long period of time and are difficult to shake. In the next section I will get more specific about the treatment approaches that are taken to cure this illness.

Sunday, March 29, 2009

Lost in Translation: Addressing Adolescent Slang in the Therapy Setting

One of the populations I work with is teenagers. I really enjoy this because aiding the development of our youth has a direct impact on the future of mankind. People in this age group are struggling for self-identity. In that quest to find themselves there is a creation of language unique from adults. This has, of course, been going on for many generations. The slang evolves uniformly over the years and is fed by current phenomena and popular culture. It evolves very quickly so that a younger sibling's slang might be completely different than his older sibling of 5 years. Speaking their own language not only helps them define themselves as separate from us adults put also serves as an encryption so that authority figures can not easily eavesdrop on their conversations and glean content. Part of being an effective therapist is breaking down people's defenses and the slang mechanism is often used to obfuscate true meaning and stall the therapy process. Breaking through this barrier is a "listening skill," that all therapist working with adolescents and children should have.

In forming an alliance with teens, I don't think that "speaking their language," is very effective in gaining trust. It forces you to behave in an unnatural and deliberate way that usually comes off as a bit phony. It is often initiated after an adult hears a slang term that he or she may or may not fully understand. So trying to seek clarity by using nomenclature that the clinician is not adept at might just further the misunderstanding, not gain clarity. Often the adolescent client is using the slang in lieu of actually identifying their meaning and feelings themselves. The slang is adjective filler because they don't have the right word in their vocabulary. So with some, just asking "what do you mean by.....," will get a more concise response. Or simply asking them to restate what they said might glean a more easily interpreted version the next time around. These probing and restating techniques are far more sincere and effective than trying to enter their precarious world of informal language.

While it may not be helpful to personally verbalize teen language, it is certainly effective to be versed in it and operationalize it. I often surprise my young clients by my understanding of some hip, new reference they made. Just keeping up with pop culture is helpful in this area. Slang is generated by observations made by teens through media and entertainment, so occasionally watching a movie about a nerd coming of age or sitting through a speed metal song will help me become more aware of youth's language and mindset.

Another aspect of slang is that by nature it must be fluid and changeable. This helps reinforce its function as cryptic, rebellious and unique. The use of the word "like," has this chameleon like quality. I think we can thank the SC valley ladies of the 80's for its popular inception, although it has been around longer than that. Depending on tone and emphasis, "like" can have many meanings. Initially, it was used as a method to stall the listener, to buy time till the right word came along. Also, it is used as filler, if the correct word never does come along. If it is expressed as slightly pressured and loud, the person is cuing you that something really profound is about to be disclosed. If "like' is stated rapidly or almost mumbled as the speaker is relating a past conversation, the listener may be warning you that he is paraphrasing the words that were said, often to make it appear that the speaker was the fairest, most cordial and accommodating or the real victim during this interchange. The speaker is signaling you that the other party said something "like" what he or she is repeating, but is also cuing you that the content is being slanted or manipulated to further his or her standing as it relates to the outcome of the conversation. This type of usage is very subtle and at the same time potentially confusing and nebulous in its meaning. So a simple 4 letter word becomes tremendously variable depending on the way it is expressed contextually.

So as a therapist, I have to try to untangle these nuanced slang references to have full understanding of where the adolescent client is coming from. When I started in this field and first heard the term "listening skills," I thought "what can be so hard about that?" But my brief discourse on understanding and treating teenagers illustrates the deeper levels of interaction and disseminating of information that occurs with this skill. Not just with teenagers, but with any unique ethnic, cultural or age cohort. Being an effective therapist and genuinely individualizing treatment is dependent on refined and practiced listening skills like these.

Sunday, March 8, 2009

Your Therapy Experience: What to Bring with You on Your 1st Appointment

We live in this modern and complicated world. When we are beset by troubles and seemingly insurmountable challenges in our lives, we often find it difficult to consider all of the viable alternatives. Having exhausted every possible course of action we can think of, we turn to friends and loved ones for guidance and reassurance. Often this resource can be successful in terms of providing comfort and support, but the deficit, the "problem" and the associated discomfort, pain and anguish are still there.

So we reach out further from our small circle for support from our community. We enlist the help of clergy, teachers, principals, our family doctor and other authority figures that we know and are familiar with and trust in our dealings of everyday life. Often the advice and wisdom of these authority figures proves fruitful and we are able to successfully address whatever mechanism is inhibiting our quest for personal happiness.

When these interventions do not work, the next logical step is to seek "professional help." This action is, in fact, often one of the solutions that is presented by these visible members of the community that your have relied on for many years. Behavior clinic's referral sources are prominently fueled by relationships with schools, doctor's and churches.

But, alas, so many are reluctant to take this next step. Although statistically supported as a viable resource for individuals who are in psychogenic pain or discomfort, many avoid the next step of talk therapy and are destined to unnecessarily suffer through many years of their lives. There are many reasons people are reluctant to do this. One I believe is cultural. An American value is to be self-reliant and vigilant. The shame and embarrassment of baring one's soul to a stranger and of being reliant on them for help contradicts this ingrained value of independence and autonomy. Another obstacle to people seeking treatment is the stigma that is attached to having their problems institutionally addressed. As one of my client's once said to me at an initial appointment "when I think of psychotherapy, I think of 'psycho,' like I am nuts or something is seriously wrong with me." There is this old-fashioned, archaic view of the therapist picking the client's brain apart over the course of many sessions and months and the identification of some serious mental disorder or cognitive deficit.

This "couch and chair," era of psychotherapy has given way to new and exciting treatment techniques that focus on one's personal betterment and more on what is "right" with the client than "wrong." Therapists identify client strengths and assets and help them develop and utilize them to overcome admitted weaknesses, deficits and external sources of stress. Hence, you are not the "problem," but it exists in your social or occupational environment and as therapists we are here to help you with that problem.

The 1st attitude "to bring with you," to an initial talk therapy session is an open mind. Do not suppose that your experience will be akin to something you were exposed to in the media or heard from a friend. Every client-therapist relationship is unique and has a life of its own. The course, quality and length of treatment are dependent on the invested energy and mutual development of trust and honesty by both parties. Relinquish that trust in your therapist at a pace you feel comfortable with, with the rate of your disclosure being one that he or she earns based on the quality of their input and the sincerity of their reactions. Remember, we are working for you.

Another important concept to grasp when preparing for that 1st session is one of equality or parity. A therapist will engage with you in a manner which is not condescending, self-righteous or critical. We are all frail human beings and it is the therapist's task to observe your behavior but not to past judgment or make value-laden recommendations. A competent and experienced therapist has been exposed to a wide spectrum of behaviors and should be accepting of yours. If the therapist can not objectively treat you based on a difference in personal values, then it is an ethical responsibility for the therapist to refer you to another. You also have the option to request another therapist if for some reason you feel uncomfortable with the current relationship.

So when you seek talk therapy services, give the therapist the benefit of the doubt. Be assured that this "stranger" will soon be a skilled confidant. Engage with them in a truthful manner and with an air of mutual respect and be comforted by the fact that there are many years of experience, training and education in the helping professions available as a resource for you. The result will be a happier, better adjusted, actualized you. The quality of future experiences and accomplishments for you, family and friends may very well depend on what you bring to that 1st appointment.

Sunday, March 1, 2009

East Meets West: Body Symmetry and Mental Health

In terms of practicality we find the old time tested ways are the best. The past 30 years of medical science has witnessed the infusion of far eastern health practices. Most of these practices are in the form of self-help as opposed to being strictly medicinal. They are considered as corrective and preventative and require the affected person's participation on a nearly daily basis.

One good example of enhancing physical health in this manner are body cleansing practices. The deliberate use of specific foods, nasal irrigation and enemas have been gaining acceptance in traditional allopathic medicine. The flushing out of toxins in specific regions of the body has been found to reduce the onset of degenerative disease in several studies.

So how does this relate to mental health, anxiety and mood? One aspect that can be borrowed from eastern medicine in enriching our emotional well-being is the concept of body symmetry. When we feel balance in our body this manufactures confidence and an air of self-content. We maintain a physical posture and development of evenness throughout our body. A recent study (Prokosch,Yeo, Miller,2005) has now indicated that environmental factors have an effect on the even development of one side of the body compared to the other. That is to say the way we move and the conditions we are exposed to effects this even sided development. The prominent and distinguished use of right-handiness, for instance, will cause a relative atrophy in the left arm and hands. Do keep in mind that perfect symmetry is an absolute, a perfection that we can all strive for but never perfectly obtain.

There are several discovered correlations between body symmetry and depression, intelligence and cognitive skill (see Prokosch et all, 2005 and Thornhill, 2002 for instance). Other studies find a correlation between body symmetry and posture and how positively we are received in courtship and in business presentations. When others around us perceive us in a positive manner, we feel better about ourselves.

Other studies by M. Sathiamurthi measure the symmetry of body auras (the Yoga and Tantra term is "chakras") by examining electromagnetic fields around our body. He has found a correlation with people who are mentally disturbed or physically ill and a significant asymmetry of these auras.

Correcting the asymmetry and finding better mental health can be achieved through some simple day to day practices. Two of the SRT exercises I discuss in the three part 'Treating Anxiety," incorporate the use of body symmetry. Body awareness and movement emphasized the smooth and deliberate movement and posture with an emphasis on balance and equal distribution of weight. This day to day, moment to moment practice will help promote and maintain body symmetry. Transcendental meditation exudes the importance of sitting in a symmetrical position to promote that relaxed state and peace of mind. This posture during meditation is thought to correct the distorted body auras and physical manifestations of asymmetry.

Another exercise to help achieve body balance can be done laying down, in bed. Lay on your back in the "dead man's position," with your arm extended fully along your side. Try your best to make everything "equal" on both sides, the slight bend in your knees, the formation of your fingers in your hands (preferably slightly bent with your palms facing outwards). Attempt to equally align and distribute your weigh along your back and spine. Feel the balance of both sides of your body being at the same time equal components forming that feeling of "oneness."

In this position, begin to examine specific dualistic elements of your body, Start with the top of your head. Feel the muscle tension on your forehead and the sinus tension below. Say to yourself "as one side feels, does the other"? Make slight adjustments by moving your neck to try to achieve the feeling of sameness on both sides. Another technique to achieving this balance is a bit more difficult to describe. It is simply focusing or "willing" that sameness and symmetry. Use your mind's strength to achieve this balanced feeling.

Continue the checklist down your head, include your eyes, nostrils and mouth. Work down your arms and hands. Try to mimic the exact position and muscle tension in your biceps, forearms and hands, for both sides, left and right. Do the same with the various facets of your legs and feet, saying "as one side, so the other side."

You will feel this amazing balance and harmony and a state of content and relaxation you have never felt before. With practice you will drift into a semiconscious state while still maintaining this personal balance. The healing of body and mind will be profound.

With current research data supporting the importance of symmetry to improved mood and adjustment, the benefit of striving for the perfect bodily state can only have a direct impact on your overall happiness and feeling of confidence and self-worth.

Sunday, February 15, 2009

New Surroundings

I have been on hiatus from blogging a bit. I recently moved into a new office for my private practice and it has kept me busy. I am happy to see that a humble following keeps hitting my page. I feel there is allot of content here in my previous 13 posts and this should keep my readers busy. I am getting more and more hits via search engines, with a particular nod to the "G" people.

I worked in the same office for 5 years, It was small and had not been redecorated in some time. I moved into a larger, newly furbished office. I did the wall hanging and furniture myself. Last work week ended with my first day in the office. I am happy to say I got a good response from my clients. The last one said he felt so comfortable he did not want to leave. And he was court ordered for therapy!

For myself, despite the added potential in a new office, the adaptation is awkward. We are all creatures of habit I suppose. A slight change in the therapeutic environment or milieu throws me off a bit. The change in the room acoustics, a slight echo in the client's voice, the room ventilation are all nuances I know I will adjust to over time. But I have to admit I had a little difficulty finding my "therapy groove" after the initial move.

I have got a couple email inquiries and I will be addressing them soon. In the meantime perhaps some of my readers can catch up with some previous posts or formulate a question for me to address.

Thank you, I will be in touch soon!

Sunday, January 25, 2009

Betrayal or Adaptation?: Revising the Wedding Vows

I received this email today. It was a very short description of a very complicated problem. When I opened it I originally thought it might be another Viagra spam, as we all get so many of these:

Hi. My name is Sam. I'm 54 with diabetes and can't get an erection. My wife, Mindy is 45 bi and wants me to give her my blessing to have sex with other men. I'd enjoy seeing her with others. Is that normal or OK? Sam

We all marry with good intentions and generally take this commitment to our partner very seriously. Along with the promise of mutual emotional and material support, fidelity is perceived as central to the marriage arrangement. A sexual experience enjoyed by either partner with a third party definitely breaks the deal. It is hard to slip on that ring with your fingers crossed.

That said, I believe marriage in this modern age can be redefined mutually to adapt to changes in circumstances. This flexibility may actually help preserve the marriage, given that adhering to the original contract might be so rigid as to make one partner feel trapped, form resentments and dissolve the marriage before any real substantial negotiation takes place.

Marriage is so multifaceted in its considerations: religious, relational, financial, its effect on extended family. But its primary role, as I see it, is to protect the well-being and future interests of the progeny produced by the reproductive union. In Sam and Mindy's case, both being in midlife, I am supposing their children, if any, are out of the picture. The introduction of infidelity into a marriage with children would more than likely cause irreparable harm to the family stability and emotional state of the children. But in this couple's case, this does not appear to apply.

If Mindy is truly actively bisexual, it appears that the practice of open marriage has already been introduced. So as long as this couple has negotiated the parameters of this defined open marriage, it appears valid. Note how much this truly complicates the relationship; health and communicable disease considerations and the potential for a myriad of negative emotions that occur from relational triangulation: the inactive partner may feel betrayed, jealous or discounted. The active member may feel objectified, unprotected, abandoned and confused as to who is the focus of his/her affection. Sam's enjoyment of a voyeuristic role may be an attempt to reenact and resolve a chaotic romantic relationship involving 3 in his past. His curiosity may have even been spawned by his observation of turmoil in his parent's bond. Once again, this letter is short, so I do have to speculate a little bit. But Sam has to truly ask himself what is meant by "enjoy," in terms of his upbringing and relational past and how this effects his internal processes and the overall health of the relationship.

Given the precarious effect triangulation has on a marriage, it would be wise to consider other alternatives. There are many diabetic males who can perform sexually with either mechanical or pharmaceutical interventions. I hesitate to give a "yes or no" answer to any personal question that has its "gray areas," and this one has many. So what is "normal" or "right" is a private value and moral decision, to be decided on a couple to couple basis. The mutual respect as well as the
emotional and sexual freedoms of both parties is what really matters, as we adapt to the changes and challenges of our marriage and life over many years.

Saturday, January 17, 2009

Pandora's Disgrace: The Bottomless Jar

I received this email yesterday, in the wee hours of the morning. The issues of marriage and family are very complex here as there are many considerations: culture shock and adjustment, depression due to illness, lifestyle changes. Included also are more familiar marital stressors such as financial difficulty and trust. The correspondence is printed as written, excepting the name which was changed to guarantee anonymity.

I married a Frenchman in California. Following a layoff and a narrow frame of "I am only qualified as an engineer to work with one specific product," we returned to France with our new born baby seeking stability and my understanding was that eventually we would return when the market picked up. Here we have too much stability. Stability that makes you not change, meaning you just sit in one place. Someone has to die or retire before moving up the latter. Salary increases are maybe 3%/year (if lucky) while cost of living increases by at least 10 - 20% per year.

Turns out now my husband doesn't want to return to the US and I feel totally betrayed, tricked, swindled...whatever the word is.
I spent the first three years in France raising our child without any family or support around. It wasn't easy, but I'm happy I was able to be there. Kids start school at age 3 in France, so when my child started school, I was hired at a French company. After I realized I was paying 50% in taxes (government retirement included), my contract was up and I decided to stop working. I had searched for work before my child started school but never found anything. It's a very difficult job market in France. Then when you finally do find work, you wind up paying most of your salary in social charges and taxes. I was hired for almost 3X minimum wage. After taxes my net was 400 Euros above minimum wage. Do you get what I'm saying?
So I have spent 5 years of my life in this country that I never really cared for, except the beautiful vacations, which entail 3 weeks/year. My husband is in hog heaven back in his country and has no intention of returning to the US, though he has said otherwise, his actions have led me to realize he really has no intention. I must say that he was diagnosed with Multiple Sclerosis about 10 years ago and doesn't want to live in the US without health insurance, and I do fully understand that. But so far his disease has not at all been progressive, yet this is the kind of disease that's very hard to predict.
I grew up in a divorced family. I didn't like it and said I would never put my child through such an unfortunate situation. But now I am like, at what point does my happiness count as equal value to the happiness of my husband's and my child's? I have always felt selfish for wanting to be happy when my child's needs are very important. But I have to acknowledge that if a child's mother is not happy then that could eventually radiate towards the child. I hide my unhappiness as best as possible, but after 5 years I know it can't go on. I don't want my husband to loose the house he so loves and paid for because of a divorce, which will happen, but at the same time - all of our money is in the house. I can't leave empty handed either. I need as much as possible to rebuild in the US.
We all know French stereotypes, and I have to say hygeine is another issue. My husband still uses cotton hankerchiefs. He blows his nose on one and then puts it back in his pocket only to reuse the same one throughout the day. This time of year, he has come down with a cold. So there is excessive mucus and he is still using and reusing the cotton ones. I have bought the pocket sized paper ones and put them in the drawer where he keeps the cotton ones but he refuses. He also left one full of mucus lying on the kitchen counter. He blows his nose in the shower only for me to find "remains" on the shower curtain. I think he has IBS and is constantly having diarreah and there are always spots on the toilette for me to clean up. I hate to sound petty, but these things really bother me. The good news is he does shower every day.
Also, the cost of living in France is more expensive than most Americans could imagine, except for maybe New Yorkers. Even then, electricity and gas (heating) and gas for cars are cheaper than in France. So we bought a house in a town with a really bad reputation, high-rise housing projects all over the place, full of Muslim immigrants, and I just don't feel safe in this town. I mean, I know most Muslims are innocent and kind people, but here we have extremists, women walking around in Burkas, with only a slit for their eyes. Men wearing long robes with long beards. It freaks me out. I guess I might have a slight phobia. But I just don't feel safe given the current political situation between the US and the Arab world.
We almost didn't get the loan for this house because of my husband's multiple sclerosis because in France, everyone is required to have a PMI (private mortgage insurance) in the case of death or disability, the insurance is required to pay our mortgage. So he doesn't want to buy a house anywhere else because of the paperwork nightmare and the high cost of this insurance.
I am just totally lost. I mean maybe the answer is obvious for you. I know the choice isn't easy. But I just don't know what to do. I was always an ambitious person. Always seeking to better myself through work and education. Working and education have come to a screeching halt in this country. And it's not from a lack of effort.
Please advise.....

This women is overwhelmed with negative emotions. In the last 6 years, her world has been turned upside down. This series of events has helped foster hopeless and helpless feelings regarding her life and future. Seemingly she is trapped in a foreign land with her child and a man she has lost genuine feelings for. Her mindset is such that she feels she has few alternatives. She feels subject to despair and isolation and blames her husband for her miserable condition.

We are culturally taught that times of adversity will be followed by some form of reprieve. Our situation can only get so bad then there will be a glimmer of hope, the light at the end of the tunnel, that the sun will shine tomorrow. In Sally's case, there is seemingly no possibility of reversing this negative trend. The adversity she experiences has been accumulating for so long, it will seemingly never end.

Understandably, her mindset is negative and her clarity of thought has been diminished. Because she has been bombarded with these personal challenges, she has narrowed her alternatives down to a lose/lose dilemma: Either live her life in a place where she can never be happy or betray the continuity of her family and return to the states.

The truth of the matter is there is always more than 2 alternatives to a dilemma. Sally must re nurture that part of her mind that gives us hope in the face of adversity. She must begin to consider what she can do to restructure her marriage and reconstruct her life. If after she has exhausted all of her alternatives and has come to the realization that despite her efforts her life in France will be woeful and miserable, then she can make that choice to leave, with the conviction that she truly tried to rectify her marriage and that leaving is the best action to ensure her child's happiness.

The 1st dynamic to consider is the mental state of her husband. From what is revealed in the letter, he appears to be chronically depressed. His pain inducing illnesses (MS and IBS) are one indicator. His deteriorating hygiene can not be chalked up to simply a difference in cultural norms. I am certain he did not present himself in this insalubrious manner when he 1st met Sally, or she never would have married him. He appears in need of professional mental health intervention and lacks the awareness to seek help.

So Sally can help him reach this insight. If his mood and personal habits change, it would provide much relief to her stress and the perception that she is being objectified by him. Which leads us to the 2nd dynamic, that there is a profound diminished communication between this couple. This would further explain his depression and Sally's dilemma. Both parties have no one to reveal their innermost thoughts directly to and receive nonjudgmental feedback. For Sally, this emotional isolation is furthered by being so far away from friends and family. Sally is reluctant to engage in any serious and productive conversation because she no longer trusts him. She feels tricked and manipulated into living a life she did not choose. Her husband is so distracted by his medical challenges and depression he can not organize his thoughts well enough to identify and elicit his feelings. And yes, he has become so focused on himself that he is severely ignoring the needs of his wife. There is an impasse in terms of honest discourse and she must make an effort to break it. The first step to improving their communication is for him to seek the aforementioned help he needs.

During this process Sally must ask herself some honest questions. One would be hypothetically "could I be happy in France if I had the love and support of my husband?" I have a feeling that with him as an ally she could overcome some of the discomfort and fears she experiences from living there and these cultural anomalies could be tolerated at least until the child is raised and she is released from the obligation to keep the family cohesive. If she feels she no longer loves this man, she must ask herself given her resentment, could she ever love him again.

If she can answer yes to all of these questions, if she can visualize tolerating the differences of those around her and a profound change in her husband's mood, she will once again become hopeful. She can envision a family life where everyone is working toward common goals of emotional stability and material betterment. If she makes this full effort to change her current familial and martial conditions and fails, at least she will have the peace of mind that she explored every option before her flight from France. She can wash her hands of this situation and never have to second guess this decision.

In these troubled times, all of us, like Sally, face some profound challenges. In order to endure our ills and the obstacles we are plagued with, we must summon all our energy and reach deeply into that vessel and obtain both strength and resolve. We must realize that hope is not to be utilized as our last resort or a means of comfort after we have conceded defeat, but is a valuable tool in addressing the seemingly insurmountable challenges of our lives.

I leave you with a quote by a colleague and coworker of mine, Dr. Ken Cunningham.

"The substance of hope is our entire narrative and our capacity to say we possess it. Our hope is a result of having lived with and being influenced by others, and when we are shaken, our hope holds us and we learn to reinvest in life. When our hope is gone, changed or altered, it takes something to give it back to us. Undoubtedly, that something is often relationship or experientially based, and in that, we learn to consider hope again."

Saturday, January 3, 2009

Nutrition and Mental Health Part 3: Treating Depression

Of all of the chronic mental disorders, depression is the one that can be the most impacted by our nutritional consumption. A good diet heightens the body's functioning and when you feel good physically, you are energetic and optimistic, more capable of dealing with stressful events and setbacks as they come about. Simply eating light healthy food will help your energy. Food that digests easily and is involved with the cellular repair and integrity that enhances the functioning of vital organs and glands should be emphasized. I focused on omega fats in part 1 of this "mini-blog.". Other considerations nutritionally for general health are antioxidants and trace minerals. These important nutritional aspects point to the need to shop frequently for fresh foods. Another viable approach consists of using vitamin and herbal supplements related to specific environmental stressors and events. For instance, using large doses of vitamin c, zinc and echinacea when one feels a cold or virus coming on. Or replenishing electrolytes after sweating profusely due to exercise, heat or illness. Or consuming garlic to fight off infection. Remedies such as this tend to be more effective when needed, as opposed to taking prolonged daily regimen.

Herbal Remedies for Depression

As I discussed earlier, there are many herbal remedies that are co indicated for anxiety and depression. One significant delineation that can be made between the two disorders is that remedies that tend to excite or stimulate the nervous system are effective in treating depression (especially during the active part of the day), while treatments designed to calm the nervous system are more effective in treating anxiety . Supplements that encourage falling asleep or staying asleep are helpful with both disorders. Here is a brief discussion of some popular herbal remedies used for depression.

St. John's Wort: This herb (the cultivated flower and leaf) has been the most bandied about depression remedies. It has been clinically confirmed to relieve mild to major depressive episodes and its efficacy is comparable or greater than SSRI medications. The chemicals
hyperforin and hypericin are thought to inhibit serotonin re uptake in a similar fashion to its pharmacological counterparts. Other chemicals in the leaf and flower may have a synergistic and buffering effect that help with its efficacy and deride potential side-effects. St. John's Wort has not been proven effective in treating dysthymia, a mood disorder with similar but less acute symptoms as depression that tends to be less episodic and have a longer duration of symptoms. Cognitive therapy alone can be successful in treating this disorder.

SJW is widely sold and quality greatly varies. A pill that contains at least 400 mg of
hyperforin should be sought so the minimum effective daily threshold of 1500 mg. can be easily reached.

Hypericin has a poisoning potential in high but easily ingested doses. This has been observed with grazing livestock. Sensitivity to light and a racing pulse are early signs of this poisoning. This supplement should therefore be secured in the household like any prescription medicine would.

There is a bit of an urban myth regarding combining SSRI's and SJW. The thought is that SJW creates a "serotonin dump," that increases the voracity of the inhibitors. There is, however, no clinical evidence that this increased neurotransmitter production occurs. As a CYA, I would say always consult your physician.

5-hydroxytryptophan: An amino acid, this is found in the seeds of the shrub Griffonia simplicifolia. It is a building block to the production of serotonin and is often used in combination with SJW. Like its chemically related cousin (it is a metabolite), L-tryptophan, it has a calming effect and helps induce sleep. L-tryptophan itself has been found to help treat jet lag, menstrual difficulties and seasonal affective disorder (SAD). It helps increase melatonin production, which in itself is an excellent sleep aid.

S-Adenosyl Methionine: or SAM, is another amino acid. It has been tied to the successful regulation of all major neurotransmitters and helps people that have poor receptor site binding. It has obtained recent attention as a potential preventative for Alzheimer's disease, although there is very little research in this area. It has been found very effective in treating depression related to physical discomfort, as it has a role in lowering the brain's sensitivity to chronic pain in liver conditions, fibromyalgia and osteoarthritis.

The use of these remedies are a valuable resource for those seeking an alternative to prescription medications. Those who do not have medical insurance or are under-insured can rely on these cures as perhaps their only resource. They are also proven to have a lower incidence of undesirable side effects then prescribed meds, i.e. weight gain and male impotency.

Research indicates that herbal and pharmacological intervention is most successful when combined with talk therapy. Any chemically induced depressive treatment provides temporary relief and allows the person to "step-back" and examine profound thinking errors, increase coping mechanisms and problem solve. When this liberation occurs, a competent psychotherapist can help guide the process of healthy cognition and improved quality of life.

This, for now, concludes my dissertation on nutrition and mental health.

Saturday, December 13, 2008

Nutrition and Mental Health Part 2: Treating Anxiety

While treating anxiety can probably best approached with cognitive behavioral therapy and gaining an understanding of the environmental cause-effect relationships and behavior chains via SRT (see previous 3 part blog), herbal remedies are gaining popularity since their acceptance (note: short of an endorsement) by the FDA in 1994. As with herbal remedies for depression, many of these cures affect brain transmission and neurotransmitters directly, so an immediate benefit can be appreciated. Many of these cures have active ingredients that were isolated by pharmaceutical researchers and used in the production of anticonvulsants, anti anxiety, antidepressants and other branded medications that slow down brain activity. The herbal source, however, is often kinder to the kidney and liver as they are buffered and diluted in their natural state.

Let's consider a few anti anxiety remedies:

Kava Root: Perhaps the most popular and also the most maligned because of its potential to reach toxic levels in the body. Recent research has confirmed that this plant is effective in lower doses administered several times a day, reducing the likelihood that a toxic threshold will be reached. It is particularly found effective in the treatment of agoraphobic and social anxiety disorders.

Valerian: A recent up and comer in the treatment of anxiety, this plant originates in Europe and has been long known for treating insomnia. Valerian extracts interact with the GABA and benzodiazepine receptors in the brain. It is often used to help people wean off of Librium and similar pharmaceuticals that are cause for physical dependence. It is very successful in the treatment of anxiety disorders that coincide with gastrointestinal disorders, such as irritable bowel and acid reflux.

Passion Flower: This exists in many forms and varieties. It contains betacarboline harmala alkaloid, which was isolated to formulate Monoamine oxidase inhibitors (MAOIs), a once popular antidepressant. As is the case with its purified form, the use of passion flower has many undesirable drug and food interactions, so it must be used with caution. Their particular value is in treating anxiety secondary to mood disorders. particularly bipolar type 2.

Because anxiety and depression are so closely related, many of the recommended cures overlap and are effective in treating both. I have tried to isolate the 3 mood and affect herbal remedies that pertain the most to anxiety disorders. In the next section, we will target the treatment of depression through natural dietary supplements.

Sunday, November 30, 2008

Nutrition and Mental Health Part 1

I received a letter recently asking me if I take nutrition into account in treatment of common psychiatric disorders. Well the simple answer is yes and there are several facets here to consider. I will try sort this out and delineate the nuances of diet and supplements as it relates to a healthy mind.

The 1st consideration is that we as human organisms are defined as a biological and physiological system. In maintaining a healthy body through diet and exercise, we also keep our minds healthy. In keeping a healthy mind, we interact in our environment with good judgment, graceful movement and compensation with the world around us. We are less likely to be accident prone, put undue stress on our joints and spine, or take risks that are cause for injury. In past blogs I have continuously referred to this mind-body dualism, but it can not be understated. The health of one is innately tied to the other Therefore practices that promote the health of both body and mind are of the utmost importance.

A good example is the use of omega fats in the diet. Popular health nutrition has pointed recently to the importance of the use of unsaturated fats, with an emphasis put on omega 3's and 6's. Monounsaturated fats, such as olive oil, have long been touted in improving cardiac and vascular health. So why are these fats so important in promoting physical and mental health? While referencing several valid overall biochemical reasons, I will highlight their importance in mental health.

Omega 3's contain DHA (decosahexaenoic acid), which is vital in cell replication and structural integrity for the entire body. Brain cells are no exception. Not only are they important in maintaining healthy brain cells, but these fats are highly concentrated in the the synapses, where brain cells communicate with one another. The smooth and consistent firing of neuropathways are profound in their benefit to mood. Cultures that have a high intake of Omega 3's such as Japan have statistically lower rates of depression. A healthy brain is a happy brain. These fats directly effect the structural integrity and functioning of brain and nervous system.

Omega 6's benefits are more indirect. They are significant in maintaining vascular health. So this lowers the risk of stroke and allows for increased circulation. The blood-brain barrier becomes more unrestricted and allows for oxygen and nutrients to pass, nourishing the brain cells.

Another aspect to consider in terms of the viability of these fats is that polyunsaturated fats can not be reproduced in the body. Consumption of plant or animal is the only way to obtain these. As soon as they are processed or taken out of their natural state (e.g. the plant is cultivated, the salmon is killed), they begin to degrade and dissipate. This puts and emphasis on freshness and simplicity in menu planning. Along with fish these healthy fats are found in high concentration in nuts, seeds and legumes.

Another consideration is a balancing the intake of the 3's and 6's in your diet. I believe this is a little overblown by nutritionist because both of these fats are good for you and what the body doesn't need it will metabolize. However, 3's are more difficult to obtain in modern diets, so reading labels or researching content may be beneficial, Additionally, these fats are also found in caloric foods and if you are trying to restrict your intake of all fats for this reason, composing a diet that has a 1:1 ratio of 3's and 6's is what is recommended by most nutritional researchers.

We have often heard to fish referred to as "brain food." This points to the high concentration of omega 3's in these foods. Fish has many other health benefits of course, as it is an excellent lean source of protein. In terms of nutritional supplements, however, please consider flax or hemp seed over fish oil. These supplements contain up to 7 times per weight more of the omega 3 and 6's than salmon oil does.

I will be writing more about specific nutritional treatment of mental disorders in part 2 of this blog module, but i wanted to kick it off by highlighting the importance of healthy fats in our diet, because they probably have the single most impact on the way we think, feel and adapt to the world around us.

Sunday, November 9, 2008

Treating Anxiety Part 3: reactive elements and body awareness

In parts 1 and 2 of this series, I examined the nature and course of anxiety as it occurs and techniques to break the escalation of anxiety in the comfort of your home or in a clinical setting. Because anxiety is cumulative, there is some benefit to seeking a reduction at anytime we feel overwhelmed with stress, even after a long day. It gives us an opportunity to "reset" and reverse the mounting pressure that our rigorous activity brought forth and put us in the proper state of mind to truly enjoy our recreational and leisure portion of the day. But addressing stress as it occurs, in the social milieu, presents an even greater challenge. When suddenly confronted with a profound external stressor, we often lose that part of us that is the most grounded and pragmatic. So the question becomes, how can I maintain control when I am at my absolute worse?

In part one, I mentioned taking "stress breaks" throughout the active part of your day, utilizing the lunch or personal time appropriated to you. You have developed some stress reduction techniques at home, but because you lack the privacy and resources to fully implement these techniques in a work, school or community setting, it is beneficial to bring SRT into play by creating "portable" versions of these techniques to implement when you have a few moments or even seconds to yourself in these settings.

Meditation and positive visualization are possible anywhere. The most important element here is being well practiced enough at home to jump quickly into the technique in more formal settings, if even for just a brief period of time. Someone who is well-practiced at home can quickly let their mind "empty out," if for just briefly before regaining focus. And break time is an opportunity to take stress on for an even more extended period of time.

Recently a client with and anxiety disorder had some moderate success with deep breathing and meditation in the clinic setting and home. The panic attacks continued at school, however. These attacks included increased heartbeat and profuse sweating. I told him he needed to take time out during the school day and deep breathe and relax. He stated he thought this impossible because he would become self-conscious, aware that others were observing him taking deep breaths. My rational response was what did he find more embarrassing, him taking deep breaths or his shirt becoming soaking wet from perspiration? In fact, there is nothing embarrassing or impractical about breathing in this manner when sedentary or involved a moderately paced activity. And there is absolutely no benefit to displaying tension to others by taking short breaths and speaking in a pressured tone. People respond positively to those that exude calmness and confidence in any formal setting.

In order to claim this calm and confident persona, we need to examine our everyday physical orientation and movement in the workplace. How you sit at your desk chair and get up from it, for example can set the tone for the way you react to stressful situations. Are the muscles of your neck and spine overly tensed? Or do you sit slouched with your shoulders slumped in a submissive manner? Either one will contribute to anxiety when exposed to a stressful situation. Extreme muscle tension causes bodily discomfort, which in turn makes our mind even more confused and less adept to deal with adversity. Slouching passively is cause for unpreparedness and ambush when we our suddenly challenged. The happy medium is a healthy orientation of your head, neck and spine. Sitting upright, shoulders pronounced but not locked square as if at attention, is the correct stress reducing posture. Your neck should allow your head to be slightly forward, but not tilted downward or fixed upright. You should feel a widening in your lower back, as the orientation of head and neck allow the muscles along your spine to relax.

The movement from office chair to copying machine or from classroom to classroom should be scrutinized also. Anxious people tend to move about in a twisting, herky-jerky fashion. They think in terms of function, quickness and utility as opposed to their physical well being and comfort. Do you pop up out of a chair suddenly and automatically with a focus on your destination or the next task at hand? If so, you are reinforcing stress. You are placing unneeded tension on your joints and spine, and once again experiencing that discomfort that is cause for even more confusion and anxiety.

Take on the task of improving the most fundamental physical ergonomics in your day to day activities. Concede that these debilitating repetitious movements are taken for granted and never scrutinized. Resolve to partake in a deliberate and fluid physical motion. Unlearn the repetitious motor movements of your body that are cause for physical and mental tension. Reinvent your physical orientation and increase your awareness in those places were you experience the most stress. Both mind and body will be that much better for it.

This concludes my clinical insight on the practical treatment of the infliction of stress and the experience of anxiety. Hopefully you have achieved an awareness and knowledge of how anxiety manifests itself, the tools and techniques to keep it at bay and the means to take it on where it is most likely to have it most profound effect, in the places where you struggle everyday for achievement, income and recognition.

Sunday, October 26, 2008

Treating Anxiety Part 2: stress reduction techniques

Empowerment is the key to a stress reduced life. I say reduced as opposed to free because we all experience stress on some level. Deadlines from work, difficulties with significant relationships and financial dealings to name a few. It's more the way we react to these situations than the content or magnitude of the challenge that makes it debilitating. A former friend of mine's favorite saying was "it is only a big deal if you make a big deal out of it." And although I wanted to slap him upside the head when he evoked this after my pet died, there is some truth to it.

We need to control and quantify our reactions to challenges and setbacks as they occur. So developing a repertoire of stress reducing and controlling techniques is a valuable weapon in the battle against anxiety disorders. Being comfortable and well practiced with them is probably the most difficult facet in being successful with them. When we feel overwhelmed with problems our narrow focus becomes the problem itself, not our disposition as we take them on. So appreciate the importance of your mind-set in dealing with your anxiety related problems.

Listed below are a few SR techniques I have had success with clinically. It is important to experiment around and find the one or many that work for you. You must gain some mastery of the technique in a comfortable setting, and then be able to implement it when you first feel the anxiety coming on, anywhere, anytime anyplace.

Deep Breathing Technique: This is the most basic and widespread of SR techniques. It is frequently ridiculed in the media and movies as a desperate measure when someone is overwhelmed. I don't know how many movies or comedy sketches I have seen wherein someone is breathing into a paper bag in the most inappropriate of settings (you don't really need the paper bag).

The most important element of DBT is control. You chose a slow deliberate pace to breathe. When you inhale, you do not let your abdominal muscles expand, as if you are filling up with air. Instead, you tighten your abdominal and diaphragm muscles. When you exhale you can slowly relax the abdominal and diaphragm and control the stream of air. Performers, particularly singers, woodwind and brass players use this technique to enhance execution when reciting.

Although the easiest to master, DBT is highly effective. It is also the most feasible to combine with other techniques. The increase in oxygen to the brain and vital organs gives one a sense of well-being. One of the main symptoms of anxiety disorders is a feeling of loss of control, in particular body functions. An increased pulse, or sweating, for instance, makes us feel even more anxious. In taking complete control of our breathing, we resume command over our bodies. We gain a calmness that lets us address these uncomfortable sensations.

Positive Visualization: When overwhelmed with disturbing thoughts, simply imagine a time and place when you were completely relaxed. A vacation at the beach, the warm breeze and the sound of the surf. Even a romantic encounter, one you truly enjoyed and does not invoke other insecurities. We all have memories that when vividly recalled will elicit the same calming sensations when the experience occurred. They can serve as a distraction when we feel on the brink of an anxiety episode.

Meditation: This technique really utilizes the power of the mind. Mediation, in a transcendental sense, is the "art of think of nothing." You position yourself seated in a quiet, non-stimulating setting. You can start with a mantra, a 2 or 3 syllable nonsense phrase or word. Keep repeating it in your mind till all meaning is lost. Eventually you can drop the mantra and jump to thoughts of nothing. When you loose the internal dialogue associated with a conscious state, all of the physical symptoms associated with stress vanish. Muscle tension in the neck, a rapid pulse, acid stomach, will slowly melt away.

Thought Stopping: This is effective for anxiety related disorders related to repetitive disturbing thoughts. It is a procedure used to stop thoughts that are cues to thinking obsessively or acting compulsively. The key is to hear “stop” literally or figuratively whenever a negative or unhealthy thought arises. You can yell it to yourself when you are at home or alone, then replace it with the imagined audible in your head when in a more formal setting. Another method entails making a tape recording of your voice by repeating the unhealthy thought, i.e, "I think my hands are dirty," over and over again for 2 minutes, then yelling "stop" loudly and repeating the cycle over and over. Then lie down in a semi-conscious state and listen to the looped tape.

The idea is to "jar" the negative thoughts and feelings out. Once you are redirected you can shift your thinking and activities to more healthy ones. Hopefully, over time, the repetitive thoughts will vanish.

Biofeedback: Biofeedback is not a SRT per se. It is a method of measuring physical responses associated with stress. A SRT is implemented and then the effectiveness of that technique is measured by the biofeedback instrument, as it looks for a decrease in a stress related physical response. It gives the client the ability to confirm the effectiveness of the technique. The client no longer will have to say "I think I am relaxing," because there is measurable confirmation to the relaxation. Once the sensation is confirmed and quantified, the client has learned to relax.

There are several biofeedback instruments available to measure stress. Some are quite inexpensive. I have found a Galvanic Skin Response instrument quite effective in practice. I paid $25 for it on ebay. Here are some definitions:

Pulse and Variable Heart Rate: When stressed, the heartbeat not only increases, but becomes more arrhythmic or uneven. Breathing does too. The "Stress Eraser, " measures both of these and keeps a diary to monitor improvement. It will even tell you when to breathe in a healthy cadence. It is portable and made of i pod style polished metal. It measures from your index fingertip. Might be an overkill on price but very stylish and effective.

Galvanic Skin Response: As mentioned above, very effective and inexpensive. Measures moisture at your fingertips, the minute "perspiration response." It emits a theramin-like tone that lowers as you relax. PC software is also cheap and attainable. These will create graphs to illustrate response over time and offer games that encourage you to relax. Time proven and effective biofeedback instrument.

Muscle Tension Instruments: Not highly commercialized, these measure tightening muscles, particularly in the neck. Highly effective in treating migraines and muscle tension-related headaches. Not very practical in terms of comfort (hard to cope with electric diodes placed on the neck).

Brain-Wave Machines: These are also used mostly in clinical settings, but are gaining popularity via the portability of the microchip. These directly measure the beta waves that are associated with a relaxed, conscious state. They are potentially the most effective way of measuring anxiety, but are also the most expensive, with the alpha-beta-wave machines of any real value topping $1k.

External Skin Temp- As we become stressed, blood rushes out of our extremities to our vital organs. These instruments measure body temp at your finger tips and scrutinize temps slightly below the normal 98.6. These are the most inexpensive in the biofeedback realm, but as you might have guessed, the least effective because there is a delay between the anxious response and the change in skin temperature, analogous to the delay in change in room temperature after you turn the thermostat down. It is therefore hard to get a feel for the cause and effect relationship of anxiety and this physical response. A mood ring is a simple example of an external skin temperature biofeedback instrument.

Stress reduction techniques do work. This is supported by research. It is difficult to find the time to implement them and find the right one that works for you. Biofeedback gives you an opportunity to confirm your progress and accomplishments and makes the dedication to anxiety reduction that much easier.

This blog has covered valuable information regarding controlling anxiety. In part one, we gained an understanding of how anxiety manifests itself and relates to our daily living and cycles. Part two has given us background on tools and techniques we can use to combat this illness. In part three, we will examine how to use stress reduction in the most practical settings, when and where it occurs in our work, travels and at home.