Psychotherapy Notes — Why Does Psychiatric and Psychological Treatment Take So Long?

Why does psychiatric or psychological treatment take so long? It’s because the things that need to be changed are not always so easy or willing to change.

If it’s a straight and pure biochemical depression, then the medications need upwards of at least a month or so to correct the biochemistry and to make shifts in how the neurons communicate with each other. There is even hard evidence that a substance called brain derived neurotrophic factor needs to repair the glia cells, that synaptic receptors change in density, and so on. All this simply takes time. Even if the right dose of the right medication is found from the onset of treatment, the brain initially resists outside influences to change it. This is really a safety mechanism. The attraction of many drugs and of alcohol is that these particular molecules get into the brain quickly and cause immediate effects. But alcohol and drugs do not repair. Medications do. So we have to convince the brain to let them work. The brain is very tenacious in so far as how it hangs onto old ways. Psychiatric medications are really reestablishing, as much as possible, a better or perhaps even a normal biochemical relationship between all the parts.

Sometimes the psychiatric symptoms are not just because of a biochemical imbalance, but because the wiring has been corrupted. Many drugs interfere with the installation, so to speak, around the neurons. When these are damaged, they may not always be fixable. So in this case, the best a medication can do is reestablish as much biochemical balance and normalcy as possible, and then the psychological part of treatment tries to teach the functioning aspects of the brain to work around the damaged parts. A stroke, ilness or injury can cause similar problems.

Sometimes people have genetic characteristics that make them prone to psychiatric problems. This can be conceptualized as a factory with a flaw. Left alone, the factory does not produce the proper products. So the science of psychopharmacology enlists medications to get the parts of the brain that can work to work to what is closer to normal.  When this ‘normalcy’ is approached, the psychological treatments then focus on ways to strengthen other parts of the persons makeup so that they can function better. Because of a genetic aspects of the problem do not change, the problem may only be controlled but never fixed. But by the same token, the psychological aspect may become strong enough to mask or even outweigh the influence of the genetic problems. This takes time.

There is also the aspect of biological brain maturation. A 14 year brain is not the same as the 28 year old, so any and all treatments to the 20 year old are being laid onto a very non-static field. (This is the topic of the  Adolescent Brain.)

I asked a good psychotherapist why she thought psychotherapy took so long. She said it requires the movement of thoughts and feelings from the brain to the gut. How interesting. The phrase is that we usually trust our gut feelings. She said that many people don’t know how to read their gut feelings, or if they can identify a gut feeling, they don’t trust it, or the situation they live in doesn’t allow them to follow these feelings. Sometimes they are even frightened of their gut feelings.

Psychotherapy is the time-consuming but necessary education of ourselves about ourselves, to understand the way we respond to situations and then to identify, and then practice, ways to change the problematic aspects of our thinking. But sometimes our emotions come from uncontrollable sources outside of our own lives, so psychotherapy may need other people or situations to change as well. If that change is impossible to make, then successful therapy requires that the person learn how to live in spite of it, or to move away.

There is a big difference between understanding a problem and developing the skills, attitudes, and raw experience of how to deal with it. Sometimes these skills and attitudes are part of what we call maturity. This also takes a lot of time to develop, but it also usually takes the ability to try new behaviors, to fail and learn from the failures, and to have a role model to copy. One aspect commonly facing the patient in psychotherapy is the coming to terms with the reality of some situation in their life that is very uncomfortable or disappointing. Another aspect is the coming to terms with the reality of themselves – and it takes time to work into this level of self honesty and the movement away from denial or rationalization. Good psychotherapy is the development of honest knowledge and self-responsibility. As a result, psychotherapy rarely is successful if the person doesn’t want to take this personal, sometimes intriguing, and sometimes painful, exploration to better themselves.

Psychotherapy is not an event. It is a process.

 

The Adolescent Brain — Protecting A Teenager’s Ability For Good Development

One of themes I follow is the importance of protecting the adolescent brain so it has the best opportunity to develop both neurologically and psychologically.  The past few years have provided us with incredible insights. These need to be broadcast and applied to our approaches to the adolescent brain.

Let’s begin with a recent interview with Dr David Gross, a psychiatrist, who gives a solid basic outline of the topic. He also includes material on what happens when the developing brain is exposed to substance abuse, in particular marijuana.

(Click to listen → )  The Adolescent Brain   — This is part of the Experts Speak podcast series from the Florida Psychiatric Society.

More to follow.

Society’s Tonics — Our Personal Medical Record Privacy and Safety

One of my deep personal concerns is the security of off-site medical records. An industrious hacker could wreck havoc on records (changing meds, allergies, history, etc.) as well as break confidentiality. The recent Sony break-in, according to Bloomberg news, was done by a hacker who bought public and inexpensive computer processing time from Amazon’s Elastic Cloud — in effect, Amazon offers very enhanced computing machines that, with designed software, can find and break through codes and firewalls. My first days of computer programing watched an angry grad student cleverly take control of a huge computer. (He seemed to disappear the day after — rumor had it that IBM hired him.)

The Bloomberg piece raises many key issues about where we are going with medical records; we need to be more patient about the reality of electronic medical records stored off-site until technology removes more of these vulnerabilities. Too many computer systems suffered break-in’s over the last few months.

I feel about this as I do about nuclear reactors — the idea is great, but the engineering is yet to be up to what we need.

The article:

http://www.bloomberg.com/news/2011-05-15/sony-attack-shows-amazon-s-cloud-service-lures-hackers-at-pennies-an-hour.html

Psychotherapy Notes — Alcohol to Hide, Alcohol to Celebrate

A friend underwent some very trying times. His days and nights were visited by chilling panic and uncertainty. Anxiety attacks became unannounced visitors that took his mind from work, removed his ability to sleep, and unwound his ability to be unruffled or think rationally. He was embarrassed by it. He felt no control over his life. He was afraid.  It was an overpowering, pungent pain that our empathy or reassurances could not relieve.

So he took to daily drinking. Without a cocktail he had no emotional control over himself. Indeed, when things seemed less ill-omened, he could even skip his daily drinks. And when things finally resolved enough that the future wasn’t as menacing, his drinking returned to his occasional, social level. (He also repeated over and over how humbled he had become, saying that could not imagine life if such a problem did not find a resolution.)

He told me that when the good news came that the problem may have a resolution, he wanted to ask us over for a drink to celebrate. How odd, he thought, that alcohol, which he used because he was afraid of the future, was now being used to celebrate the future.

He asked what it was about tranquilizers that had this duality of effect. How is it that the same substance which was used to separate him from his fears, which worked in a way to extinguish the pain of his anticipated emotional annihilation, was now being asked to undo the past tensions and take joy in the end of war?  He found it intriguing that alcohol and tranquilizers softened our projections of a painful future, and yet they could also highlight, with euphoria, our projections of a new-found, or newly beginning, better future. “How so?” he asked.

Could it be that these substances induce a euphoria that dilutes out the pain when the future is bleak or scary, but when it doesn’t have to dilute out the bleak or scary, it leaves us with the euphoria. Is it like cooking?  Can a single spice be used to cover up bad taste to make a dish less distasteful, and yet this same spice can embellish something which is already tasty? It appears so.

But it is not always so simple. Alcohol can also worsen depression, be dysphoric, unleash emotions or complicate a multitude of other variables in a person’s life.

But for the purpose of this post, we expect tranquilizers to infuse euphoria. Their ultimate effect depends on into what situation are they being infused.

 

 

Psychotherapy Notes — Touching

We need to be touched. Touch is our core tranquilizer.

We touch in many ways. A handhold or a hug, a smile or a voice, a hope of what will be, or a good memory of what was.  Touch makes us feel un-alone.

We adapt to no touch or to bad touching. The transformation is a psychic maneuver to demote the need for touch because wanting to be touched hurts too much.

Touch is psychotherapy’s pal and competitor. Our professional endeavors cannot compete with touch. Mental health treatments only prepare the person to be touched. It can explain the how or why of a life, but touch heals.

Medications, which can include drugs, remove the emptiness of not being touched; they enable a person to ignore the fear aspects of reality so, hopefully, the rest of a person can face the day. We function best when lonesomeness is controlled. Medications can take the panic out of fear. Medications do what the rest of a person’s world so often can not – they un-do the feeling of being scared  or alone.

A wise patient said that medications, like touch, turn cold into warm. Another person said his medications “make me ignore how untouched and unsafe I feel”.

Good touch seems as if it ought to be able to replace many medications or drugs. Yes, very true. But touch is not always as available as is a drug or medication.

We are born trusting touch; yet too many of us quickly learn that getting touched may not be comfortable. We all live wanting touch.  Many live with strategies developed, like a government’s foreign policy, to build a life in spite of not having the touch we need. The memory of the pain when that need is rejected can define the inside of our souls. Psychotherapy works to find and make ‘safe touch’ available; it teaches how to try the touch when it is offered. Touch requires an interaction; be it a person, a God, a hope, an audience, or a pet.

But our brains are not all equally equipped. We know that some people need a medication to calm the inner neuro-storms  that rage even within the best of emotional communities.

A very fine woman lived in an emotionally cold marriage from which she could not escape. He died, and for three years thereafter she mourned his death, but she came to realize that she mourned the loss of the hope that the man she once loved would reach over to her, to cuddle and feel her soul, and to share their lives.

Then she declared she would never allow someone to be close to her again.

Until one storybook day.  Followed by months of storybook hesitancy, and  one “I let myself go” night, when “we lie in bed, hugging, touching,  and I felt warmth, and no shame, and no fear, and not alone.”

She has a glow now. She has a smile. And she tells now the most basic story of our needs. For all our complexity, we are simple.  And anyone who is not being nutritiously touched knows how true this is.

© Abbey Strauss 2011

Psychotherapy Notes — Loosing The Last Connection

Today a woman told me that her 88-year-old father is near death. His life was good, his family is strong, and she says that the peace he made with his fate is comforting to she and her sisters. His peace is becoming his legacy.

But one sister can’t let go. It is as if she doesn’t feel the soothing harmonics coming out of her father’s personal acceptance of a life well led and a death un-fought. The sisters asked a minister to help their troubled sibling fine tune her emotions and her philosophy so that she too could share in their father’s gift of comfort.

As we spoke we realized that her younger sister couldn’t break the connection. And that opened up a notion that he was the last connection to so much of her prior life. I realized then that I too had the same sensation when my aunt died. She was the last of my father’s family. She was the last person who could speak about him as a child, who remembered his early birthdays, of the sibling squabbles between he and my other aunts, when she used to help him with his homework, of her fears when he was a soldier in World War II, and of stories about how he fell in love with my mother. She was his living biography.

My aunt was a connection to my father. She became the curator of his life before he met my Mom. I wanted to share more with him and to feel his harmonics. Her memories and stories of their family — of my family! —  delightfully gushed into pulsating and nurturing dimensions.

My aunt’s death, like the death of my patient’s father, is not just the loss of a person.  No, it’s a symbol of something else that is now gone. It’s the end of the last connection. Now I, my siblings and my cousins are the last connections to that family, but our history books are incomplete. My aunt lived it. We only heard about it.

The lesson is simple — helping others requires that every therapist  look into themselves as much as they look into their patients.

Psychotherapy Notes — The Family Soup

I asked the young lady to describe her family history. I was interested in any evidence of blood relatives with psychiatric disorders, or non-blood relatives whose psychiatric disorders or character makeups psychologically affected the patient.  As she began to offer descriptions and insights into the multitude of people who had  infused – or were still infusing –  some aspect of themselves into her life, I made the off-the-cuff comment that her family was complex, like a vegetable stew.

So I changed the wording of my question, and asked her to describe her family soup. This allowed for all the variables that were being mixed in to produce the environment in which she lived. Then she noted that the soup, to use the term, is her nutrition. But in her case the nutrition was often tainted or not as healthy as one would like it to be, but she had no other source of nutrition. She was stuck.

The metaphor worked because it was broad enough to be all-encompassing, but specific enough to explain many of her difficulties. Our goal eventually became identified as finding her a different soup — one that would heal and encourage growth rather than keep her in the rickety status of minimal, but predictable, emotional and physical sustenance.

We both felt delight in the family soup concept.

Daughters Who Are Never Good Enough

A book about  difficult mother-daughter relationships  that can cause anger,  frustration and troubled self-confidence.

NOW → Purchase in most  e-book formats

This is a  book for daughters whose mother’s never let them be individuals. These relationships can be abusive; they can hinder personal growth and destroy a sence of self. These mothers, who are often narcissistic,  leave their daughters feeling not good enough about so many parts of their lives. Both young and adult daughters can suffer from this harsh psychological predicament.

“The book gives insight and ways to manage things….” LY

“Short, to the point, helpful….I want to give a copy to my mother.” OD

“My therapist and I use this to help me; some needed self examining for all of us.” WG

But a daughter can escape from the bondage. The process takes time. It may be difficult; but it is not impossible. This book explains aspects of such a relationship, how to understand it, and how to break away. It is a book about how to change a daughter, who isn’t allowed to feel good enough about herself,  into her own, good enough self.

Those who have read it comment “that  book is so much of  my life….I always wished things would be different, but they aren’t — so I needed the hope and guidance…”

“Daughters Who Are Never Good Enough”  is now available in most e-book formats for $3.99 USD,  and in print form for $10.99 USD — see below.  It  is also available through Barnes and Noble, Sony,  and vendors as well.

Click here to buy the e-book or read a sample.    Click here to buy a hard copy.

The author, Abbey Strauss, is both a social worker and a psychiatrist with nearly 4 decades of mental health treatment experience.

Psychotherapy Notes: Narcissism and Hobson’s Choices

 A man struggled with a poor self-image for many years. He lessened his pain by heavy drinking, but in time it stopped. He married a woman because “it seemed I made her happy.” Even though they had children (whom he loved dearly), he stayed married out of commitment to the family, but not from love for his wife. His intellect and curiosity was far keener than his wife’s, and though he wanted to, he never divorced.  Eventually, an annoying, ever present unhappiness permeated his life.

In psychotherapy he was able to acknowledge how subtly controlling his wife was. He wondered why he was so accepting of this. Little by little his understanding, when combined with the on-going experience of living with her, lead to his conclusion that she was a narcissist.  He realized that years ago, just before they met, he needed ego boosting. He also realized that he was a  guaranteed audience to applaud her need to control. “It was surely a very funny, pathological, yet courteous match…but without any real dialogue.”

Disagreeing with her was exhausting and non-productive, so he gave up. He realized that her desires were dictates, of sorts, and any list of options she presented to him were not options at all.  I then suggested this was a Hobson choice. “This makes perfect sense, ” he said, “ and there was, in the emotional reality of living with her, no choice, though she presented as if she offered me options and areas to honestly debate. Had I disagreed, I would be painfully admonished or chided.”

A Hobson choice is between something (in this case,  her desires, which were not always desirable by him), or nothing at all. It is a ‘take it or leave it’ ultimatum . The notion is thought to come from Thomas Hobson (1544-1631) who told his livery customers to choose any horse in the stable as long as it was the one nearest the door.  The Hobson choice is when only one option is actually offered.

A week later the pateint returned with this quote from Thomas Ward’s 1688 poem “England’s Reformation”: ‘Tis Hobson’s choice—take that, or none.”

Then he told me that “I’ve come to better see my life now, and in her narcissism I initially found safety because she needed to control someone, and I needed to be cared for.  But as I grew, I realized living with a narcissist was giving in to endless Hobson’s choices.  She insisted I had choices, but not really. And so now my contribution to the definition of narcissism is that it includes the absence of meaningful discourse and of an endless list of overt, and some covert, Hobson’s choices.”

Society’s Tonic — The Oil Leak’s Effect on Mental Health – Collective Grief

There is no easy way to accept a loss caused by someone else’s error. But loss is relative — some levels of loss are more an annoyance. Some levels rank as an invasion that can change the entirety of one’s life and livelihood. The Horizon deep water oil spill’s effects covers the entire range, depending on where one lives and works in relation to the oil. Yet there is also a larger emotional and spiritual effect, a ripple, that floats over many people and businesses, both far and near,  whose sustenance depends on the sales to, or products of, the oil leak effected market.

The two most pressing emotional responses are anger and fear. “What will I do, how will I survive?” is matched to “I don’t know where to put these emotions at the people who did this to us…”

Brief mental health counseling may help, and even medications may be needed on occasion. But these are real problems, and they demand real solutions. People need coping skills and hope. Marital and family issues may appear. Substance abuse and sub-clinical emotional problems may erupt. The ability to get medical care (because no income means no insurance coverage) can cause enormous anger and fright.  So those effected need not to feel alone. Yet — for an inherently independent person — asking for help may be difficult. The emotional layers are many and can be complex; the solutions might be equally complex. Even if BP can stop the leak, the leak’s impact on the people and the enviroment — both are the victims in this case — will not be as easily stopped.

A good therapeutic model is that of collective grief. It speaks to how the community helps the individuals. It keeps the situation from being personal, and in that union is strength. In the past communities used to help its members as a group.  Leaders took control and gave community focus. Too much modern mental health has become help on a one-to-one basis.

David Randle is a pastoral counselor who spoke of collective grief. His words are worthy of your time. His podcast interview is at The Experts Speak (via iTunes) or directly at David Randle- Collective Grief.  These interviews are a provided by the Florida Psychiatric Society.

Society’s Tonic — Oil Spill Health Effects on Humans and the Environment

The April 20, 2010 Gulf of Mexico Deepwater spill — actually an ongoing leak – requires that we look at the effects on human health as well as aquatic, costal plant and other wildlife.

First, Gena Solomon MD, from the University of California, San Francisco, works in environmental health. She is also a senior scientist with the Natural Resourses Defense Council. The focus is on the breathing of crude oil fumes from the oil leak.

Click here to  listen to her interview

Next listen to Dr Leonard Berry

Dr Berry is director of the Florida Center for Enviromental Studies, Florida Atlantic University and is the coordinator for the FAU Climate Change Initiative. He speaks to other concerns of the spill, the long term food chain worries, effects on shore line mangroves, changes in the ocean itself before the spill, that it may impact Palm Beach County more than other east coast areas, and of how much we know — and don’t know.

 These interviews are part of the The Experts Speak Series by the Florida Psychiatric Society,  because all  of us are influenced by events in our environment.

Society’s Tonic – Safe Disposal of Unused Medications

SMARxT DISPOSAL  is a conjoint project of the US Fish and Wildlife Service,  The American Pharmacists Association, and the Pharmaceutical Research and Manufactures of America. They list recommendations for the safe disposal of unused medications.

Basically, medications should not – with rare exception — be flushed or poured down a drain.  Solid data is appearing how medications are showing up in wildlife, and a real environmental danger is brewing that can, in many ways, be avoided or markedly reduced.

Recently antipsychotics have been found in mussels. And anticholesteral medications may limit the grow patterns of fish.

Society’s Tonics – Mental Health Parity Update Feb 2010

 The Wellstone-Domenici Mental Health Parity and Addictions Law passed Congress in 2008. Some people considered this as equal to a civil rights victory for the mentally ill. But implementation issues needed clarification. Much talk exists that the ultimate interpretations will be made in the courts as patients and their advocates challenge insurance companies about the ‘true intent’ of the law. The initial grassroots regulations of how to implement parity comes from the US Departments of Health and Human Services, Labor and Treasury (see below link).

In my mind — did the bill writers, supporters, and debaters not consult with insurance minded people to anticipate these issues? Or perhaps it was intentional, to either delay the implementation or to force these issues into the courts.

These rules will be effective April 5, 2010 and generally apply to group health plans and group health insurance issuers for plan years beginning on or after July 1, 2010.

The below DOL link is important to at least review. Also, the DSM-5 draft is available for review and comment at http://www.dsm5.org/ from February 10 to April 20, 2010.

Below is the 2-2-2010 link of these regulations that just appeared. Here are the four major issues:

1. Defining what is a medical versus a psychiatric disorder. If insurers call an entity a medical disorder, it will be exempt from parity coverage. Autism and PDD are widely viewed as medical, not psychiatric disorders. If schizophrenia only needed medications to treat, then it would be a medical disorder. But it requires a range of psychosocial interventions as well. However, diabetes also requires a range of psychosocial interventions as well, but it is considered a medical disorder. Clearly this labeling process has political and scientific elements, and it remains copiously unresolved and unfinished. We will see what the DSM-V does to this progression.

2. Insurers are exploring if there can be separate deductibles for mental health & substance abuse versus general medical disorders. Many argue the deductibles should be combined as in Medicare. The 1996 parity law allowed for separate lifetime benefit benefits. Separate deductibles are considered discriminatory. The below rules clarify that separate deductables are not allowed.

3. Management – related to complicated needs for treatment authorizations. The law seems to suggest that management/authorizations can be more stringent than for medical/surgical benefits. Fail first requirements are all possible – that failure of less costly treatments may be needed before referral to more costly ones (does this mean failed antidepressant use by an internist before referral to a mental health provider?) Having a parity level benefit on paper and having clinical access to that benefit are two different events.

4. Scope of coverage – if a plan allows for treatment of a particular mental health disorder, what limits can they impose on levels or types of care. This is called ‘treatment limitations.” The law is not specific enough. Insurance companies cover illnesses based on their choice of coverages, and then on documented evidence of a necessity to provide coverage. In mental health, absolute and immovable evidence-based treatments do not yet exist, so will treatment be limited to medications, CBT, ECT, but not marital or analytic therapy? Or will 4, or 8 or 12 psychotherapy sessions be allowed. It’s known that insurance companies fear endless verbal psychotherapy, but all mental health professionals know that prolonged verbal and cognitive therapy is, at times, needed. A suggestion exists that mental health providers may choose a primary diagnosis that is covered, and then add a host of secondary diagnoses – this is not a new practice to medicine. Also, as patients learn more about their parity benefits, more and more may seek treatment. That will increase costs at some levels, but it will also be better for the community as more mental illness is treated, people will miss fewer work days, hopefully fewer people will have associated legal problems, etc.

This is to the latest set of proposed government rules:

http://www.dol.gov/federalregister/HtmlDisplay.aspx?DocId=23511&AgencyId=8&DocumentType=2

Psychotherapy Notes — Food Insecurity

Consider this: that 1 in 7  families in the US face ‘food insecurity.’  This means that 14% of all American households struggled to put enough food on  the table in 2008.  U.S. Agriculture Secretary Tom Vilsack  said it could be even higher in 2009. “Food insecurity” sounds a little like it ought to be a psychiatric term. It is not, but it can have psychiatric ramifications.

For example, we too often assume that kids have enough food to eat. But the elderly also have food insecurity. Many have to choose between food, medications or rent.  I suspect that these 14%  of American  families are in specific geographical clusters. But poor areas  often dwell within in rich counties.

The problem is world-wide too. The causes are politically complex.  Yet a quick local fix is possible — share our food. Look at what you throw away! Many restaurants and stores donate left over food.

Soup kitchens and food banks have long histories. Go to a kitchen or food bank. Meet the people. Imagine what their lives are like. Learn how they survive. Learn about the ones who do not. Ask how living with hunger might color their moods. Imagine the combination of a depression or anxiety disorder co-existing with hunger?  Imagine a kids’  body not growing up with enough food.

Bring your kids to the kitchens. Do it regularly.  Ask  teachers to make it a school project.  Let them see what most of them cannot imagine.  This is an environmental issue  — it is the growing of  and  maintainance of 14% of us.

Holiday donations are fine, but people eat all year-round.

And by the way, on the days you visit or take the kids to the kitchens, skip breakfast. It’s akin to being irreligious to be physically and psychologically well fed in front of people who are not. Share your food with them, and let them share their lives with you.

Then as a family write the government officials to address food insecurity.

Society’s Tonics – Melting Ice, Rising Seas, Our World, Our Choices

A December 2009 international conference in Copenhagen focuses  on the issues of global warming.  The effect of melting ice melting on sea levels is one of the issues. The below link  is an excellent summary of a study about  ice melting in Greenland and how it is increasing sea levels.

From Reuters on Greenland’s melting ice.

From the BBC  -  Q & A on the Copenhagen conference in December 2009.

What preparations are being made if the rising seas cannot be stopped, and what if all that exists along our coasts will be flooded?  The rate of the rising sea levels seem so minimal right now that they don’t feel scary, but the projections are serious. We cannot merely hope that science will solve the problem before the projected ill-effects become unfixable. Governments need to address the projections by policy changes. We need to address the projections by each changing our life styles.

Even if the warming is partly a natural environmental cycle, the effects will still be incredible. We need to reduce our contributions to the warming. We simply need to prepare for the end effects, regardless of the cause.  How will our children look back at us? Will they rightly blame us for spending more time arguing so much about the cause that we missed the opportunity to prepare for what more and more science  projects will happen to their world?

Some say it is only a gloomy projection. That is a weak argument. But even if, by some chance, all the global climate changes turn out to be not dangerous, we should nonetheless respect our planet more. We need to help it provide us with a safe place to live. The earth is not endlessly forgiving of our choices. This is a prime example of the precautionary principle. But the precautionary principle takes self-discipline and personal responsibility.

Psychotherapy Notes: ‘No’ is a safe place to be

One of the more frustrating hurdles in psychotherapy is getting a patient to try something new, with the hopes that the ‘something new’ is healthier or more productive than their older ways of doing things. I was struck by a spontaneous comment from a 39-year-old man, who in his own way is quite creative and insightful, but who didn’t expect the breath of fresh air that came into our therapy as a result of his comment. I said to him that he so often says no to suggestions. He would intellectually acknowledge the logic behind the suggestions, but his actions said no. I said why?  And he just spilled out the comment that “no is a lot safer.”

‘No’ was his sentinel against anxiety and fears of failures. In subsequent sessions, he said that he was seeing how ‘no’ was a defense mechanism and it was as frustrating to him as it was to his family when he hid behind the wall of  ‘no’.  That is why he came into verbal therapy. His style of fears had been called phobias before, but medications did little to soften them.  So as we refocused our efforts, and looked at the things to which he had historically said “no, I don’t like that” or “no, that’s not for me”, our sessions took those responses as the first part of this sentence: “so if you say no, let’s dig a bit further, and what are you afraid of?” It took some time to unravel where these fears came from, and we are still working on the malevolent and unconstructive comfort that comes from maintaining the word ‘no’ as his guard. He joked with me, saying that “ ’no’ is really a very safe place to be.”

How so often true.

Psychotherapy Notes — High Dose Psychotherapy

Two patients came from extraordinarily dysfunctional families.

Both of them simply didn’t know how to live a life that the rest of us would have considered even ‘somewhat normal.’  Both went in and out of numerous therapeutic relationships, tried countless legal and illegal drugs, but they never could break away from their legacies. It was as if they graduated from adolescence without ever having been taught how to be an adult. Eventually both of them ended up on disability under Medicare or Medicaid. It quickly emerged that neither of them could benefit from a once or twice a week therapy session because they didn’t have the ego tools to carry the concepts developed in therapy into the rest of their lives. One of the patients was so impaired that I conceptualized her as having no functioning ego. The other patient had such a massive superego and came from a family where his mother kept him, for her own needs, more of a child such that she did not let him grow up. When she died, he had no idea of what to do in life.

These two patients benefited from what can be called ‘high dose psychotherapy.’ The usual quantities of therapeutic contact were insufficient. The insurance companies complained because they were outliers. The world wanted them to be needing only of average doses of psychotherapy. That wasn’t sufficient. In days by gone, hospitals would accept people for months and months, with intensive therapy on almost a daily basis. A few hospitals still use that model, but they are costly.

The analogy here is to medication. Some people simply need more than others. So too for psychotherapy. These two patients needed a massive restructuring of almost every element of their biopsychosocial worlds. It took a lot of weekly time and an effort that spanned years. Though they were, frankly, at times exasperating and annoying because of the intensity of their needs, they nonetheless slowly creeped towards better mental health because of high dose psychotherapy. We also needed to be aware of the negative countertranferance that could have developed. There was some contact with them almost every day, perhaps for only a minute or two, but that was sufficient to reassure their psyche’s that they were okay, or that the tensions that they were feeling were not lethal, and that they were not emotionally alone in the world.  Sometimes psychotherapy is actually the experiencing, and hence learning, of core emotional skills in a safe manner that allows for growth.

Society’s Tonics – The Cocaine Vaccine

So wouldn’t it be wonderful if we could control cocaine the way we control polio or smallpox. The recent discussions about a vaccine for cocaine need some close examination. Traditionally a vaccine  is something that is the product of modified microorganism that would cause the body to develop antibodies against a particular bacteria or virus, and then when the bacteria or virus came into the person’s body, they could fight it off. We  often talk about it in the terms that someone was immunized against the virus. It’s a little different when it comes to items like cocaine. We’re not trying to immunize someone against the effects of the disease, but rather to immunize them against the effects of a molecule. The cocaine molecule is so tiny that the body cannot fight it by making antibodies. So the body has to be tricked. Researchers take cocaine and attach it to the inactivated cholera protein. Don’t worry, it’s impossible to get cholera from this combination. The body however makes antibodies to the combined cholera and the cocaine unit. The spin off is that this enables to body to make antibodies to the cocaine. What this meant is that if a person then takes cocaine after they have these cocaine antibodies in their system, the antibodies stop the cocaine from going into the brain. This has the effect of blocking the  rush that cocaine addicts like. The cocaine, from a technical point of view, becomes stuck, or bound up with, to one use the full technical term, to fairly large cocaine antibodies. These antibodies are too big to through what is known as the blood brain barrier. So in effect the antibodies sponge up the cocaine and keep it outside of the brain. The hope is that with enough time the addicts get used to not getting the rush and it will deter continued cocaine use because there will be no response from the drug.  But it’s very important point to note that as the cocaine use stops, there has to also be a lot of rehabilitation, and psychological work to go along with it as well.

This vaccine may lead to vaccines for nicotine users as well.

More detail from researchers is on the 2010 podcast The Experts Speak from the Florida Psychiartric Society.

Psychotherapy Notes — It’s where I’m going that’s scary

She’s the victim of incredible emotional abuse and multiple real illnesses. For years she used cocaine to lift her spirits. 

We spoke about how she’s got to leave the past, to accept the fact that sometimes in life justice isn’t available the way we would like it to be, and that she has to revise her priorities. She had to give up trying to get her family to be different from how they are. She never knew who to trust and who to emulate.  Her models were all short-sighted. She went looking to justify her own needy feelings rather than seek a teacher who would teach her better skills.

Now, in her mid 40′s, she came to the very insightful realization that she didn’t know how to live differently.  As simple and as obvious as it is, she realized that psychotherapy is undoing the bad lessons learned in adolescence and young adulthood. But via that she was also giving up  the familarity of so many notions that she acquired through her life’s distorted experiences. She came realize that ‘day one’  in life is to teach us how to go through ‘day two’, and so on. She realized she stayed in day one because she didn’t know how to survive in  day two.  ”It’s not where I was leaving that was scary; it’s where I have to go that is scary.”

Psychotherapy Notes — Choosing my own thoughts

A young man reveled in his new ability to focus once the attention deficit disorder was under control. He felt life had  a new dimension — he could attend to family matters, he could sit through a movie, he could even sit through a meal without feeling the need to go on to some other activity. He described his pre-medication life as if he were sitting in a room with multiple suitors, all of whom wanted his attention. He remembers that he could not control what thoughts went through his mind, and he couldn’t even compel himself to grab onto one long enough to complete whatever  was needed for it to be completed.

For the first time he could sit and ponder a thought. He described it as the  ability to  “choose my own thoughts.”  We spoke about  how this  condensation of thought into the phrase of  ”choosing my own thought” captured the reality of his life before the medications. “Now I feel released from the onslaught of  too many simultaneous attractions.”

I told him I would gladly, yet anonymously, credit him when I plagiarized the phrase. I wanted to turn this blurb into a clinical measuring stick for me. In the beginning of treatment I would ask patients  what sense of control did they have over choices, and then as treatment progressed I would ask how that control increased. I had a very simple but sensitive measure of progress as people gained the skills to move from non-selectable to selectable options in their lives. I’ve since asked this question to suffers of anxiety, OCD, and many other phobias — they like the concept and report how neatly it applies to them as well.

I told him “thanks for the tool.”  He smiled and said that now he hopes to fill the chest with other new tools.