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.

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.

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

]]> http://abbeystrauss.wordpress.com/2011/05/17/societys-tonics-our-personal-medical-record-privacy-and-safety/feed/ 0 astrauss http://abbeystrauss.wordpress.com/2011/02/20/psychotherapy-notes-alcohol-to-hide-alcohol-to-celebrate/ http://abbeystrauss.wordpress.com/2011/02/20/psychotherapy-notes-alcohol-to-hide-alcohol-to-celebrate/#comments Sun, 20 Feb 2011 18:52:10 +0000 astrauss http://abbeystrauss.com/?p=658 Continue reading →]]> 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.

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

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.

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.

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.

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.”

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.