To the depressed person:

“Just think positively.” “Just go out and have some fun.” “Just get more exercise.” “Just stop wallowing in your misery.”

To the traumatized person:

“Just put the past behind you.” “Just move on.” “Just get over it.”

Most notoriously, to the addict:

“Just say no to drugs.”

In summary, just say no to psychiatric disorders. And, while you’re at it, just change your brain chemistry.

The j-word

Used by others, the j-word can be annoying or worse – a fighting word. But how much do you use it on yourself?

• “I just need to relax.”
• “I just need to control my temper.”
• “I just need to be more assertive.”
• “I just need to say no.”
• “I just need to stop trying to be perfect.”
• “I just need to be more affectionate toward my wife.”

Just stop with the minimizing

All these admonishments might be valid. But “just” is a minimizing word: It minimizes a difficulty or a feeling, making it that much harder to understand clearly the extent of the problem one must address. It minimizes by implying that all these changes are made easily.

Any time you hear the j-word, ask: How? Just relax. How? Just put the past behind you. How? Just forgive. How?

The challenge of changing

The depressed person just needs to stop thinking negatively – as if this change could be made by an act of will. Of course the depressed person can learn to think more flexibly and reasonably. But this learning process may take many months of hard work with the help of an expert cognitive therapist. The seriously depressed person might also need the help of antidepressant medication to do this hard work of changing thought patterns. And the person whose depression is embedded in emotional and interpersonal conflicts might need the help of extended psychotherapy to make these changes.

We have become so accustomed to hearing the j-word that we say it automatically and unconsciously. We need to pay attention to it. Listen for it in others’ speech and in your own. Listen for it in your thoughts. Minimizing the difficulty of making changes is demoralizing – there’s no “just” about it. Minimizing the extent of the challenges can deter people from getting the treatment they need and sticking with it when the changes are difficult to make.

We’d best face the seriousness of the problems that we’re all too inclined to dismiss with the j-word. The j-word reflects wishful thinking. In contrast, hope is predicated on facing reality squarely and finding ways of moving forward – often slowly and with considerable effort, making use of help when needed.

It is not uncommon for patients with histories of neglect and abuse to express profound doubts about whether their therapist “really” cares about them:

“Of course you act like you care; you’re trained to do that and that’s what you’re paid for.”

And there’s actually a grain of truth to this generalization. Indeed, therapists do care for patients in a different way than they care for their spouses or children. Only then is a healthy, effective therapeutic relationship able to develop.

On the other hand, those who doubt the reality of a therapist’s caring should know more about the impact of a patient’s suicide on the therapist. Indeed, the impact of such a jarring loss is often a revelation to the therapist as well.

Research on impact of a patient’s suicide

The research on this topic is consistent and clear: When therapists who have lost a patient to suicide (somewhere between 20 and 50 percent) are studied as a group, most are found to have been profoundly affected. One study using an instrument called the Impact of Events Scale found that, on average, the sense of shock and loss was on a par with the death of a family member. Some therapists were found to have such profound self-doubts stemming from the experience that they contemplated leaving the field.

“What’s up with this?” you might be thinking, “Surgeons and nursing home workers lose patients all the time; they understand that it goes with the territory.”

The loss of a psychotherapy patient to suicide differs in some important ways. First, when death is self-inflicted, myriad thoughts about preventability inexorably arise: What did I miss? What might I have done differently to prevent this?

Second, in contrast to the surgeon, the primary tool of the psychotherapist is the person himself or herself. And, to the extent that the therapy has failed, it can be argued that it is the self of the therapist that has failed.

Suffering together

Finally, it is practically impossible for one human being to have deep knowledge of another person’s suffering without to some extent sharing that suffering and, by extension, suffering in response to that person’s death. It is simply how we are wired. Ever notice how uneasy you feel when you witness another person being seriously embarrassed? Or emotionally or physically injured? Imagine experiencing the death of someone who has shared with you his or her deepest insecurities, fears and traumatic memories, and someone in whom you have seen great promise and potential for future happiness. The extent of the tragedy of a self-inflicted death is never more apparent than in this context.

It is well-known that one of the leading reasons for malpractice lawsuits against mental health professionals is for wrongful death in cases of a family member’s suicide. What is less well-known is that, even more often, families understand the difficulties the clinician faced and the limitations of the power of psychotherapy in challenging cases. Some even appreciate that freedom, even when constrained by illness, can result in a choice to end life. Indeed, stories of family members, even in the throes of grief, reaching out to therapists to ask, “Are you OK?” are surprisingly common.

When a clinician loses a patient to suicide, the memory of the person, and the experiences shared, remain. Mourning the loss often entails a memorial service, as well as ongoing discussion with colleagues and private reflection. Like other losses, expressions of compassion and shared suffering are perhaps the surest route to coping and eventual recovery.

I play jazz piano and have composed about 70 songs over the past 50 years – a small number in the 1960s and many in the 1990s. My playing isn’t that great, but lots of the songs are really good.

Given my enduring interest in jazz, it’s not surprising that I occasionally have thought that psychotherapy is like jazz: We must improvise. Yet, after a recent dialog with my son, Clifford – a jazz historian and critic – I started to take this analogy more seriously.

Similarities between psychotherapy and jazz

A caveat: In making the analogy to jazz, I am referring (egocentrically) to what I think of as “classic” jazz – a style in the 1960s when I was a teenager and got hooked on jazz. Miles Davis’s Kind of Blue is a prototype. To the uninitiated, such jazz might seem freewheeling. On the contrary, it is highly structured in many respects: time signature, tempo, rhythm, harmonic organization and divisions into fixed numbers of measures.

Moreover, this “classic” jazz often resembles classical music (prototypically, “classical” classical, as in Haydn, Mozart and Beethoven). We are presented with themes and variations, with a difference: In jazz, the themes are written down, and the variations are improvised.

With the caveat comes the distinction between “classic” jazz and “free” jazz, which is loosely structured at most and (to my uneducated ears) can sound like cacophony. Of course, this distinction lies in a broad continuum from more to less structure. I like ample structure along with lots of freedom to improvise.

First effort with psychotherapy

My first effort to conduct psychotherapy (in 1968) was fateful. As a novice, I could undertake this endeavor legitimately, because I was to conduct a highly structured procedure: systematic desensitization for a person with a speaking phobia.

It’s simple. You ask the client to construct a graded series of increasingly frightening speaking scenarios (e.g., from making a point to a few friends to addressing a stadium full of critics). You teach relaxation, and the client imagines the scenarios (from least to most frightening) while maintaining a state of relaxation. Amazingly, it works. It was an “evidence-based” therapy.

But something troubling happened insidiously: The client wanted merely to talk to me about his life. I was stumped, stuck with the written score. I didn’t know how to improvise.

After decades of practicing psychotherapy, I’ve given up looking for the score, embracing improvisation and declaring myself a practitioner of “plain old therapy” – talk therapy.

Prompted by my dialog with Clifford, I looked up “improvise” in the Oxford English Dictionary:

“Compose (music or verse) or utter or do (anything) on the spur of the moment.”

This definition encompasses the whole continuum from classic to free jazz.

I’ve declared myself a plain old therapist because I don’t like too much structure. I find myriad “brands” of “evidence-based” therapies too constricting. From my critical vantage point, they are turning what should be improvised (i.e., intuitive and spontaneous) into a score – too technological, excessively governed by procedures, techniques and rules.

Learning to improvise

I acknowledge a caricature here, which I employ to make a point: Even the most structured of psychotherapies cannot be conducted without improvisation, as I discovered with my first client.

In psychotherapy as in jazz, I am a classicist, preferring improvisation within a structure. I like to have a focus for the therapy: one main theme – or at most a few themes – to explore in an improvisatory way. Often, I like to have a written formulation agreed with the client to provide some handholds for improvisation.

Sometimes, despite my best efforts, I wind up conducting a process more akin to free jazz, freewheeling without structure, everything “on the spur of the moment,” within and between sessions. Sometimes it can seem helpful to the client; I can do it, but I don’t like it.

Now for my tendentious point, based on my first experience as a therapist: Have we constructed all these therapy brands and procedures because we are not good at improvising or too timid to do it?

As I discovered in psychotherapy as in jazz, we can learn to improvise. We have many good teachers and models. As I learned at the outset, to some degree, we must learn to improvise. But many therapists, like me, will need a structure and a style. Kind of Blue works for me, and the title is apt for much of my work.

Stigma is something many people with mental illness have long endured. Menninger’s Say No To Stigma blog was created to help dispel stigma. To further that cause, I hope you’ll take a few minutes to watch this video about Ms. Lizzie Velasquez.

She does not have a brain disease, rather another biological disorder that manifests itself visibly. Consequently, she has had to endure criticism and bullying on a scale few people could relate to. Her tips for coping and the way she thinks are inspirational.

Long before the emo generation, parents questioned the influence of music on impressionable youth.

This topic caught my attention recently as an adolescent shared with me the importance of music in her recovery. She described how listening to “emo” music provided her with a sense of belonging to a larger community, something missing in her life otherwise. Her parents expressed concern as to whether allowing her to continue listening to her increasingly “dark” music was the right thing to do. They wondered if listening to this music might have contributed to her recent peak in depressive symptoms.

Adolescents listen to music anywhere from two to eight hours each day. It plays an important role in adolescent socialization and identity formation and has affect regulation potential. Yet their relationship with music is complicated.

Music’s impact on teens

Music is an important form of communication. It provides words for adolescents who might otherwise struggle to communicate increasingly complex emotions and experiences. Rapid growth in cognitive-emotional capacity, technology driven over-exposure and expanding awareness result in adolescents whose resources are rapidly overwhelmed by adult-world difficulties. Adolescents grieving the loss of protection by an idealized parental superhero and rapidly confronting adult-world hypocrisies often turn to music that validates this perception of the world. Some adolescents embrace an ideological stance where music offers a safer venue for rebelling against authority figures or the establishment.

Music supports identity formation and group affiliation. For adolescents seeking a stable identity, music provides a quick means of establishing a group affiliation. Common interests are a binding and healthy aspect of most friendships.

Music provides common humanity. Adolescents struggling with emotional difficulties or psychiatric illness often select music that matches their internal state. A depressed teen listening to music with themes of isolation and despair might at first sound like a really bad idea. However, if this activity provides a sense of belonging, something to reduce their terrible sense of isolation, the music may provide tremendous comfort. Common humanity is offered in a three-minute soundtrack, and suffering is lessened.

Demonstrate interest

However, parents and professionals should demonstrate interest in the soundtrack of our youth. Music has significant influence on mood and thus behavior. Studies have documented music’s influence on adolescent self-injury, suicidality, substance use, promiscuity and violence. As one example, a recent study revealed the average adolescent is exposed to more than 80 references to substance use each day while listening to music. References depict the social use of illicit substances with a positive social outcome.

Talk with your teen about their music. There is research to support that simply asking a young person about their experience of their music is likely to correlate with their behavioral response. A relationship with a young person in which there is curiosity, openness and a lack of judgment provides a space in which one can ask questions that promote reflection and joint exploration around the choices and influences in their life. There are no guarantees, but an open dialogue at least increases the likelihood that the adolescent will consider how and when they listen to their various playlists.

Parents may find some of the current music so offensive that they are tempted to react by trying to shut off an adolescent’s access. Reactivity and coercive efforts are likely to illicit greater rebellion, reduce communication and in this era of internet radio and inexpensive media players, a parent’s control over exposure to musical influence is limited. Taking a more thoughtful and collaborative approach is much more likely to offer a young person the opportunity to develop the internal guide needed to navigate our media-saturated culture.

Reference

Have you heard a college student say this before?

“I don’t drink every day so I’m not an alcoholic.”

When most people picture someone with a drinking problem, they probably imagine someone who drinks every day and can’t function without alcohol. But even those who aren’t dependent on alcohol yet routinely drink to excess, i.e., binge drinkers, are in danger of experiencing long-term consequences.

The National Institute on Alcohol Abuse and Alcoholism is very clear about the high costs of college drinking: Alcohol poisoning, assault, unsafe sex, sexual abuse, injury, academic problems and death are some of the agonizing consequences of binge drinking.

So what is considered binge drinking?

Many people may feel that having a drink to take the edge off is a good way to start socializing. And though it’s true alcohol decreases inhibitions, those who drink to excess often find themselves consuming more drinks than they had intended. For women, that means consuming four or more drinks over the course of a couple of hours and for men it’s five drinks. (Keep in mind that this number may be lower depending on a person’s body mass and that blood-alcohol levels continue to increase after the last drink is consumed, which increases the chances of alcohol poisoning.)

Important factors in the development of binge drinking include:

• Learned patterns regarding drinking
• Genetic factors
• Attachment to family or significant caregivers
• Core beliefs about oneself and
• The age at which someone starts drinking
  

So how do these factors play into the college experience?

College is an exciting and eye-opening time filled with new challenges, relationships and environments. It is a time of testing independence and discovery. For most, this is exactly what they have been anticipating.

In times of exponential change like this, many of the underlying beliefs that people hold about drinking and how it relates to them socially can be intensified. Brain development continues to mature well into the 20s, which means the brain can be prone to increased risk taking; so learning stress-management skills during the college years is vital.

Drinking to fit in

Four out of five college students drink alcohol and half of them binge drink. “Drinking to fit in” is one of the top reasons for drinking in college. Young adults being treated for alcohol-related issues endorse social anxiety, social fears (like not fitting in) and difficulty creating new relationships as reasons for their drinking.

For those who drink, it seems that alcohol becomes a social equalizer of sorts. If those entering college have the perception that drinking helps them fit in and those who are already in college uphold similar beliefs, then it can be difficult to challenge this association.

This perception, coupled with increased feelings of loneliness and isolation, puts young adults at a greater risk for developing excessive drinking habits like binge drinking. Those who are likely to turn to alcohol due to stress are likely to develop excessive drinking habits that can lead to dependency on the substance. Dependency on alcohol ultimately leads to drinking alone, which is the paradox of “drinking to fit in.”

Decreasing risk

Young adults who are able to evaluate their actions and motives for coping are better able to channel stress into manageable outlets. This usually stems from the ability to recognize and utilize significant people in their life who are reliable, which creates increased feelings of safety and decreased loneliness.

Such young adults tend to feel safer in exploring their new environment without turning to alcohol. Finding sober activities, creating a structured homework environment, touching base with important social support and utilizing and evaluating coping skills are all ways to decrease binge drinking behavior.

The bottom of the glass

In the end, severe consequences are not just a result of daily drinking: Those who engage in less frequent drinking but who drink greater amounts are also in danger. If you or someone you know is binge drinking, discuss the risks. Explore how they might seek help or handle stress without turning to alcohol.

If you or someone you know is unable to limit their drinking, dependency on alcohol may be developing. Remember that after your last drink, your blood-alcohol level continues to rise and symptoms of alcohol poisoning may develop. Most people feel responsible for alcohol-related tragedies when they may have missed the signs and did not seek help.

Whether you plan on drinking at college or not, please learn more about the risks associated with drinking and have emergency numbers ready to call. It may not be the popular thing to do, but it’s the right thing to do.

Resources

• College Drinking: Changing the Culture
• Adult Attachment Security and College Student Substance Use
• The Truth about College Binge Drinking

Ambition’s dark side regularly captures our attention. The relentless quest for status, fame and power is not only off putting but also damaging to the extent that the quest comes at a cost — getting to the top by climbing over the backs of others, potentially injuring them in the process.

Narcissistic personality disorder

Psychiatry, in its inclusive spirit, has a diagnosis for the dark side of ambition: narcissistic personality disorder. Here are some of the pertinent diagnostic criteria: grandiose sense of self-importance; preoccupation with fantasies of unlimited success, power and brilliance; belief of being special and unique; requiring excessive admiration; entitlement; interpersonal exploitation; envy; and arrogant attitudes. Dark indeed.

But the fruits of ambition also capture our attention. President Kennedy’s challenge to put a man on the moon in a decade launched an extraordinarily ambitious project with spectacular success and spinoffs with substantial social benefits.

But ambitions need not be so grand to be fruitful. For many of us, identity is forged by our life projects that embody our ambitions, be they great or more modest. And ambitious projects need not be as tangible as putting a man on the moon. Raising and caring for a family is ambitious and perhaps the ambition most crucial to our collective well-being. We might say that ambition accounts for much of our cultural progress and achievement. Without ambition, we stagnate as individuals, institutions and societies.

Ambition: virtue and vice

Perhaps we should think of ambition as a double-edged sword — potentially a virtue and a vice. Ambition goes awry when it is driven more by the status of the self than the value of the project. But we should not think of healthy ambition as selfless.

I was inspired to write this piece by the thinking of a contemporary philosopher whom I greatly admire, Christine Korsgaard. She articulates the ideal integration of the self with ambitious projects. Befitting her profession, she gives the example of wanting to write a book (on Kant’s ethics) that would be good enough as to be required reading in all ethics classes. She acknowledges that this desire could be perceived as “raw vanity” (the dark side). But she sees the desire differently; in her own words, excerpted from her book, Self-Constitution: Agency, Identity and Integrity:

“I think that such a book would be a good thing and my ambition is not conceivable without that thought. It is an ambition to do something good …. I think someone should write a book on Kant’s ethics good enough that it will be required reading. I think that this is something for which there is a public reason.

This doesn’t, however, mean that my ambition is just a disinterested response to that public reason …. I don’t just want it to be the case that someone writes the book. I want to be the someone who writes that book.” (pp. 210-211, emphasis in original).

Korsgaard goes on to acknowledge that the personal component to ambition is often essential to carrying out the arduous work of one’s projects. She is keenly aware that this personal ambition might lead one to subvert others’ efforts to carry out the same project, for example, undermining a colleague’s attempt to write the book. She wisely asserts, “This is not an expression of ambition, but rather a very familiar perversion of it.”

More broadly, I think this “perversion” includes ambitious self-enhancement devoid of investment in worthy projects for their own sake. The desire to be “Number One” is ubiquitous in our culture. We must ask: For what purpose? Toward what end? Sheer shelf-aggrandizement will not do. With such misguided directions of ambition, we move from what we psychologists call “healthy narcissism” (as Korsgaard brilliantly exemplifies) to “pathological narcissism.” And who wants that?

References

APA (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, DSM-5. Washington, D.C. American Psychiatric Association.

Korsgaard, C.M. (2009). Self-Constitution: Agency, Identity, and Integrity. New York: Oxford University Press.

http://mirziamov.ru/mfo-online/zaim-ekapusta.html
My name is not Anonymous, but it will suffice for this blog post because I must be, well, anonymous.

Volunteering to help others in a crisis

I’m one of hundreds of suicide/crisis hotline volunteers around the United States, and who we are is not important relative to our callers. Their crises are what we focus on, and we use an alias because the only thing callers need to know about us is that we have a sincere desire to help them get to a point where they can help themselves.

I get nervous on the drive over to the hotline location. I’ve been trained well on the crisis model, but there’s no script and these calls are high stakes. I want to say just the right things to help people validate their feelings, but it’s a challenge because I never know what kind of calls I’ll get. Here are just a few of the people I’ve tried to help:

• A man with a diaper fetish.
• Many distraught teenagers who have broken up with their girlfriend or boyfriend.
• A girl who had been sexually abused by both her biological mother and father, and having left that abusive situation was raped in a group home.
• A husband crying because his wife found another liquor bottle hidden in their house, and it was the last straw – she wanted him to leave forever because of his drinking. “You could stop anytime you want to,” she screamed at him.
• A wife whose husband had cheated on her and then wouldn’t let their daughter go to a friend’s quinceañera because he thought she’d have sex with her boyfriend that night.
• Elderly people who were isolated and lonely.
• People who want to end their life because the emotional pain they’re experiencing is too overwhelming to bear. (We have specific ways of caring for these callers. Our job is to buy time in the hope that the help we provide will allow the callers to reconsider and come to a different decision.)

A need in common

What do these callers all have in common? An urgent need to talk to someone who does not know them, who cannot see them, who will actively listen and who will not judge them for anything they say or don’t say. Sometimes, I’m so actively listening that my head is bowed and my hands cup the earphones of my headset so I can hear every word. It’s important to get into the rhythm of each caller’s speech so you don’t talk over them — that way I have a better chance of helping them expand their options.

Taking care of myself

When I leave my shift, I close my ring binder of training notes and say to myself that I’ve done what I could. Enough callers thank me each shift to make up for the ones who still feel powerless when they hang up. (The best thank-you I’ve received so far is from a Vietnam vet who told me he would not put a shotgun in his mouth and pull the trigger that night because he felt better talking to me.) When I get home, I count my blessings and take care of myself. I have a mug of hot chocolate, an Epson salts bath and call it a night.

National network

There’s a network of United States hotlines so if one city is short of staff/volunteers, the calls roll over to people who are available. Volunteers are never alone, there is always a paid staff member there, and staff members are usually the ones who work the phones in the deepest dark of night up till dawn.

If you’re even slightly interested in volunteering on a crisis hotline, I urge you to contact your local office and at least go through the training. Then decide. If it’s not a good fit for you, no worries; you will have learned valuable communication skills. If you do end up volunteering, you’ll know that you’re having a direct and positive effect on people’s lives.

I am a nutrition geek. The science behind how our body and brain work is so amazing to me. The foods we eat help our brain work efficiently, and I love being able to teach others the link between food and mood.

National Nutrition Month

March is National Nutrition Month, and while my colleague, Tessa, and I were researching various handouts for our Nutrition Challenge, we were reminded we have to create many of our handouts because there’s so much misleading information out there.

For example, we ordered bookmarks made by the Academy of Nutrition and Dietetics. They should be fantastic, right? I was super excited after I pushed the purchase button. When they arrived, I quickly tore open the package, pulled out a bookmark and read: “Balancing calories: Enjoy your food but eat less.”

Wait … what? I love my food; why should I eat less? Is there something wrong with the way I eat? Am I eating too much? Am I expected to eat more of things I do not enjoy and eat less of the foods I love? Then I quickly pushed my mental pause button and checked in with myself.

I am a normalized eater. I eat intuitively by eating when I am hungry and stopping when I am full. (Well, other than my favorite fun food: peanut butter M&Ms. Those are impossible for me to eat intuitively.)

Yet the world we live and work in is obsessed with calories and perceived healthy eating. While my dietitian brain understands that many Americans overeat and that those words on the bookmark were intended to educate them on eating in moderation, I also know many people struggling with their relationship to food will take that simple bullet point to heart.

What my bookmarks would say

If I had designed my own bookmarks, these are the bullet points I would include:

Eat to fuel your body!

• Calories are intended to provide your body with energy for optimal function, not to manipulate your weight.
• Provide your brain with energy every 3-4 hours and enjoy an evening snack 2-3 hours before you go to bed. Maximum brain recovery and repair happen while you are sleeping.
• While eating, check in with your body and listen for hunger and fullness cues. Follow those cues!

Eat to maximize your mood!

• Carbohydrate-rich foods like grains and fruit help tryptophan enter your brain and release serotonin, which promotes happiness and a sense of calm.
• Enjoy fatty fish like salmon and tuna 3-4 times a week for brain and mood health. Dislike fish? Enjoy walnuts or flaxseed instead.
• A hydrated body can think more clearly and move nutrients around your body more efficiently.

Eat to show respect to your body!

• Eat a variety of foods. Each food group and even color group of food provides your body with unique vitamins, minerals and antioxidants. There is no perfect food. Eat the rainbow.
• Eat in moderation. Be mindful not to over-eat or under-eat. Let your hunger and satiety cues lead the way.
• There are no good or bad foods. All foods fit — it’s up to you to find a strategy to balance it out.

Mental and physical health depend on a well-nourished and respected body. Please think about incorporating my bullet points into your eating. Enjoy food. Love your body. Have a nourishful day.

I read the obituary of Marianne Theresa Johnson-Reddick with interest.

She tortured people by her cruelty.

This abusive mother did not get a free pass to the afterlife. Two of her eight children let the world know how they were all “abrasively exposed to her evil and violent life” in her obituary.

“Mom” ran a prostitution ring, or “escort service” as the woeful women who turn tricks and the desperate men who pay for them prefer to call it.

“Everyone she met, adult or child, was tortured by her cruelty and exposure to violence, criminal activity, vulgarity and hatred of the gentle or kind human spirit,” the obituary said. “Our greatest wish now is to stimulate a national movement that mandates a purposeful and dedicated war against child abuse in the United States of America.”

It’s unfortunate that eight children had to suffer for so long, but I applaud the desire of the two who wrote her obituary to use their mother’s death as a call to shine a light on child abuse. (Learn more about what you can do to prevent child abuse.)

Perhaps that discussion will include the following valuable tidbit: Family planning is an excellent strategy for men and women who don’t want to be parents to remain childless.