One of those mementos is a government-issued civil defense handbook published in 1972:

I received Your Chance to Live early in grade school, when the cold war was winding down. It was meant to teach young children how to avoid environmental dangers, natural disasters, and nuclear wars.

The book was a collaboration between the Civil Defense Preparedness Agency, the California State Board of Education, and other government entities. Rarely will you find a better example of a product designed by committee. While it does contain good advice, the tone is confusing, the writing is just plain weird, and the illustrations are the stuff of bad dreams. Take this image (please):

All these years later, I remain simultaneously transfixed and repulsed by it. Is he going to eat that dog food, or molest it?

Neither one, according to Your Chance to Live. He’s going to save it! The aforementioned group of well-compensated government employees created this image to persuade children like me – and I was none too bright, mind you – to stock up on food. Did it work? You be the judge. I showed this image to my five-year-old daughter, who is much smarter than I was at her age. This is her interpretation:

“He looks like he’s going to eat something in a can, except maybe he should dump it out first on his plate. That would be yucky if it was raw. Why do his eyes look like that?”

She missed the point of the illustration, which is this: store food for the radioactive pedophiles who will come a-callin’ after Armageddon. If she missed the point, there was certainly no hope for a kid like me.

How do I know that the book was written for children? Because it contains specific instructions for kids. Tell your parents to keep a full tank of gas. Remind them to stock up on medicine. Make sure they construct a lead-lined, crank-ventilated, blast-proof bunker deep beneath your sandbox.

It also contains morbid, kid-oriented limericks like this one:

One summer day Franz’s sibling, named Pete,
Was totally zapped by the heat.
My goodness, said she,
I am bothered to see,
A puddle where Pete used to be.

The poem (Keats, I believe) offers no advice for avoiding Pete’s fate. No matter, because I didn’t understand it anyway. I didn’t realize that Pete had spontaneously combusted, leaving only a puddle of interstitial fluid in his place. I assumed that he had taken a leak and walked away intact.

Here’s one about fire:

Lady bug, lady bug,
Fly away home.
Your house is on fire,
And your children.

Your Chance to Live is much more than disturbing poetry. It contains a parade of disturbing characters, beginning with your friendly government greeter. Would you shake this hand?

Here’s our malevolent old friend again, this time pilfering water from the toilet. Or as my daughter sees it, “he’s looking in a trash can. Maybe he’s going to sort the trash.” The intended message is that you can purify and drink toilet water, in a pinch. (Personally, I’d check the water heater first.)

This character was surely the result of a bad trip:

As was this one:

Note the text that surrounds this disfigured fellow:

“Just use your quaggles” is from an incoherent story about aliens preparing to invade Earth. They are studying our frailties, one of which is susceptibility to heat. The story does not define their mission, nor does it tell us what quaggles are. But you can probably guess. Here’s a line from the first paragraph of the story, in which Professor Quantle is preparing his students for their encounter with humans:

“They are susceptible to — ah — shall we say — ah — termination, by factors so numerous that their continuation as a species is miraculous.”

You don’t have to be Professor Quantle to read between the lines. You can add Death By Quaggles to your list of things to worry about, kid.

There are other futuristic annihilations in store for the young ‘uns, including evil robots…

…and well-endowed, radioactive women:

I took this image to mean that women are alluring but deadly. That message followed me well into adulthood.

In Your Chance to Live, even the moon is in peril:

My daughter says he’s thinking, “oh man, I’m gonna have more craters!”

Here are some creeps under a car (my daughter thinks they’re hiding from the police):

Here is a tortured creep:

And here are some dead creeps:

In case you cannot make out the text, the epitaph under the evil sun reads “DECEASED: Miss Sunny Hott by excessive heat and insolation, July 19, 1984.” Had I bothered to do the math, I would have realized that I would be dead before the age of 18, and I should avoid insolation. The other tombstones read:

• “Killed in laboratory”
• “Drank potent medicine with healing radium salts”
• “Died from exposure to x-ray”

Guess what crossed my mind when the dentist said, “let’s take some pictures of those teeth!”

All of this weirdness is bound to leave a person with a…

Maybe it’s a trick of his perfectly spherical head, but his eyes follow you… all the way into your nightmares. Can you decipher the symbolism of that image? I cannot, though I suspect that some psilocybin would put me in the same frame of mind as the illustrator.

Here’s the beginning of the section on mental health:

“We’ve all heard stories about how people flip out in drastic, mindboggling emergencies — like the lady who took her children down to the beach to watch the tidal wave come in, or the seaman who, during the Pearl Harbor attack, ran back into a burning ship to put on his new shoes. These stories are incredible, and even amusing in the telling.”

Amusing? Wrong. “Flipping out” is hilarious! Here’s a cute example to which kids can relate:

“Take a simple event like falling out of a tree house. You know you’ve fallen, you feel the blood gushing, and what you normally do is limp home, feeling sorry for yourself, and get the thing fixed. But what if you’re knocked silly, or seized by fear? Jumping blindly up, you run into the road, where a car hits you. That takes care of your head wound and possibly all your other problems.”

…Because you’re DEAD, you stupid rugrat! What should you do instead of running into traffic? Let’s look at another example.

“Now imagine you’re in line at the bank. The customer in front of you whips out a gun, and yells, ‘Everybody freeze!’ The sensible thing to do is just that. Freeze. But what if the sight of the gun terrifies you? Instead of standing there, you either feint, run, or leap at the bandit. Of the three, feinting is the only reasonably safe course.”

…So do that instead.

Hey! Here comes some good news:

What kind of disaster? How about the Smoke Monster from Lost, for starters:

My daughter says, “it looks like something caught those people, and it’s trying to eat their heads off.” Once again, the authors seem to have missed their intended message. (Unless that really was their intended message.)

Here’s another reason to stay indoors:

That illustration puzzled my daughter. “What is that thing,” she asked. I believe it is supposed to be the sun, I said. “Well, he got a person. To eat, maybe. Why would the sun eat a person?”

Staying indoors won’t save you from this gruesome end, which she interprets as the arms of an angry God:

And if God doesn’t get you, there’s always whatever the hell this is:

But don’t worry. This tale of woe has a happy ending, judging by the joyful expression on this man’s face:

To be fair, this perfectly bizarre handbook contains good advice about staying safe in a dangerous world. Keep extra food and water, have an escape plan, and avoid heat stroke. Oh, and keep an eye out for nuclear bombs.

Sleep tight!

-IS

Dear Mike,

It seems counter-intuitive to be lookin’ for love when your body is under attack, but you are not alone. When I searched Google for phrases such as “sick and horny” I found men and women wondering why they feel frisky when they’re fighting infection.

How prevalent is it? Darned if I know. What causes it? I don’t know that either. It turns out that there is very little research on immuno-induced friskiness.

But surprisingly, I stumbled across an obscure study from 1995 that touches on your question and suggests that there may be biochemical mechanism for what you experience. Let’s come back to that. First we need to establish some background on your sexy immune system.

Sex and the Modern Immune System

Did you know that men are at higher risk than women for major infections after surgery? Or that women are at higher risk for autoimmune problems? (Offner et al., 1999; Ahmed et al., 1985.)

These immune system differences are related to testosterone – the rocket fuel of reproduction. Other things being equal, more testosterone means less immunity. (Interestingly, the researchers pointed out that men’s increased risk of infection can be reversed by castration. So can your average guy’s reason for living.)

Across many species, males pay a price for the possession of testosterone. (Women have testosterone too, but in lower levels.) The male red grouse, for example, suffers more parasite infections during the spring when his testosterone is elevated (Mougeot et al., 2005). Other bird species suffer similar testosterone-related vulnerability.

There are different theories for the lackluster immune performance of otherwise virile birds. Some researchers believe their bodies must make sacrifices when allocating resources, and so they pay the price of reduced immunity in order to produce secondary sex characteristics like ornamental feathers that attract females. Others believe that testosterone actively suppresses immune function so that only the most viable animals survive long enough to reproduce (Munoz et al., 2008; Roberts et al., 2009).

Whatever the cause, cocks pay a price for virility. (A cock is a male bird. What did you think I meant?)

Human males pay a similar price. Testosterone and the effectiveness of one’s immune system are linked, and women appear to be the beneficiaries – sort of. Pre-menopausal women, with their low testosterone levels, have a stronger adaptive immunity to the common cold than men (Carroll et al., 2010). Unfortunately, there are no free lunches in life. More sensitive immune systems make women more prone to the aforementioned autoimmune problems.

Clearly, sex hormones and the immune system are intertwined. Sex can even boost your immunity because orgasm increases the number of leukocytes in the blood (Haake et al., 2004). It’s all a rich tapestry, to quote a minor character from The Simpsons.

You may have noticed that I am straying from your question, Mike. You didn’t ask me to explain how sex hormones affect immune response, you asked how the immune response affects sex drive.

Welcome to my world. That is precisely the frustration I encountered when researching your question. There is plenty of research on the effects of sex hormones, but very little concerning your question. We’re going to have to dig a little deeper.

Immunity May Be the Sixth Sense

In a saucy editorial (saucy for a professional journal, anyway) Felice Bedford (2011) argued that the immune system should be counted as one of our senses, along with taste, vision, and hearing. She was drawing on a body of research that describes how the immune system detects foreign bodies, sends signals to the brain, and drives behavior.

She makes a compelling case. If a baseball player’s visual system detects a bean-ball headed his way, the player’s behavior will change. He will get out of the way rather than swinging the bat.

In a not dissimilar fashion, a person’s immune system affects behavior when it detects injury or infection (Maier & Watkins, 2000). Rather than communicating via nerve bundles, the immune system uses cytokines, which are messenger molecules similar to hormones, to communicate with the brain.

Researchers Larson & Dunn (2001) discovered that cytokines produce several behavioral changes. Theirs was a very sensuous paper with erotic phrases like this:

“…cytokines may act on brain endothelial cells activating cyclooxygenase, enabling the synthesis of prostaglandins, which could readily cross the endothelial barrier to penetrate the brain parenchyma.”

Ooh, baby! Talk dirty to me.

Their findings suggest that cytokines released during an immune response can bypass normal channels and directly affect the brain. According to Larson & Dunn, cytokines cause the brain to reduce food intake, physical activity, and social behavior. They change sleep patterns, impair certain cognitive functions, and suppress pleasure-driven behavior. They turn us into dopey, unmotivated grumps.

Your question is particularly interesting, Mike, because an increase in sex drive contradicts what we know about the the immune response. An activated immune system typically depresses behavior rather than revving our engines.

But there appears to be an exception. In a dark corner of an arcane 1995 journal article is an inscrutable phrase that may hold the germ of a beginning of a slightly possible answer to your question. After suffering through at least 20 articles on the subject – none of which approached your question – I was plenty intrigued to find this little gem:

“Post hoc tests indicated that male [rats] injected with the high dose of IL-1β had significantly higher PP score than those injected with saline” (Yirmiya et al. 1995).

I was in nerd heaven. Here’s a translation. Recall from your high school biology class that macrophages are immune system cells that cruise around the body, cleaning up messes and attacking troublemakers.

When macrophages become activated, as they do when attacking an invader, they release a cytokine (the aforementioned messenger molecule) called interleukin-1. Interleukin-1 suppresses sexual behaviors in female rats, but has no such effect on males. In fact, high doses of interleukin-1 increased male rats’ motivation to find a willing mate. (Other sexual behaviors remained mostly unaffected.)

You might wonder why interleukin-1 has this unlikely effect on sexual behavior. Is it an evolutionary adaptation that compels male rats to mate one last time before they die? A cunning scheme by which nefarious viruses branch out to other warm bodies? A mere quirk of the rat’s immune system?

Those questions bring us back to square one. I don’t know why the immune system would have that effect. I don’t even know if this explains what you experience when you’re sick, Mike. It certainly doesn’t explain why women in my Google search described a similar experience, why my friends and family denied the experience, or why several of them slapped me for bringing it up.

But it is an indication that the immune response, by way of some complex mechanism, has the potential to be as stimulating as Charlize Theron or David Hasselhoff, depending on your groove.

All I can say for certain is that the immune system is bafflingly complex (to me, at least) and has a permeating influence over our behavior. I’ve done my best, and now I turn the matter over to any adventurous endocrinologists who wish to weigh in, because I give up.

-IS

PS – I’m curious to hear from others who have this experience since the research is so scant. Does infection make you randy, baby? Do share. But keep it clean!

References

Ahmed, S.A., Penhale, W.J., & Talal, N. (1985). Sex hormones, immune response, and autoimmune disease. American Journal of Pathology, 121, 531-551.

Bedford, F.L. (2011). The missing sense modality: the immune system. Perception, 40, 1265-1267.

Carroll, M.L., Yerkovich, S.T., Pritchard, A.L., Davies, J.M., and Upham, J.W. (2010). Adaptive immunity to rhinoviruses: sex and age matter. Respiratory Research, 11, 184-193.

Haake, P., Krueger, T.H., Goebel, M.U., Heberling, K.M., Hartmann, U., and Schedlowski, M. (2004). Effects of sexual arousal on lymphocyte subset circulation and cytokine production in man. Neuroimmunomodulation, 11(5), 293-298.

Larson, S.J., & Dunn, A.J. (2001). Behavioral effects of cytokines. Brain, Behavior, and Immunity, 15, 371-387.

Maier, S.F., & Watkins, L.R. (2000). The immune system as a sensory system: implications for psychology. Current Directions in Psychological Research, 9, 98-102.

Mougeot, F., Redpath, S.M., & Piertney, S.B. (2005). Elevated spring testosterone increases parasite intensity in male red grouse. Behavioral Ecology, 17, 117-125.

Munoz, A., Aparicio, J.M., Bonal, R. (2008). Male barn swallows use different resource allocation rules to produce ornamental tail feathers. Behavioral Ecology, 19(2), 404-409.

Offner, P.J., Moore, E.E., & Biffle, W.L. (1999). Male gender is a risk factor for major infections after surgery. Archives of Surgery, 134, 935-949.

Roberts, M.L., Buchanan, K.L., Evans, M.R., Marin, R.H., and Satterlee, D.G. (2009). The effects of testosterone on immune function in quail selected for divergent plasma corticosterone response. The Journal of Experimental Biology, 212, 3125-3131.

Yirmiya. R., Avitsur, R, Donchin, O, and Cohen, E. (1995). Interleukin-1 inhibits sexual behavior in female but not in male rats. Brain, Behavior, and Immunity, 9, 220-233.

Dear BD,

Dr. Irving Kirsch, a professor at The University of Hull, has caused a stir lately with a body of research suggesting that SSRIs, the major class of antidepressant, are no better than placebos. (You might watch this 60-Minutes story about his findings.) Of course, for every SSRI skeptic there are any number of evangelists who swear by the drugs.

It’s an interesting debate, and I am unwilling to pass judgement on the effectiveness of antidepressants. Quite frequently, I’ve seen SSRIs aggravate depression by muting happy emotions and adding unpleasant side-effects, while offering no measurable antidepressant effect. But I have also seen them help. In rare cases, they have been a godsend.

If you’re considering antidepressants, I humbly suggest that the question, do antidepressants work, is the wrong question. The more relevant and pragmatic question is this: might antidepressants be helpful in my particular case?

The SSRI debate is useful in general, but it is mostly irrelevant to individual cases. It’s a bit like debating the effectiveness of transmission replacements for cars. Sometimes a new transmission fixes a car, sometimes it doesn’t. It depends on the problem.

If I found a mechanic who insisted on rebuilding every transmission (or who reflexively opposed it) I would find a new mechanic, pronto. I wouldn’t settle for one who failed to define the problem before tearing into my car. Yet that is often what is expected of patients who seek treatment for depression. Describe your symptoms – quickly! – and don’t question my treatment.

It seems to me that our central nervous systems should get at least as much respect as our cars. Of the many times that I have witnessed the failure of an antidepressant, there has been a corresponding misapplication of the drug. The correlation difficult to ignore.

But don’t take my word for it. There is compelling research suggesting that antidepressants are routinely misused in Western countries. In a rather conservative study, Jureidini and Tonkin (2006) found that many prescriptions (one third or more, depending on the measure and the population) fell outside clinical indications, were given in excessive doses, or were prescribed for far longer than they should have been.

According to another study, only about one-third of patients experience relief after taking an antidepressant for a sufficient period of time (Cascade, Kalali, and Blier, 2007). That’s an exceptionally low number, and I suspect that has more to do with poor diagnosis than the effectiveness of the medication.

Antidepressants may be the first and best option in cases of severe depression. But in mild or moderate cases – which are the vast majority – behavioral interventions work better. Addressing the problems that lie behind depression is often more effective and longer lasting than medication (Dobson et al. 2008).

(Ironically, Jureidini and Tonkin also found that antidepressants are under-prescribed among the seriously depressed who could most benefit from them. They noted that fewer than 25 percent of US, Canadian, and European patients meeting criteria for major depression receive proper medication management.)

My point is that antidepressants appear to be helpful in severe cases but they are probably useless and potentially harmful when they are incorrectly prescribed. In the service of helping you find the right response to your mood problem, BD, I believe that you and your physician should answer these four questions before you take SSRIs:

1. How severe is the depression? There are a number of depression inventories to help answer this question. If the symptoms are in the mild to moderate range, SSRIs are probably an inappropriate intervention.
2. Is the depression most likely a result of circumstances or lifestyle choices that will remain unaffected by medication? If so, pills may blunt your mood but they won’t fix the problem.
3. Have physical causes been ruled out? Depression can be secondary to thyroid problems, low testosterone levels, nutritional deficiencies, sleep difficulties, and other physical problems. SSRIs fix none of these.
4. Have healthier interventions failed? Making tough decisions about exercise, diet, sleep, alcohol use, and other lifestyle choices should be the first order of business in cases of mild to moderate depression. Physical exercise alone is as effective as any antidepressant in most cases (exercise is the benign cure-all that SSRIs wish they could be), and cognitive behavioral therapy is an excellent response to circumstances or lifestyle choices that contribute to depression.

SSRIs should only be taken with considerable deliberation and a solid understanding of the problem at hand. Despite their benign image, they are the furthest thing from harmless happy pills. They come with side effects, and there is evidence that they can have serious, long-term effects on the central nervous system. If SSRI’s are the right answer for you, then by all means, use them. But please take the time to properly define the problem first.

I realize that it is an investment of time and money, and I know that depression deprives a person of gung-ho initiative. It might be simpler to skip the process and take the pills, but this is your brain we’re talking about. You only get one. Taking time to define the problem could prevent years of wasted effort and needless suffering.

-IS

References
Cascade, E. F., Kalali, A. H., and Blier, P. (2007). Treatment of depression: antidepressant monotherapy and combination therapy. Psychiatry 4, 25–­27.

Jureidini, J., and Tonkin, A. (2006). Overuse of antidepressant drugs for the treatment of depression. CNS Drugs 20, 623–­32.

Dear Just Asking,

Each of your questions would qualify for one of my trademark essays: long, convoluted, and in need of a good editor. Today, I’ll shoot for a different standard: short, unreliable, and barely coherent. I’ll skip my usual review of the literature and instead pepper my answers with mixed metaphors. Why? It seems like the right thing to do since I’m depriving you of citations.

1. There is information that certain countries have more or less mental illness (and other diseases) than others so my question is: Are certain mental illnesses more prevalent in certain parts of the U.S. vs. other parts of the country?

American trends in mental illness more closely follow socioeconomic status than geography (and the reverse is true: socioeconomic status follows mental health). Treatment options are limited for the poor. Since the Community Mental Health Act of 1963, jails have become the de facto mental health institutions for the seriously mentally ill who have no resources. Having worked in a prison, I can attest that treatment resources are stretched as thin as a drum. Of course, relatively few people end up in prison. More often, people with mental illness and minimal resources somehow manage to get by. They suffer a reduced quality of life that frequently includes poverty.

2. Why does a heterosexual fantasize about a three-some (2 men/1 woman or 2 women/1 man) and/or a homosexual sexual liaison? Does this mean there are some latent homosexual tendencies or desires in said heterosexual?

It is fortunate that I’m avoiding the professional journals today. Articles in this realm tend to have titles like Moonbeams On Sappho: A Post-Deconstructionist Exploration of Whitmanesque Archetypes, and they slide rapidly downhill from there. Only in an American university can a person become an expert on sex while never having participated.

So. Here’s my clinical take on homoerotic and orgy fantasies: they’re normal, don’t worry about them. Sexual orientation is hardwired, but that doesn’t preclude a bit of leeway. Finding something attractive in people of the same gender is perfectly normal for a heterosexual.

3. Is sexual fantasy and masturbation healthy? Is it more or less healthy if one is married vs. being single, assuming you are not fantasizing about your spouse or significant other?

Sure, it’s healthy. Your average teenage boy would say it’s inevitable. The evolutionary-minded say it even has a purpose. There is evidence that male masturbation serves to rotate the stock so that there is always a fresh batch of gametes at the ready.

As for fantasizing about people other than your partner, I make the distinction between thoughts and actions. Thinking about a sexy coworker is worlds apart from actual intercourse. But that’s my personal ethical slant. Other people, like Jimmy Carter, prefer a stricter approach. Regardless, the only true danger in fantasy is that it can go too far and serve as a way to avoid real-life responsibilities. If a person is fantasizing to the exclusion of intimate connection with his or her partner, then clearly there is a problem.

4. If one has suffered from depression, anxiety, etc. in the past, is that person obligated to tell a future significant other about said past? In other words, how important is full disclosure especially if you don’t anticipate a future problem?

I am not a believer in full and reckless disclosure. Partners and spouses don’t need to know every little thing about each other. Will you and your special someone truly benefit by disclosing some forgotten, unfortunate episode that has no chance of recurring or rebounding? Probably not.

But in this particular case, I’m wondering why a person wouldn’t want a partner or spouse to know about past struggles. Educating them on your past need not involve every gory detail, but offering a general synopsis should bring you closer to that person. If discussing past difficulties proves to be harmful, then perhaps the relationship has bigger problems.

5. Do you think people with a prior mental illness, be it depression, anxiety, PTSD, etc., should be allowed to adopt children? What about people with personality disorders, bipolar disorder, etc.?

Adoptive parents are low on the list of society’s ills. On the other hand, I could take you on a magical tour of unstable, untreated bio-parents at my neighborhood Walmart.

The salient issue is treatment. Whether a parent has diabetes or depression, there is a duty to properly manage the problem. Parents who intentionally neglect their mental or emotional difficulties are as useless as a tin roof on a bull. Their children, and society at large, pay the price for their self-neglect.

So in answer to your question: properly treated problems should not preclude adoption. I believe that the ability to overcome hardship makes one a better parent.

6. Can Borderline Personality be cured or is it a life sentence?

Borderline personality disorder is certainly treatable, and I am ever-optimistic that anyone who is sufficiently motivated can find real relief. One of the most difficult aspects of recovery is learning to tolerate, accept, and disobey overwhelming emotional impulses. It’s hard to imagine how difficult it must be to tackle that hurdle. I give mad props, as the kids say, to anyone with the strength and willpower to overcome borderline tendencies.

7. Can Borderline Personality be misdiagnosed? If so, what could be at play that makes a professional, such as yourself, think that one has BP when they don’t?

I don’t know how often, but borderline personality disorder (BPD) is wrongly diagnosed sometimes. One reason is simply that some of the features of BPD loosely resemble other conditions such as bipolar disorder, and so a clinician who is rushed, inexperienced, or impatient can be misled. (Presently, bipolar disorder seems to be the catch-all diagnosis for everything from irritability to acne.)

A second reason, and I’m sad to say that I’ve seen it happen, is anger or frustration on the part of the clinician. Some clinicians blame the patient when therapy goes poorly. By branding their “difficult” patient as borderline, they perhaps feel absolved of responsibility for an unsuccessful course of treatment.

On the other side of the sword, there is also an under-diagnosis of BPD among men because the disorder has come to be associated with women. Men are more likely to be diagnosed with antisocial personality disorder (APD) when BPD is a more fitting diagnosis. Likewise, women who fit the diagnostic criteria for APD are more likely to be diagnosed as BPD. That’s the gut feeling off the top of my head, anyway – perhaps other clinicians will weigh in.

Despite clear examples of misdiagnosis, I think BPD is typically diagnosed correctly. As a constellation of symptoms, recognizing this one is like shooting ducks in a barrel.

8. In a previous blog, you wrote of a patient having a crush on her therapist. Can therapists usually tell when a client is so enamored? If so, how? If so, should the therapist approach the subject with said client?

I doubt that therapists are especially adept at detecting hidden romantic interest. We’re not much better than anyone else at detecting lies or omissions, so there is no reason to believe that we have special radar for secret crushes.

Yes, the clinician should bring it up if he or she senses something, lest it become the white elephant in the room. A skilled clinician should be able to find a non-threatening approach.

9. Do therapists ever have feelings – sexual or relational – for their clients? Can a therapist and client develop a relationship after a certain period of time has elapsed between the therapeutic relationship and the romantic one?

Yes, therapists certainly develop attraction to their clients. Often it is platonic, and sometimes it is romantic. The ethics code of the American Psychological Association advises that psychologists abstain from from sexual intimacy with clients “for at least two years after cessation or termination of therapy,” and then only under “most unusual circumstances.” I am certain that some shrinks interpret that liberally. Yippee! Only 730 days until I can boink my former patient!

The APA takes a pretty hard stance against all manner of dual relationships. Obviously we should not sleep with patients, but we should also avoid working with our friend’s mother or the grocer that we see each week. Of course there are exceptions. For example, it’s hard for a small-town psychologist to avoid dual relationships entirely. But for the most part, it’s a prudent policy. Strong boundaries make for a more effective clinician.

10. Is it true that once a person has an episode or two of depression, that person will most likely continue to have episodes throughout life?

Statistically, the chances of a major depressive episode are elevated for someone who has already had one or more episodes. Statistically, that’s especially true for women. Statistically, it’s hard to stop that ball once it starts rolling down the drain.  However, no person is a statistic. We have choices. We can render these statistics meaningless by availing ourselves of the wonderful, empirically-validated treatment options – especially mindfulness-based therapies that have lifelong benefits and no side effects. Statistics be damned, I say.

Well, there you go, JA. I do hope this arrived in time to prevent these questions from burning clean through. I’m sure you need another hole in your head like I need another drink.

-IS

For some reason,

Actually, this essay didn’t get cut; it’s an afterthought. Think of it as a bonus chapter to an odd little book that can use all the help it can get.

In The User’s Guide, I wrote about some of the mind’s most inexplicable and troubling tendencies, and what to do about them. Today I’ll discuss one of the most important things we should know about our minds before attempting to use them in public: we perceive only bits and pieces of the world around us, but our minds fill in the blanks to create the illusion of a seamless experience.

Our perception of the world is like a telegram with every other word missing. We get the gist of things, while our minds fill in the missing pieces. Sometimes our minds get it right; sometimes they are spectacularly wrong.

The following is a little example of the latter case using a quirk of our visual system.

The Disappearing O

You should have noticed that the O was replaced by white space when it vanished. Now, repeat the same process with this image:

This time, you probably noticed that the O disappeared but the horizontal and vertical lines did not. They may have been squiggly or imperfect, but for the most part the lines should have remained intact while the O vanished. What gives?

In each eye there is a blind spot where the optic nerve joins the retina. Photoreceptors are absent at this junction, called the optic disc, but the mind manages to fill in that blind spot using visual information from the general vicinity.

In the second half of the demonstration, the mind assumes that straight lines remain straight, and so it gives us the experience of perceiving straight lines when we are not actually seeing straight lines. It’s a pretty impressive computational feat. (It’s also prone to mistakes. If we didn’t know the O was supposed to be there, we would be none the wiser and that O could have snuck up on us.)

The visual system does this sort of thing routinely, and in different ways (Weil & Rees, 2011). In the image below, we can see seven segments of violin string (the upper left segment disappears into the shadow of the fingerboard) but we perceive four continuous strings. Our brains routinely feeds us contrived bits of information, making the world seem smooth and predictable.

In truth, the brain relies on scant few bits of information as we navigate the world. We simply cannot perceive all that is around us, and luckily we don’t need to. In the above image, we see only a few features, but we know it is a violin. Or an evil robot. But probably a violin.

Even if we could absorb more information, we couldn’t process it. Our brains routinely encounter information bottlenecks as we’re seeing, hearing, and interacting with the world. Our brains make snap decisions about which pieces of information to process and which to discard (Tombu et al. 2011). The copious gaps get filled in with good guesses.

Relating On Autopilot

It’s an imperfect analogy, but a similar process takes place in relationships. We form views of others that seem continuous, predictable, and reliable. That makes us prone to certain errors, just as our vision is prone to errors.

For example, have you ever assumed that someone was upset with you because his or her behavior seemed cold or distant, then later discovered that their behavior had nothing to do with you?

We assign personalities to people that help us understand and predict their behavior. Cognitive psychologists call them schemas. When a person’s behavior violates our schema, the mind is always at the ready with a quick and easy explanation: Uncle Marty forgot my birthday. Clearly he is angry with me.

From a mind’s point of view, the most sensible explanation is the one that ensures our safety. If a mind assumes that Uncle Marty is angry, then we will feel compelled to respond, perhaps by repairing the relationship or distancing ourselves from it. …Gosh, I better figure out why Uncle Marty is angry. Or, …Screw Uncle Marty. I never liked him anyway.

Even though automatic interpretations can be inaccurate, like the missing O, there is something beautiful about them. They are designed to minimize our exposure to rejection or emotional injury by compelling us to respond to problems. Whichever direction the mind pushes us, we end up less vulnerable, in theory. (Of course we always have the option of ignoring what our minds tell us.)

No matter how counterproductive, annoying, or just plain wrong the mind may be, it is almost always watching out for our safety. That is the beauty of minds – and the trouble with them. They are often trying to save our lives, even when our lives aren’t in danger.

Filling in the blanks is just one of the mind’s survival-driven, error-prone functions. In The User’s Guide to the Human Mind, I discuss other engrained mental functions that serve to keep us safe:

• Confusing the present for the past. When we become physically or emotionally injured, the mind will forever be on the lookout for it to happen again. It will even find ways to recreate the injury. There’s a clear survival value in this. When the mind errs on the side of over-preparation, we’re less likely to be caught with our pants down.
• Double standards. The mind often has higher standards for ourselves than for others, even with things like emotions: it’s OK if others feel this way, but I shouldn’t. This particular double standard makes us forgiving of other people while keeping our own behavior in check so that we don’t become too annoying and risk being ostracized. Other kinds of double standards function similarly to keep us safe.
• Pessimistic thinking. We tend to think of pessimism as a bad quality, but in fact pessimistic thinking is one of the mind’s most powerful armaments against danger. Think of it as one of the mind’s error-management systems. It helps us err on the side of caution so that we don’t get hurt. The trick is in knowing how to use pessimism correctly.

Most of what our minds do behind the scenes is geared toward survival. Even things like anxiety, depression, and addiction stem from mental adaptations to a dangerous world. When these minds of ours seem to be beating up on us, we are usually better served by exercising compassion for them rather than cursing them and trying to change their nature.

How to Live With a Human Mind

You may be saying, “Fine, Dr. Smartypants, my mind is watching out for me. What the heck am I supposed to do about it, because it sure doesn’t feel like my mind is on my side.” The answer is fairly simple on paper, but it requires a bit of practice.

The first step is simply to build awareness of what the mind is doing, and why. The second step is to recognize the choices we have in responding to our minds. We don’t always have to do what it says.

For example, most minds have a lot to say about public speaking. Everyone will judge you. Your whole career is riding on this speech. They will all notice your [fill in your greatest insecurity]. Rarely is any of it true, but the mind can certainly convince us that it is. We’re at a disadvantage when we get sucked into powerful thoughts and feelings without realizing it.

Noticing the mind’s activities is not merely an academic exercise. Observing our internal processes with distance and dispassion is a powerful step toward managing anxiety, depression, destructive relationship patterns, and other problems.

Maybe the mind is a bit like an anchor being dragged around behind our boat. If we don’t know why it’s there or what it is for, we will probably come to resent it. We’ll see that anchor as dead weight, and we’ll do our best to navigate around it.

But that anchor can become something cherished when know why it exists and how to use it. It can keep us steady and safe when necessary, or we can carry it along without impediment when the seas are calm.

Well, that is a little taste of The User’s Guide to the Human Mind. Like any good book, mine can be summed up in one sentence: the government is engaged in a massive Bigfoot coverup.

Wait, that’s the wrong thesis. Here’s a better one: the mind is almost always looking out for us, and we don’t have to believe everything it says.

Hungry for more? You can read the book’s introduction here, and drop me a line if you would like my haggis recipe.

– IS

References

Tombu, M.N., Asplund, C.L., Dux, P.E., Godwin, D., Martin, J.W., and Marios, R. (2011). A unified attentional bottleneck in the human brain. Proceedings of the National Academy of Sciences of the United States of America, 108(33), 13426-13431.

Weil, R.S. & Rees, G. (2011). A new taxonomy for perceptual filling-in. Brain Research Reviews, 67, 40-45.

(Author’s note: I realized after writing this piece that it needs a bit of context and preamble. In this essay, I offer some pointed thoughts about female tendencies in relationships. I mistakenly assumed that this needn’t be said: some men are lazy and inconsiderate, and no amount of effort from their partners will fix that. I don’t discuss male problems in this essay, but I fully realize that they exist. Also, this essay critically examines the actions of one woman who made her relationship behavior very public. Her story is a useful example of a common pattern. I do not think she is a bad person, nor do I believe her behavior is representative of all women.)

Do you feel like your husband or boyfriend has become lazy and uncaring? That he has stopped listening and no longer does his fair share? Are you two becoming increasingly irritated with each other over simple tasks?

It’s a common pattern that can feed on itself and grow like an ugly weed. “I love you, snickerdoodle” turns into “you never help me anymore,” followed by “maybe I would if you’d get off my back.”

Let’s talk about three of the most important things you can do to gain more cooperation out of your man. But first, an example of how not to motivate most members of the male species.

At The End of Her Rope

In a recent Parenting Magazine article, Martha Brockenbrough vented her abundant anger about the bumbling, lazy, irresponsible behavior of men in general, and her own husband in particular. This is the first impression she paints of the man with whom she has vowed to spend her life:

“Once, when I was dangling at the end of my rope, I insisted he go to the doctor for a hearing test. I was quite certain the man was deaf. How else, for instance, could he have taken my grandma’s books to Goodwill instead of the antique-book dealer, as I’d asked when he was cleaning out the basement?”

Mrs. Brockenbrough’s article included survey results of 1000 mothers. Among the results, “46% of moms get irate with their husbands once a week or more.” Not angry or frustrated, but irate.

Magazine surveys are notoriously slanted and unreliable, but Parenting Magazine nevertheless found 460 women who admitted to becoming irate more frequently than I fill my gas tank. It’s a pattern that I’ve seen countless times in my clinical practice.

Both partners lose when this type of interaction becomes routine. The woman ends up feeling perpetually disappointed, and she’s resentful that she has been put in the position of a nag. The man feels belittled, and he’s weary of being on the defensive against his wife.

They find themselves wondering how their relationship came to this. Where is the kind and nurturing woman he married? Where is the dependable, stand-up guy with whom she fell in love?

Since I’m writing to women right now, I won’t offer advice to men except this: if you make a promise, then man up and keep it. If you have no intention of doing what she has asked of you, then say so. Don’t avoid things like a 10-year-old boy trying dodge his homework.

Now, back to the women in the room. Mrs. Brockenbrough demonstrated some common tactical errors that create resentment and discord in a marriage. If you want a man who won’t lift a finger but will instead focus his energy on avoiding and undermining you, simply follow this recipe.

1. Loss of Perspective

The first error is a loss of perspective. Mrs. Brockenbrough got so upset about how her husband helped her that she seems to have lost sight of the fact that he did, in fact, help her. He cleaned the basement and, at her request, made a special trip to dispose of her grandmother’s books.

Yes, he made a mistake. Here is my suggestion for coping with the disappointment: thank him for the clean basement, retrieve your books from the Goodwill store, and go out for a nice dinner together. Life is short, and your time with him will be over soon enough. Until then, you can choose to behave like the bright and shiny center of his world, or you can be the poo in his punch bowl.

(Another author’s note: after posting this essay, I received some feedback that the above advice is insensitive and perhaps sexist. Rest assured, it is the same advice I would give a man. I understand how easy it is to interpret mistakes as a lack of caring: Grandmother’s books were special to me. If you loved me, you would have understood that, and you would have done what I asked. Even if that is true, it is more useful to discuss the underlying issue (I’m worried that you don’t care about me) than to go to war over the particular incident.)

Rather than maintaining perspective and behaving graciously, she seems to have fixated on his mistake and committed a second strategic blunder…

2. Exercising Aversive Control 

“Aversive control” refers to the use of repeated punishment to manage behavior. It works only as long as the oppressive agent is present. As soon as the prison guard steps out for a cigarette break, the inmates begin to mutter their discontent and plot their revenge. Speeding tickets are an example of aversive control. How fast would you drive if you knew that you could never be fined?

Mrs. Brockenbrough responded to her husband’s mistake with severe retaliation: a demeaning, publicly-humiliating essay. I cannot imagine treating my spouse with such hostility.

Couples who are locked in a cycle of aversive control can look forward to two problems. The first is an exhausting battle for control in which one person tries to dominate while the other tries to avoid being controlled. Each behavior increases the other. The more one partner tries to dominate, the more the other tries to avoid, which leads to increased efforts to dominate, and so on.

The second problem is that they will lose respect for one another, and that is a difficult thing from which to recover. Human minds never forget an injury. We can learn to look past them, but history never goes away, and so it pays to choose behaviors wisely.

Mrs. Brockenbrough is probably a lovely person who has simply allowed her frustration to overtake her. Patterns like this are so insidious that even lovely people can become enmeshed in them. Let’s look at some alternatives.

1. Offer Reinforcement

Guys are relatively uncomplicated. Most of the time we want to make you happy. Each time you tell us what makes you happy – for example, by thanking us when we’ve done something you appreciate – then you’ve just increased the odds that we will do it again.

This is not rocket science, yet so many women I have met insist on telling their men what they don’t want. They don’t want him working past 6:00; they don’t want his friends marking up the coffee table; they don’t want a repeat of last year’s vacation at that cheap resort.

A man who cannot please his woman will stop trying. And you probably don’t want that. So do tell us what you want, and do express some gratitude when we hit the mark. (Bonus tip: express your gratitude with more than words if you want serious results.)

2. Attack Patterns, Not People

If you and your fella have fallen into a pattern of tug-o-wars, power struggles, or pointless arguments, avoid the temptation to pin all the blame on either him or yourself. Instead, tackle the pattern that has cropped up between you.

Relationship problems are like snowflakes. Each one is unique. Together, you and your man will create relationship patterns – both good and bad – that would be impossible to precisely replicate with another human being. So when the destructive patterns crop up, attack those patterns as a team rather than focusing anger on each other.

Here’s an example. Suppose that a couple has regular shouting matches over household chores. She wants more help; he wants time to relax after a stressful day. The temptation is to focus on the surface behaviors: she doesn’t like what seems like a lack of concern; he doesn’t like what seems like domineering behavior.

Instead, develop some curiosity about the pattern. When did it start? What happens in the days before the arguments? What goes on in each of their heads before the shouting starts? What happens during and after an argument that sets them up for another one? Looking at patterns of interaction rather than targets of blame diffuses some of the emotion and focuses attention on a shared problem to be solved.

It takes mental discipline to step away from blame and anger, and the process requires mutual commitment, but attacking patterns is much more productive than attacking each other. In my clinical experience, most men are willing to communicate and sink their teeth into a problem if they have some assurance that they won’t simply be a target for anger.

3. Behave Respectfully, Even If You Don’t Feel Like It

One of the truly unfortunate aspects of Mrs. Brockenbrough’s essay was the profound lack of respect for the person she once admired enough to marry. In essence, she called him an idiot. Publicly. It was downright rude.

Mutually respectful behavior is important because it sets the tone of the relationship. It is like the strings section of a symphony. The music simply cannot be complete without it.

I know what some of you are thinking because I’ve had similar thoughts. Why should I make the first move? HE is the one who is uncaring. Frankly, I’m just too angry to be respectful.

Refusing to make the first peace offering in a relationship may feel righteous in the moment, but it is one of those behaviors that almost always achieves the opposite of our desires.

The Danger of Quick Fixes

The motivations of men are generally less complex than women and that is to your great advantage. We tend to respond fairly directly to incentives, which means that you have a great deal of influence over our happiness. That in turn gives you a great deal of influence over our behavior.

Destructive patterns are so tempting and ensnaring because of their payoff ratios. Becoming irate or exercising aversive control can feel quite satisfying in the short term. Let’s face it: sometimes it feels good to vent anger. It’s a quick fix. The downside doesn’t show up until later.

On the other hand, thoughtful, constructive responses pay off in the long run but feel ever-so-unsatisfying in the here and now.

The desire for quick fixes comes naturally to humans and it’s nothing to be ashamed of. The drive for quick fixes is simply one of the mind’s strategies for solving problems. When the mind identifies a source of discomfort (such as a husband who appears to be disengaged or uncaring), it wants to fix the problem as quickly as possible. Luckily, we don’t have to obey every emotion that comes along.

If you’ve already traveled down the path of power struggles and aversive control, don’t despair. If you married a real man he should be more than willing to help improve things. Most men don’t want to feel like children in their marriages, and most women certainly don’t want to feel like mothers to grown men. Identifying the pattern and resolving to change the day-to-day behaviors that cause it can be the most difficult but important step.

-IS

Now each day shows us how quickly things change, and how consistently life asks us to surrender precious things. Gone are the days when I could spoon-feed her or cause fits of laughter simply by tossing her in the air.

Well, that’s not true. She still laughs when I toss her around, but she has grown and it’s harder than it used to be. I hope she doesn’t expect that when she’s fifteen.

Five years is a milestone. School is in full swing, she folds her own clothes, and she’s halfway to the double digits. It’s a good time to take inventory of the lessons she has taught me. She has helped me with practical matters like hide-and-seek strategy (see photo at right), and she has set forth a number of useful lessons on important topics like these…

• Relationships: “I’m leaving you! But only if you come with me.”
• Existence: “Do you know what’s really not fun? Being a human. I wish I was an oviraptor.”
• Playing a trumpet: “You just put your lips in it, push all kinds of buttons, and you’re doing it!”
• Biology: “My right hand is called Mr. Grabby and my left hand is called Mr. Holdy.”
• The little joys in life: “A playground? Next to a lake!? WOW!”

I can’t compete with wisdom like that, but I can share what I’ve learned along the way. In no particular order, here are five lessons my daughter has taught me about fatherhood:

1: Fatigue Is Hard on Bodies, Minds, and Relationships
We are an active family, and it’s tempting to make sleep a low priority. We try to ensure that our daughter gets sufficient rest. Really, we do. But time sometimes escapes us. When fatigue builds up over the course of a few days, kidlets become short-tempered, unfocused, unhappy, and generally unpleasant to be around. Maybe this is Mother Nature’s way of persuading parents to put the kid to bed already.

Fathers also need sufficient sleep. Fatigued dads become short-tempered, unfocused, unhappy, and generally unpleasant to be around. Mother Nature is certainly consistent.

It’s probably an obvious point, but fatigue is hard on bodies, minds, relationships. Unfortunately, by it’s very nature, fatigue dulls the wits and blinds us to its effects. It’s an insidious foe. Despite my years of fancy book learnin’, keeping it at bay still takes conscious effort.

2: Distraction Is a Sublime Art
While I have made plenty of mistakes, one thing I have done well is to capitalize on the mystical, magical, fabulously fantastical powers of distraction. Wielded effectively and sparingly, this tool can avert conflict and increase productivity. (Every dad is part CEO.) Let’s look at an example, starting with the wrong way to handle a common situation:

Daughter: “I don’t want to brush my teeth tonight.”
Father: “I know, but you have to do it anyway.”
Daughter: “But we always, always, always brush teeth. I don’t want to!”
Father: “I didn’t ask if you wanted to. Now march into that bathroom, young lady!”
Daughter:  (Tears forming) “But I don’t want to!”

…And so on. Dad has stepped into a trap. Now here’s the same situation with the magic of distraction:

Daughter: “I don’t want to brush my teeth tonight.”
Father: “I know. Hey, remember that time I was brushing my teeth and drooled toothpaste on the front of my shirt?”
Daughter: “YEAH! Ha ha ha!”
Father: “I looked like a crazy dog!” (Starts walking toward the bathroom.)
Daughter: “HA HA! You looked like a wackadoo crazy dog!” (Following him into the bathroom.)

If all goes to plan, she will gladly brush her her teeth while focusing on something more pleasant. The downside to this strategy is that she will one day use it on me:

Daughter: “Dad, it’s time to get your new dentures.”
Old dad: “Why? I’ve had this set for 15 year and I ain’t starved yet!”
Daughter: “Hey dad, remember my first ride on a roller coaster?” (Starts walking toward the car.)
Old dad: “Yeah, heh heh. You didn’t know which way was up afterward.” (Following her to the car.) 

3: How to Dampen Electronic Speakers on Plastic Toys
Here’s a practical tip that every father should know: a bit of sticky tape will significantly dampen the loud, tinny, electronic speakers found on many plastic toys. You can cover the speaker holes partially or entirely to control the volume. If that fails, your local thrift store will gladly take the toy off your hands in order to preserve your sanity. Everybody is happier when daddy isn’t feeling demented because his ears are bleeding.

4: Have a Plan, and Be a United Front
Every now and then, our little princess decides to test-drive her bad manners for a day or two. For no apparent reason, she becomes surly, snappish, and demanding. These phases are perfectly normal.

Her mother and I respond to impudence simply by giving her a brief time-out, followed by the opportunity to repackage her message into a less turd-like presentation. We hope to teach her that people won’t associate with her if she acts like a jerk. We don’t battle with her or vie for dominance, we simply refuse to participate in discourtesy.

The result? People routinely compliment her etiquette. Every kid loves compliments, and she is learning how to get what she needs without alienating people.

I think this works because her mother and I are consistent. For the most part, our daughter gets the same responses from each of us because we routinely confer on the best way to respond to her. (She hates that we do that, and has even asked us to stop. Sorry, Kiddo.)

Sometimes her mother and I fail to communicate and we find ourselves with different goals – but only until we recognize the problem and realign ourselves. I can see how parents end up battling each other rather than focusing on the mutual task of raising a civilized human being. Remember, your spouse or partner is not your opponent. The child is your opponent.

(Kidding.) (Mostly.)

5: Give Away Responsibility
As an overly protective father, it is tempting to micromanage my daughter’s behavior. Of course, that’s about as unproductive as struggling against quicksand. The more I try to control her, the more she will resist. If I’m not careful, she will consider me her avowed enemy before she’s sixteen.

I grasp this point academically, but still I must work to restrain myself. For example, she started kindergarten this year, and several weeks into the school year I noticed a destructive pattern. She and I were battling each morning about punctuality. The harder I tried to get her out the door on time, the slower she would go. It was becoming a contest of wills. That is not the kind of relationship I want with my daughter.

My brain eventually began to function correctly on the matter. I realized that I was concerned about her punctuality, and she was not. That’s entirely backward. What do I care if she’s late? I’m not the one who will pay the price for her tardiness or reap the rewards of timeliness. I was making both of us crazy and depriving her of consequences that she needs to experience in order to learn about the world.

So I stopped fighting the battle. We explained to her the benefits of time management and taught her how to be mindful of the clock. She would be responsible for getting out the door on time.

It’s no surprise that our good kid rose to the occasion. With only two exceptions, she has been on time. She paid a small price for her tardiness, and reaped a large reward for punctuality. She’s now a little more independent, and our mornings are much more pleasant.

I think that one of the tasks of parenting is helping children make mistakes at the right time. Kindergarten is the perfect place to learn about time management. Mistakes are cheap at her age. She cannot get fired or expelled. For now, the only cost of tardiness is a few minutes subtracted from recess.

My task is more difficult than hers. I need to relinquish control at the right time and place. It might be easier to simply lord over her every move, but that’s not my job.

Love Means Letting Go… But Not Yet
One day, out of the blue, our little angel channeled Lauren Bacall. “You know how to whistle, don’t you? You just put your lips together and PHPHPHPTTT!”

It’s beautiful that children have no idea how much they don’t know about the world, yet they are never without an explanation for things. For instance, did you know that cavity-causing germs have a name? According to our daughter, it’s Bob Troubleman.

Here’s another of her lessons: “It’s not so smart to dye your hair green, but if you dye up your whole self green you could hide in the grass to escape from predators like tyrannosaurus rex.”

It’s sad to think of her outgrowing such innocence and whimsy. I mourned the day she started saying “yellow” instead of “laddow.” But with each passing stage comes something new and equally exciting – provided I’m willing to relinquish control and grow along with her. Hopefully, I’ll learn a few more things in the next five years.

For now, I still get to be her protective father, and I’ll try to be smart about it. Luckily, some things are no-brainers, like the time I was using the circular saw and she announced with an eager smile, “my turn!”

Not just yet, Sweetheart.

-IS

Book update! The Kindle edition of The User’s Guide to the Human Mind is up at Amazon. If you order now, dainty Internet seraphim will deliver it on December 1st. I’ll even autograph the front of your Kindle if you like!

Dear Dr. Michelle,

For those unfamiliar with the term, a sliding-scale fee structure is a variable rate based on a person’s ability to pay for a product or service. People of means pay the full fee, while those with financial difficulties pay less for the same service. While I think they’re nice in theory, sliding scales come with some hefty trade-offs for both therapist and client.

You and I know, Michelle, that we psychologists hate to talk about money. It is one of the only consistently taboo subjects in therapy. While we welcome the most ghastly details of life, we avoid this topic like a politician avoids the confession booth.

In a 1996 study (an old study but one of the most recent since we avoid discussions of money even in our own professional literature) Catherine Keuffel found that we shrinks avoid the topic of payment because we tie it to our own insecurities. Those fears include potential conflict with the client, questions of self-worth, uncertainties about the definition of the service we provide, and other bits of neuroticism. I’ll admit to some anxiety about posting this essay for fear of looking like the Grinch.

Our reticence on the matter is just plain wimpy since we ask our clients to face their own insecurities. So in the spirit of chipping away at a needless taboo I’ll share my opinion on sliding scales. I hope you don’t mind a cold and unsentimental discussion that runs contrary to our lessons from shrink school.

Psychologists are taught that it is our moral responsibility to work for little or nothing at least part of the time. The APA’s code of ethics instructs psychologist to “strive to contribute a portion of their professional time for little or no compensation or personal advantage.”

Unfortunately, the APA doesn’t explain who should pay the costs associated with treatment, how to monitor the effects of charity, or how to implement a fair fee structure. Being well-intentioned people, they probably assume that their call to altruism needs no explanation, but actions of the heart can have unintended consequences. While sliding scales can feel good – and in fact they may be good – they can also be philosophically and pragmatically troublesome.

Psychologist who offer sliding scales should be perfectly clear with themselves and with her clients about who is paying for what. As is often the case with charitable acts, some unknowing third party can end up paying the bill. Worse still, charity sometimes achieves undesired ends.

Here are some reasons that psychologists should think carefully about sliding scales:

Sliding scales create a potential moral hazard.

Minimal or no payment insulates a client from the risk of losing his or her monetary investment. Clients who don’t pay are therefore less likely to treat the service respectfully or work hard for their desired outcome. People simply tend to devalue things for which they bear little responsibility. That is obviously not true for everyone, but it is true for humans in general.

Consider the manner in which people treat rental cars. I’ll admit that I’m a little less concerned about speed bumps when I’m driving a rental, and I’ve never changed the oil in a rented engine. Why should I? I have a negligible investment in the vehicle.

I believe that reduced fees should be reserved for people who are somehow invested in treatment. I realize that a minimal payment can represent a significant monetary investment for someone with limited resources. The point is that investment in some form or another is necessary for good outcomes. The absence of investment is a recipe for resentment and wasted time.

I know whereof I speak, having worked in a prison where services are provided at no charge to the recipient. As you might imagine, those free services are treated with the respect befitting a rented Yugo while taxpayers foot the bill. Therein lies the moral hazard, which brings brings me to my next point:

Sliding scales can force one client unknowingly to subsidize another.

As you pointed out, Michelle, we psychologists must pay our bills. We have a finite number of hours in which to generate enough income to do so, and we don’t typically make a lot of money. If a psychologist charges someone a fee that is insufficient to cover the bills for that portion of time, then she must recover that loss from someone else.

This is where altruism and good intentions get complicated. It may feel good to donate services to a particular client, but the psychologist who does so may be overcharging others in order to pay for that charity. It can hardly be called altruistic to donate someone else’s money.

One clinic I’m aware of openly states that a certain percentage of payment from full-fee clients is used to subsidize reduced-fee clients. That seems a perfectly reasonable and ethical approach. The clinic is acknowledging that their prices are higher than they would be otherwise, and they are giving their full-fee clients the option of participating in a charitable act. Those clients can choose a different clinic if they wish to avoid the added expense.

Sliding scales turn psychologists into social engineers.

Sliding scales force a psychologist to decide who is worthy of special treatment, and who is unworthy. In private practice, where a clinician typically has no objective method of determining “worthiness,” the decision must ultimately rest on sloppy, emotional impulses: This person deserves it; that person does not. Ick.

To complicate things, the psychologist cannot be sure that the recipient of charity is the most deserving. I’ve seen cases in which relatively wealthy individuals finagle a reduced fee while everyone else pays the full fee.

To prevent that problem, some clinics devise semi-objective, progressive fee scales based on documentation of income. That is more consistent than gut impulse, but as a private practitioner I’m not about to begin tracking the income of my clients, nor am I willing to dabble in the ugly business of devising charts and fee scales that remain subjective at their core.

One of the reasons I will never run for public office is that I have no stomach for the partiality and nepotism that comes with it. I want no part of deciding who is worthy of special favors and who must suffer to pay for those favors. The very idea is repellant because it invariably involves stealing one person’s dignity and another person’s resources.

Does that mean that I oppose charity? Absolutely not. I’ll return to that topic shortly.

Sliding scales punish those who are willing to pay for the psychologist’s expertise and time, and they reward those who are unwilling to pay.

I realize this isn’t the intent of sliding scales, but it is on one of the effects, and it is the worst business model I’ve ever heard of. Other industries offer sliding scales, but I can’t think of any profession that supplicates itself like mental health professionals do. I can’t recall the last time a grocer, a plumber, or an accountant offered to take less money out of the goodness of his heart.

That’s not to say that their hearts aren’t good, but they may be operating under different assumptions. They may assume, for example, that catering to people who are unwilling to remunerate them would kill their business.

So how do we psychologists offer so much sliding-scale work and manage to stay afloat? We work longer hours and see extra patients. But that, too, can come with unintended costs paid by unconsenting others, which brings me to my next two points…

Sliding scales can force a clinician to work longer hours, which may reduce his or her effectiveness.

Psychology is tiring work, and psychologists are prone to burnout. Any clinician who works extra hours in order to offer reduced fees should, in my opinion, ensure that her clinical effectiveness does not suffer. Reduced effectiveness is essentially another subsidy paid by unconsenting clients who are paying the full fee and deserve our best performance.

Sliding scales can force the psychologist’s loved ones to subsidize treatment.

Because reduced-fee services can require longer hours, there may be less time and fewer emotional resources available to other important people in the psychologist’s life. Any psychologist with a sliding scale should ensure that his fee policy isn’t exacting added costs on loved ones who never agreed to the payment policy.

Having said all that, I think sliding scales are a fine idea. I am very aware that some financially strapped people are better served by private-practice psychologists than overwhelmed, underfunded clinics. And at the risk of sounding defensive, I have donated literally thousands of hours of my time to charitable causes.

But any psychologist who offers a sliding scale should guard against unintended consequences. Since you are searching for objective guidelines, Michelle, I think that sliding scales should meet the following criteria:

• The time and expertise that we donate must be our charitable contribution alone. We should not force clients to subsidize one another by way of money or reduced effectiveness.
• We should be mindful of the potential moral hazard inherent to sliding scales, and we should address the problem immediately if outcomes are in jeopardy.
• Our fee structure should not cause us to neglect loved ones or other important obligations.
• We should be be able to justify, if only to ourselves, our method of determining charitable worthiness.

As the APA demonstrates with its vague call to altruism, it is easy to submit to emotional sentiment, outcomes be damned. But of all people, we psychologists should obey two principles: that emotions shouldn’t rule behavior, and that forethought can prevent unwanted and unintended consequences.

-IS

References

Keuffel, C.R. (1996). The money metaphor: Therapists’ experience with fee transactions with their clients. Dissertation Abstracts International: Section B: The Sciences and Engineering, 57(5-B), 3413.

At about 25 miles in length from east to west, they say that Colfax is one of the longest continuous commercial streets in the world. If you’re anything like me, your mind gives you thoughts like this: “I should walk from one end to the other!”

So on a lovely fall day, Iron Wife and I plotted a complex route:

Having thus worked out the details, we rode the bus to the east side of town and started walking toward the foothills west of Denver – a 19.5 mile hike.

This was not a fundraiser, or an exercise in mindfulness, or any other admirable enterprise. It was just a self-indulgent, sentimental stroll along a colorful street.

Colfax traverses a wild array of neighborhoods. Some are wealthy, others are poor. Some are perfectly safe, others require you to watch your back. We started our hike in a neighborhood working its way up from the very definition of “sketchy” thanks to the ongoing installation of the University of Colorado Health Sciences Center (visible on the right).

It’s on the site of the old Fitzsimmons Army hospital, some vestiges of which still remain.

My pre-doctoral internship was headquartered on this campus but I spent my time at other locations, so it didn’t evoke any impulse to linger and reminisce. Onward. The foothills in the distance were the destination, and they looked awfully far away.

One of the first restaurants we passed was an old school McDonalds.

…but Colfax has more interesting offerings:

Pete’s Kitchen has been there as long as I can remember. This sign is a friendly beacon in the night to anyone who has been hungry and drunk at 4:00 AM.

Traveling out of Aurora and into Denver, I think we saw Engine 8 a few times. They always seemed to be in a hurry. Fire engines are my favorite vehicles. I would drive one if I could afford to.

Even though we were in Denver now, those mountains were still far away.

All along Colfax are small hotels, some in better repair than others.

“B ig Bunny” is a Denver legend. By the way, our intellectual property attorneys have asked us to remind you that this is not, nor has it ever been, the Bugs Bunny Motel.

Colfax and Broadway is in the middle of Denver. It’s like the nexus of the universe to a local kid like me. That’s the Denver Post building in the background. I forgot who’s riding that horse.

Here we see pigeons proceeding in an orderly fashion with The Cathedral Basilica of the Immaculate Conception in the background.

Still at Colfax and Broadway, outside the capitol building. It would be unusual not to find somebody protesting here.

West of downtown is the Colfax viaduct. It was long, hot, and mostly uninteresting – except that I unintentionally gave the lady on the bicycle a face full of cigar smoke. She was good natured enough not to complain. Sorry about that. Mountains are getting closer!

Here we see people doing something useful with their Saturday. And I don’t care what Sports Authority says, THAT is Mile High Stadium.

Colfax has lots of cool signs that don’t seem to crop up elsewhere. That’s a shame. The world would be a better place with more signs like these.

It also has plenty of local landmarks, and even some national ones. Some are more reputable than others. (Kitty’s is an ancient pr0n store. I think it predates Charlemagne.)

A self-portrait taken at the halfway point. Did I mention that the Iron Wife is a really good sport? Iron Child, on the other hand, gave up and got left behind at mile two. (Kidding.)

Downtown is behind us now. The building in the background with the gold dome is the state capitol. In the foreground, a randomly placed port-a-potty. I’ll forgo the obvious comparisons.

Careful! Don’t fall into the…

I stopped here to pick up a few essentials.

Locals will recognize this as one of the finest restaurants in Denver. I will not entertain dissension on this point. They give you unlimited tacos. I rest my case. It sits on the former site of the Jewish Consumptive Relief Society (or near it, I don’t know for sure).

I lived within walking distance of Davies’ for years and still haven’t eaten there. A shame, since I love pancakes, steaks, and fried chicken.

This is the heart of Lakewood, where Colfax is dominated by miles of used car lots. Sorry, no pictures of those. You’ll have to use your imagination. The foothills are getting closer!

Fast forward a few miles, and we’re at the top of the last hill. Just a bit further.

This spot overlooks Golden. Yes, that is an actual view about 100 feet off Colfax.

Tucked away in a rather odd corner of Colfax is this tribute. The inscription says, “Dedicated to the courageous American citizen soldiers who have so nobly sacrificed their lives upon the alter of freedom.”

Back to the parking lot just before sunset. Time for some pancakes, steaks, and fried chicken!

Dear Sean,

As someone who once plowed up a snake, I can appreciate your metaphor.

I exaggerate. In truth, I was using a spade, not a plow.

And it wasn’t really a snake. It was a small earthworm. But it was frightening.

Please know that I’m not making light of your symptoms, but rather drawing attention to them in my own tactless and ham-fisted way. You sound irritable more than you sound depressed, and the true sources of irritability are commonly overlooked or misidentified – especially in men, for whom irritability frequently masks a mood problem.

Seasonal depression conjures images of sadness, hopelessness, despair, loss of energy, and other stereotypical depressive symptoms. While you mentioned sad feelings, the thrust of your complaint is that you are crabby during the dark months, not classically sad and depressed.

Might that be a flavor of depression? Let’s discuss proper diagnosis, and then we’ll get to the possible interventions.

Mixed Symptoms

You were kind enough to send me more information about the symptoms you experience during the winter months. Some of your symptoms match the typical picture of seasonal depression. For example:

• You live in a higher latitude, where seasonal mood problems are more common than in those closer to the equator.
• You go to bed earlier and sleep more in the winter.
• You feel sad.
• You gain weight (though you indicated that this is due to inactivity more than diet change).

So far, these are symptoms associated with what’s been termed Seasonal Affective Disorder (SAD), with the exception of your mode of weight gain. The condition is usually characterized by classic signs of depression, along with some unique features like carbohydrate cravings.

However, your picture is a little different. You did not endorse other symptoms associated with seasonal depression, such as hopelessness, difficulty concentrating, feelings of worthlessness, overeating, diminished interest in pleasurable activities, or loss of energy.

In fact, you told me, “it’s my attitude and not my energy that suffers.” You indicated that you lack motivation, not vitality, and that your inactivity during the winter months is due mainly to the fact that you cannot be outdoors where you tend to get exercise. “I’m not a guy who can go to the gym and get on a treadmill like a gerbil,” you wrote. You also informed me that you find yourself “going stir crazy with severe cabin fever mixed with the blues.” I take that to mean that you feel agitated.

So. During winter, you are fractious, stir crazy, sad, and stricken with inertia despite ample energy. So far, these are not the classical depressive symptoms as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the holy and ordained catalogue of mental illnesses. In fact, they don’t really match any diagnosis that I can find in the DSM.

Yet, in the first few words of your question, you surmised that you are struggling with seasonal depression. Perhaps you have a more nuanced understanding of mood disorders than the DSM.

While the DSM grows in size and weight with each iteration, the list of mood disorders is rather unrefined. The DSM contains fairly blunt descriptions of either 1) depressive or 2) bipolar disorders, to which one can add various specifiers (those are descriptions that denote a subcategory of the disorder). That’s it.

Any depressive disorder that doesn’t fit neatly into one of two broad diagnoses is lumped into the category Depressive Disorder NOS (not otherwise specified). Your symptoms might be tossed into the even less descriptive Mood Disorder NOS. There is a specifier called “With Seasonal Pattern” that can be appended to these diagnoses, but even with that you don’t fit neatly into a DSM box.

Normally, I don’t get too hung up on diagnosis. Heck, I mostly use the DSM to prop up the short leg of the couch. That’s because pinpoint diagnoses are marginally useful in my type of clinical work. A person might be diagnosed as alcoholic, but that doesn’t tell me why the person drinks, how alcohol functions in his life, or what to do about it. I’m usually more interested in function than category.

But where mood disorders are concerned, accurate diagnosis matters because they sometimes involve biological interventions like medication or phototherapy (we’ll discuss those shortly). The wrong intervention can make things much worse.

For example, a person with a history of manic symptoms can be thrown into a very unpleasant episode of mania if they are mistakenly prescribed antidepressants or even phototherapy. And applying antidepressants like SSRIs in a situation that is better managed behaviorally can have serious, long-term consequences.

Of course, I am not the first to point out the limited scope of DSM mood diagnoses and the importance of rediscovering the old wisdom that mood disorders cover a wide spectrum. In an editorial to the American Psychiatric Association, Christohper Shenk (2009) argued for a more nuanced understanding of mixed states, like yours perhaps, to help physicians avoid treatment errors.

Since the 1800s, people have found many labels for the various flavors of Agitated Depression – a diagnosis for which you might barely qualify for several months out of the year. That diagnosis usually includes some of the classic symptoms of depression along with inner agitation, racing thoughts, irritability, and so forth. In keeping with my tradition of advancing arcane trivia, here’s a sampling of the names that have described various mixed mood states (Koukopoulos et al., 2007):

• melancholia phrontis
• melancholia moria
• melancholia saltans
• melancholia errabunda
• melancholia silvestris
• melancholia furens
• melancholia activa
• melancholia excitata
• melancholia delirans
• melancholia persecutionis
• melancholia convulsiva
• melancholia maniaca
• melancholia malevolens
• melancholia homicidialis
• melancholia metamorphosis
• melancholia uterina
• lycanthropia
• melancholia enthusiastica
• mania melancholica
• melancholie maniaque
• melancholia agitans

Clearly, this is not a new problem. Koukopoulos et al. argued that Agitated Depression is an important diagnosis that should be included in the DSM. Benazzi & Akiskal (2005) argued for the inclusion of a more specific diagnosis, Irritable-Hostile Depression, that more accurately describes a clear constellation of symptoms like those you describe, and has specific treatment implications.

Time for me to bring this to a point. I’m not picking on the DSM. No tool is perfect. But in your case, where a proper understanding of the problem is critical, there is no clear-cut diagnosis on which to base treatment.

OK. You’re Special. Now What?

I recommend that you meet with a licensed psychologist – not a psychiatrist – who possesses a clear understanding of mood disorders. He or she will want to gather your mood history and other diagnostic factors. (For example, you mentioned that you have two small children who might be affecting your marital bliss and your peaceful home. This is no small detail.) Also, get a physical. There are a number of medical problems that can involve mood changes.

But do not, I beg of you, begin a course of antidepressant medication without serious consideration. I’m not suggesting that medication is necessarily the wrong answer. Some pills like Wellbutrin have been successful in treating SAD. But there are serious tradeoffs to consider. Antidepressants are not the benign cure-all that their promiscuous reputation and liberal use would suggest.

Since you function well in the winter, meaning that you did not describe debilitating symptoms like becoming housebound or suicidal, you might want to begin by exploring least-restrictive, behavioral interventions like these:

Phototherapy. This involves exposure to a certain variety of bright light early in the morning. It emulates what one might experience outdoors when the sun rises. Light therapy appears to be effective with just over half of those who use this intervention (Rastad et al. 2008), and the effectiveness increases as the intensity of the mood problem decreases (Priviter et al. 20010). As already mentioned, proper diagnosis is important before applying this type of treatment.

Exercise. While it’s not typically listed as a primary intervention for SAD, I’m putting it high on the list anyway. As I’ve said many times before, exercise is a magic brain pill. It is every bit as effective for depression as antidepressants, but without the side effects or long-term tradeoffs. Exercise is the benign cure-all that antidepressants wish they could be.

You indicated that physical activity is important to you, and you mentioned that you might begin snowshoeing this winter. A fabulous idea. Even better if you do it each morning. If it accomplishes nothing else, it may prevent that winter weight gain. Exercise early in the day also helps to manage sleep cycles at night.

Sleep Management. Sleeping too much can have a depressing effect. It can leave a person fatigued, foggy-brained, and irritable, and it can put circadian rhythms out of whack. You might try keeping a sleep schedule similar to that of summer. An effective way to do that is to…

Manage Your Zeitgebers. Zeitgeber means “time giver” or “synchronizer.” All animals use synchronizers to keep their bodies in proper rhythm with the natural environment. For us, light exposure is the most prominent synchronizer. Others include exercise, social activity, eating and drinking patterns, and even temperature. (A decrease in temperature is one of the environmental cues that tells a body it’s time to bed down.) You can structure your environment and activities to capitalize on your body’s natural tendency to track with the environment even when certain zeitgebers go missing for the season.

Nutrition. A psychologist should be able to talk to you about diet and supplements that help with mood. There is some evidence that a proper balance of carbohydrates can improve SAD (Mischoulon et al., 2009). Vitamin D also seems to play a role in various forms of depression, including SAD (Penckofer et al., 2010).

Other treatment options include cognitive-behavioral therapy specifically for SAD and, of course, antidepressant medication.

While I don’t have enough to go on, Sean, my Spidey-sense tells me that your condition may be particularly responsive to behavioral interventions like exercise, nutrition, light exposure, and sleep management. My suggestion: get thee to a psychologist for a proper assessment before the winter. I hope you’ll let me know how it turns out.

-IS

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Benazzi, F. & Akiskal, H. (2005). Irritable-hostile depression: further validation as a bipolar depressive mixed state. Journal of Affective Disorders, 84, 197-207.

Koukopoulos A., Sani G., Koukopoulos A.E., Manfredi G., Pacchiarotti I., & Girardi P. (2007). Melancholia agitata and mixed depression. Acta Psychiatrica Scandinavica, 115, 50-57.

Mischoulon, D., Pedrelli, P., Wurtman, J.,Vangel, M., & Wurtman, R. (2009). Report of two double-blind randomized placebo-controlled pilot studies of a carbohydrate-rich nutrient mixture for treatment of seasonal affective disorder (SAD). CNS Neuorscience and Therapeutics, 16(13-24).

Penckofer, S., Kouba, J., and Byrn, M. (2010). Vitamin D and depression: where is all the sunshine? Issues in Mental Health Nursing, 31, 385–393.

Privitera, M.R., Moynihan, J., Tan, W., and Khan, A. (2010). Light therapy for seasonal affective disorder in a clinical office setting. Journal of Psychiatric Practice, 16(6), 387-393.

Rastad, C., Ulfberg, J., & Lindberg, P. (2008). Light room therapy effective in mild forms of seasonal affective disorder – a randomized controlled study. Journal of Affective Disorders, 108, 291-296.

Schenk, C.D. (2009). Mixed Depression: The importance of rediscovering subtypes of mixed mood states. American Journal of Psychiatry, 166, 127-130.