Stress Management Blogging #6

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“Hard on yourself” can mean a hard time seeing support.

If you’ve been in a child therapist’s office, you’ve seen posters illustrating basic emotions – joy, terror, humiliation, etc. Research using photos of such broadly-expressed feelings has shown those with schizophrenia and autism struggle partly due to difficulty identifying others’ emotions. At the University of Cardiff, Kirsten McEwan and  her research team investigated people’s responses to photos of more-understated sentiments. They’ve found that highly self-critical people may have subtler difficulties recognizing a subtler emotion: compassion.  

McEwan, et al began by photographing actors they’d asked to express ‘social emotions’, such as sympathy, embarrassment or a critical attitude. They kept or discarded images for future research, based on whether their first group of study subjects could consistently agree on the emotion shown.


A sample set of social-emotion expressions from the research study.

They asked their second group of study subjects to watch the images on a screen, and press a button whenever a dot appeared. Such “computer visual probe tests” give clues to a person’s attention: the farther their eyes are from the dot, the longer they take to press the button. McEwan, et al separated their study participants into two groups: those who were highly self-critical and those who were no tougher on themselves than average. They found that those in the average category were quicker to respond when a compassionate face was replaced by a dot. Those who were higher in self-criticism took just as long or longer  - suggesting they were less attentive to supportive expressions.

High self-criticism is a common aspect of depression. While our depressed clients tell us, “Nobody cares,” their friends and family may well be wondering, “Can’t they see how worried we are? That we’re all here for them?” McEwan, et al’s data shows the answer, to an extent, may be, “No. They can’t.”


Therapists in private practice may want to consider the researchers’ comments about beaming faces:

“Recent research suggests the ‘full-smile’ of a happy/joyful face can actually be aversive, and processed as a threat by some individuals. Schultheiss and colleagues (2005, 2007) suggest that this is because some types of smile – especially broad smiles – communicate social dominance; hence, smiles can be aversive.”

Psychology Today‘s “Find a Therapist” site is a parade of clinicians grinning like lottery winners. Our photos may draw more clients if our expressions say, “Compassionate, gently-concerned clinician,” more, and “The cat who ate the canary,” less.


McEwan K, Gilbert P, Dandeneau S, Lipka S, Maratos F, et al. (2014) Facial Expressions Depicting Compassionate and Critical Emotions: The Development and Validation of a New Emotional Face Stimulus Set. PLoS ONE 9(2): e88783. doi:10.1371/journal.pone.0088783

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Wim Wenders on Psychotherapy

An opposing view from the director of Wings of Desire and Pina:

"My advice is don't spend your money on therapy. Spend it in a record store." Wim Wenders




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New Warning Signs of Suicide

Doctors worry they might kill their patients. Therapists have to worry their clients will kill themselves. Lethality assessment shouldn’t be a nerve-wracking process of guesswork and intuition, but clients can’t always think clearly enough in crisis to give us straightforward answers. Three recent studies identify newly-substantiated risk factors for us to consider.

Trauma and suicide are clearly linked. In a 2009 article [i] for the Journal of Traumatic Stress, Jakupcak, Cook, et al found that veterans who meet criteria for post-traumatic stress disorder are four times more likely to consider suicide than those who don’t. Researchers at the University of Manitoba [ii] have identified key post-traumatic symptoms that indicate higher risk. After talking to 2,322 subjects and controlling for other mental health issues, they found that physical reactions to reminders of the trauma, being unable to recall some part of the trauma, and having a sense of foreshortened future were all strongly associated with suicide attempts. If you felt wrenched with every reminder of something you couldn’t remember properly, how long could you tolerate a persistent sense of doom?

Client’s families can also give clues to the risk of suicide.  Anju Mathew and Anil Prabhakaran of the Government Medical College, Thiruvanathapuram, Kerala, India, tracked “expressed emotion,” a measure of how much criticism, hostility, or emotional over-involvement family members show. Per their findings [iii], the more clients felt criticized after a suicide attempt, the more likely they were to try it again. We wish all of our clients returned from the hospital to supportive, understanding families. Unfortunately, it’s too rare that people with such serious issues have families that respond in a caring, validating way.  Prabhakaran and Mathew suggest therapists involve the family members in sessions after a suicide attempt. They suggest families will be less critical if they have the chance to work through their thoughts and feelings, and better understand their loved one’s needs. At the very least, we should ask such clients, “How did your family take this?”

If you’ve ever told clients, “Everyone thinks about suicide now and then,” stop.  A 1999 review of nine western countries [iv] found the highest percentage that had considered suicide at some point during their lives was only 18.51%.  (This was in New Zealand – apparently a hobbit-ridden archipelago of despair.) Ideation is highly correlated with attempts. Simon, Rutter, et al [v] reviewed Patient Health Questionnaire (PHQ-9) Depression Screens  completed between 2007 and 2011 by 84,418 primary-care patients; 704 of whom would attempt suicide and forty-six of whom would die from it. The PHQ-9 asks, “Over the past two weeks, how often have you been bothered by the following problems?” Those who reported, “Thoughts that you would be better off dead, or of hurting yourself,” had bothered them nearly every day were ten times more likely to attempt suicide over the next year than those who answered, “Not at all.” They were ten times more likely to succeed. If the actual percentages are relatively small,  (from 0.4% to 4% for an attempt, and 0.03% to 0.3% for successful suicide), the factor of ten makes it worth our time to ask how often clients think about ending their lives.

Marsha Linehan’s UWRAP and UWRAMP protocols are helpful checklists to use when assessing suicidal clients. They don’t tell us which clients are more likely to reach a suicidal crisis. These studies give us three more questions to ask when considering how carefully to watch a client: “How did your family respond when you attempted suicide?” “Have you been having physical reactions to reminders something you can’t remember, but left you feeling jinxed?” and, most simply, “How often does suicide cross your mind?”

@ 2014 Jonathan Miller All Rights Reserved


[i] Jakupcak MCook JImel ZFontana ARosenheck RMcFall M. Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. J Trauma Stress. 2009 Aug;22(4):303-6. doi: 10.1002/jts.20423.

[ii] 2. Zeynep M.H. Selamana, Hayley K. Chartrandb,  James M. Boltona, Jitender Sareena, Which symptoms of post-traumatic stress disorder are associated with suicide attempts?

[iii] Mathew A, Prabhakaran, A. Perceived Expressed Emotion as a Risk Factor for Attempted Suicide – A Case Control Study International Journal of Recent Trends in Science and Technology, Volume 9, Issue 2, December 2013 pp 299-302

[iv] Weissman MM, Bland RC, Canino GJ, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubio-Stipec M, Wells JE, Wickramaratne PJ, Wittchen HU, Yeh EK. Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, Volume: 29  Issue: 1  Pages: 9-17, DOI: 10.1017/S0033291798007867

 [v] Simon GE, Rutter CM, Peterson D, Oliver M, Whiteside U, Operskalski B, Ludman EJ. Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death? Psychiatric Services 2013; doi: 10.1176/


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Sex Addicts and Cheerleaders on a Hot Stove Lid

(Today’s post talks about sexual addiction, whether it’s a genuine mental health issue and whether ‘addiction’ is the right word. To keep this readable, I’ve used ‘addicts’ to mean people who report trouble controlling their sexual behavior.)

Like sex? Vaughn R. Steele, Cameron Staley and others in the Southwest U.S. ran MRIs on people who really like sex (1). They tested two groups – people who reported trouble limiting the time they spent on porn, and those who reported powerful libidos, but denied it caused them any trouble.

Bartus LeventeliquorresizedSteele, et al watched how the brainwaves changed as the subjects looked at various pictures – neutral, pleasant, unpleasant and pornographic images. For their study, the researchers focused on the P300 – a section of the brain wave that swells when we evaluate something. Mention alcohol, and it will grab an alcoholic’s attention – you can tell by the way their P300 increases in amplitude. When the porn addicts viewed sexy images, their P300 didn’t – at least not more than for those who reported only strong sexual desire. Moreover, there didn’t seem to be any pattern of greater or lesser P300 amplitude in those who reported greater or lesser degrees of compulsive sexual behavior.

This means sex addiction isn’t a legitimate problem, right? Maybe.  The debate has gone on long enough to be discussed on Cartoon Network (NSFW).  The most common points of view can be condensed like so:

If it Walks Like a Duck and Quacks Like a Duck…:

Thesis: Of course it’s an addiction. Around the world, thousands of people report they used sex to cope with anxiety, continued to do so despite negative consequences, but could stick to healthy limits with addiction-model treatment and twelve-step groups.

Pros: Describes the sex addicts’ experience with a clear, compassionate metaphor

Cons:  This study, which found very non-duck-like brainwaves.

No Addictive Substance? No Addiction:

Thesis: Addiction isn’t a pattern of behavior, it’s a state of the brain. If you aren’t introducing an addictive substance to the body, then you don’t have an addiction.

Pros: Adheres to a formal biological definition of addiction

Cons: The brain produces showers of neurotransmitters like dopamine and norepinephrine during sexual arousal – and they’re substances.

There Ain’t No Such Animal #1:

Photo @ 2005 by Paddy Briggs

Photo @ 2005 by Paddy Briggs

Thesis: There’s no addiction,  just selfish, greedy people trying to excuse their irresponsibility.

Pros: Speaks to our values of self-reliance and self-control. Based on careful, clinical assessment of gossip-column items, it seems to fit celebrities well.

Cons: Doesn’t actually explain the recovering addicts who couldn’t take responsibility on their own, but did with the help of addiction-model treatment.

There Ain’t No Such Animal #2:

Thesis: There’s no addiction and really, no problem – just a bunch of self-appointed bluenoses who insist anyone who takes pleasure in what’s pleasurable must have a disease.

Pros: Reminds us not to pathologize behavior of which we disapprove.

Cons: Doesn’t actually explain the recovering addicts who report they got zero pleasure from their behavior, but couldn’t stop without support.

Steele and his fellow researchers argue their findings mean these problems might be treatable by lowering sexual desire. They’re willing to believe those who say their sexual behavior stretches out of their control, but they don’t believe it’s an addiction.

Does it have to be?

Is everything that takes athleticism a sport?

Is everything that takes athleticism a sport?

There’s those who  insist cheerleading is a sport, because it requires intense stamina, training and physical effort. That’s also true of the trapeze and ballet, and neither will be in the Olympics any time soon.  There’s a fifth common viewpoint on sex addiction; one that matches sex addicts’ subjective reports, isn’t contradicted by these findings, and elides some of the debate on phraseology:

“Behavioral Addictions” are Actually Compulsions:

Thesis: Gambling, eating, shopping and sexual behavior become compulsive when they are the main tool for coping with stress and unhappiness.  If  a behavior that pushes the pleasure button in the brain is someone’s only way to get by, that behavior will be repeated again and again, long after rewards stop coming and self-esteem crumbles.

Pros: Addicts reports they consistently engage in sexual behavior to maintain emotional and physiological stability, despite negative consequences. That’s (about) as good a definition of a compulsion as you could ask for.

Cons: Compulsions usually involve the belief the behavior will keep one safe. Sex addicts report they often break the limits they planned to hold when triggered. This makes it seem more like an impulse-control problem than a compulsion – and also matches addicts’ descriptions of their relapses.*

Mark Twain“We should be careful to get out of an experience all the wisdom that is in it — not like the cat that sits on a hot stove lid. She will never sit down on a hot lid again — and that is well; but also she will never sit down on a cold  one anymore.” -  Mark Twain

Our knowledge of the brain has grown so fast, our vocabulary hasn’t kept up. When you start with, “Can this fairly be described as addiction?” the conversation turns to an ethical debate of, “Does this word mean addicts avoid  responsibility or accept  it?” before it becomes a semiotic dispute of, “What do you mean when you say ‘real’?” As Rory C. Reid, PhD, assistant professor of psychiatry at UCLA and colleague of one of the researchers points out, the larger question isn’t, “Is this an addiction?” but “What is an addiction?”

Neurology may add so much to our knowledge that terms like ‘addiction’ and ‘compulsion’ will blow apart from within. In science, this is a good thing.  Read Psychiatric Times‘ article (2) on distinguishing impulsivity from compulsivity, and you’ll notice the authors refer to “sexual compulsion” and “compulsive shopping”, while explaining these are considered impulsivity problems.  When newer, precisely-defined, empirically-validated constructs are ready, tangled tongues won’t complicate our understanding. Until then, let’s be careful that, “This doesn’t fit the clinical definition,” isn’t mistaken for, “There ain’t no such animal.”

* Thanks to Karen E. Engbretsen PsyD, LLC who pointed out the important components of impulsivity in sex addiction.


(1) Steele, Vaughn R. ; Staley, Cameron ; Fong, Timothy & Prause, Nicole (2013). Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images. Socioaffective Neuroscience and Psychology 2013, 3: 20770 –

(2) Berlin, H., Hollander, E. (2008, July 1). Understanding the Differences Between Impulsivity and Compulsivity. Psychiatric Times

@ 2013 Jonathan Miller All Rights Reserved

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October is AD/HD Awareness Month

To celebrate 2013′s Attention-Deficit/Hyperactivity Disorder Awareness Month, AD/HD-related groups including ADDitude Magazine, the Attention Deficit Disorder Association (ADDA), and CHADD have scheduled free webinars and created a useful page of resources here.

While you’re perusing those, enjoy this distraction from the golden age of MTV:

“Tell me about your childhood.”

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RIP William Glasser / Minimalist Therapy

… one woman had been attending the clinic for three years and had spent most of that time blaming her nervousness and depression on her now-dead grandfather. Glasser told her that he would see her only if she would never again mention her grandfather. She was shocked and responded, “If I don’t talk about my grandfather, what will I talk about?”

- Frew, J., & Spiegler, M. D. (2012). Contemporary Psychotherapies For a Diverse World., pg. 298, London: Routledge.

William Glasser MD, the founder of  “Reality Therapy”, died August 23, 2013 of respiratory failure. He was eighty-eight years old.

William Glasser, around 1953.

William Glasser, around 1953.

Raised in Cleveland, OH, and initially educated as a chemical engineer, Glasser trained in conventional psychoanalysis. At his first residency, he quickly lost faith in Freud. Attributing clients’ behavior to external factors irked him. He could see their insights weren’t leading to change. He noticed his effective sessions were those focused on action in the present. He decided we weren’t motivated by conflicts or drives, but by needs: survival, freedom, power, belonging and fun. In his view, everything we do is a choice we make to obtain those essentials. Mental illness is nothing but coping through negative choices – including unhappiness. Change comes when we turn away from daydreams and unrealistic hopes, commit to a plan of making better choices and follow through.

Such anti-analytical thinking sat poorly with management. Glasser’s residency ended with the conspicuous lack of a job offer. He moved on to the Ventura School for Delinquent Girls in Ojai, CA, where the most insightful analysis had failed young offenders. His new theories, applied as part of a warm, validating relationship,  helped them change.

Glasser was working in the late 1950′s and early 1960′s, a time when great minds were thinking minimally. Artists like Frank Stella and Agnes Martin painted with the simplest of lines, shapes and colors. Composers like Phillip Glass and Steven Reich overlapped tape loops of speech to make music without musicians or instruments. The inspiration was writers like Samuel Beckett, architects such as Ludwig Mies van Der Rohe and designers like the De Stijl school.  The challenge was to create an emotional response with as little stimulus as possible. By stripping away Freudian conflicts, Pavlovian associations and Skinnerian reinforcers, Glasser created a minimalist therapy.

Reality Therapy (RT) was simple enough to help others through a paperback book. With small adjustments, it translated well to other cultures. (In China, therapists don’t ask, “Is this behavior  bringing you closer to your goal?” but, “Do your actions bring shame or honor to your parents?”) Unlike Skinner’s operant conditioning, it addressed the fact that people have innate needs. RT, which Glasser later refined into Choice Theory,  can be viewed as an ancestor to ‘activation therapies’,  like ACT and Dialectical Behavioral Therapy. Since the therapist’s job is to help the client generate better choices, it’s like an empty apartment – one that can be furnished with any therapeutic intervention that helps the client choose more wisely.

William Ira Glasser, in 2009, photo copyright 2013 by Brother Bulldog

William Ira Glasser, in 2009, photo copyright 2013 by Brother Bulldog

At times, Glasser’s reductionism went too far. To claim that all mental illness consists of poor choices is to ignore the reality of delusions and hallucinations. Telling someone with Post-Traumatic Stress Disorder to focus on the present and move forward does nothing for their nightmares and flashbacks. In 1998, Glasser wrote, “We choose everything we do, including the misery we feel.”  By then, neurology had already demonstrated that our rational mind’s personal agency is something less than 100%.

Since Glasser’s principles could be surprisingly subtle, they were also easy to misuse. When an adult tells a child with AD/HD, “You can choose to raise your hand before speaking, or you can choose to stay after school,” they’ve twisted ‘personal responsibility’ into a passive-aggressive head game – one that lets them escape the responsibility to properly assess the child’s needs.  Glasser stressed, “No blaming, no punishment,” in dealing with clients;  it’s ironic to see his  “success identity” concept corrupted into, “I chose to be successful. Others chose to be losers. Therefore, they don’t deserve any help or sympathy.”

Glasser’s reductionism was a route to an effective therapy – not the definition of everything involved. He knew no one consciously decides, “I feel like feeling depressed today.” By reframing emotions as actions, he helped agitation seem more controllable. He understood no one leaps into changes in behavior. By repeatedly returning to, “What’s your plan?” he focused the Ventura School students on small steps towards new habits. The girls there had been told their upbringing meant they were not responsible for their criminal acts. In a compassionate, understanding way, he told them that they were. Neurology, environment and abuse all played a role in his clients’ problems.  Glasser succeeded in helping them change, because he ignored everything except what a reform-school kid could control.

Minimalist art sometimes created a minimal impression. Glasser’s therapy provided clients with a more-than-minimal level of control.

@ 2013 Jonathan Miller All Rights Reserved

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