Stress Management Blogging #5

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Invalidation at the Multiplex

... and invalidation won't actually toughen up your kid.

… and invalidation won’t actually toughen up your kid.

This week, I spotted ads for the upcoming After Earth at the local movie theater. Between the tensed faces of Will and Jaden Smith, the poster blurbs, “Danger is Real. Fear is a Choice.

Oh, Hollywood. So much sex. So much violence. So little psychological accuracy. Any $275-per-hour L.A. psychologist could have told you: emotions aren’t a rational choice, any more than logic is an emotional impulse. To tell people otherwise is invalidating.

Invalidation happens any time clients get the message their emotions or beliefs are flawed, wrong or unimportant. It is more than just negativity: “You failed the test,” states a fact. “Don’t tell me you studied when you bring home an F,” invalidates all of the student’s effort.

Everyone can handle a little. What kid has never heard, “You can’t be hungry, you just ate”? Repeated invalidation leaves people in doubt about their emotions and themselves. It’s associated with poor social skills in childrenself-harm in teen-agers, psychological distress in adulthood and worsened rheumatoid arthritis in sufferers of all ages.  In cognitive-behavioral therapy, it takes a delicate touch to challenge clients’ beliefs without invalidating them as people. When people hear enough repetitions of, “You put the pressure on yourself,” “Let’s hold a pity party,” or “Stop being so dramatic,” they’ll start invalidating themselves.

New, hesitant clients often say, “Maybe I should just get over it.”  They’ve absorbed the idea they can fix their emotional issues by choosing not to have them. The trouble is, emotions are like pets and children. We’re each responsible for our own, but we control them indirectly at best.  If you start by believing anxiety means you are weak and self-indulgent, you can wind up certain you are a failure when it doesn’t go away.

C’mon, Tinseltown! How about a tag line like,

“Danger is real.

Fear is a normal, healthy emotion everyone experiences.

You can manage it effectively with  mindful acceptance and self-validation.”

That would be much more accurate, and only cut ticket sales by half.

n.b.: . Steve Hein, of EQI.org has a .pdf on invalidation for parents of teen-agers here. Worth a read.

@ 2013 Jonathan Miller All Rights Reserved

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Hearts, Darkness and Chinua Achebe

The Nigerian novelist, Chinua Achebe,  died last week. Besides being, “one of the greatest writers of the 20th century,”  he was also a publisher, professor, deputy vice-president of a Nigerian political party and a stalwart champion for third-world writers. I studied under Achebe in undergrad.  In one class, he taught something invaluable for therapy practice.

Chinua_Achebe_- resized

RIP Chinua Achebe: November 16, 1930 – March 21, 2013

This day, we asked Professor Achebe about his famous critique of Joseph Conrad’s Heart of Darkness. First, we took deep breaths. The professor always spoke with quiet, measured dignity; so much so, it took courage once to tell him he was teaching next week’s book. Pulses calmed, we asked: was it fair to call Conrad’s masterwork racist? Didn’t  Kurtz’s character show it was Europeans who disgusted the author?

Gently, he explained we had missed his point entirely.

heartofdarknessAchebe told us about childhood in a Nigeria that was part of the British empire; where his schoolbooks taught the story of, “we Britons,” and the few Africans in storybooks were savages.  To him, it wasn’t the spears or loincloths that made these fictional natives sub-human.  He himself wrote a book in which tribesmen kill and eat a man, chatting casually over their meal. His point was speech. The only natives who speak aloud in Heart of Darkness, he said, are those under the ‘civilizing influence’ Conrad viewed with irony and despair.  The professor, a master of many languages, opined Conrad dehumanizes his natives because he limits them to animalistic shrieks and war whoops. At least Achebe let his cannibals talk.

In our first counseling class, we’re taught we should speak 30% of the time and listen 70%.  In session, we fight the urge to interrupt our clients and tell them how to fix their problems. A psychology professor told me in his years as a therapist, the lesson he’d re-learned the most was, “Shut up and listen.” Professor Achebe would have appreciated his effort. Clients often come to us because no one else will hear. Letting people talk can give back their humanity.

@ 2013 Jonathan Miller All Rights Reserved

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Mindfulness vs. PTSD

The Washington Post reported this week on new studies addressing Post-Traumatic Stress Disorder with mindfulness. Research has already found regular practice may help those with PTSD recover faster. New findings suggest it may do even more.

Elizabeth A. Stanley, PhD, of Georgetown University

Elizabeth A. Stanley, PhD, of Georgetown University

Elizabeth A. Stanley, Ph.D is professor of security studies at Georgetown University. She’s not a psychologist, but she ‘s among those who’ve found regular mindfulness practice significantly eased their post-traumatic symptoms.  Per the Post’s article, Stanley’s new study tracked 320 marines through simulated combat training. The results showed those schooled in mindfulness weren’t just calmer during the exercises, they also responded faster to new threats.

This is crucial, says Tom Minor, a University of California at San Diego neuroscientist who was one of the researchers. “That was one thing we worried about: ‘Are we going to take a bunch of Marines and turn them into chanting monks who couldn’t generate a stress response?’ But they didn’t get too relaxed.”

“Too relaxed,” is a fear for many traumatized people. With a constant perception of danger, it can be unnerving to think one might be lackadaisical about threats. Clinical evidence that mindfulness reduces response time can be a major selling point to the hypervigilant.

Opens with the titular Vietnam vet practicing mindfulness in a Buddhist monastery. Discuss.

In the “Baba Rum Raisin” days of the late 1960s and early 1970s, meditation was peddled as a cure for everything. Skepticism bordered on cynicism. This article cites peer-reviewed, clinically-validated studies such as  Thomas F. Minor‘s research, which indicates meditation boosts the hormones that repair stress-related damage and decreases the chemicals that cause it. It also mentions Martin M. Paulus’ work that shows mindfulness boosts activity in areas of the brain devoted to awareness and control of emotions.  The sample sizes are too small and the results need to be reproduced a few more times,  but the findings on mindfulness and PTSD have started to verge on Maharishi-esque territory.

Of all the goodies in the Post article, the most tantalizing (and least empirically-supported) is the suggestion that mindfulness practice may reduce the risk of developing post-traumatic symptoms:

(Marine medic Del) Cochran says he believes meditation helped him stay much calmer during his second tour in Iraq. “The first tour, I was freaked out all the time,” he says. “There was so much static. With meditation, you’re much more in tune — what is a target, what is not a target. You are much more focused on what you are doing.”

Meta-analyses of studies of traumatized children shows pre-existing anxiety may increase one’s vulnerability to PTSD. Who wants to fund a study comparing PTSD rates among veterans from countries with a cultural tradition of mindfulness practice and those without?

Citations:

Kohn, David (2013, February 18) Mindfulness and meditation training could ease PTSD symptoms, researchers say. The Washington Post. Retrieved on February 22, 2013.

Examining the protective effects of mindfulness training on working memory capacity and affective experience. By Jha, Amishi P.; Stanley, Elizabeth A.; Kiyonaga, Anastasia; Wong, Ling; Gelfand, Lois
Emotion, Vol 10(1), Feb 2010, 54-64.
 

@ 2013 Jonathan Miller All Rights Reserved

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Grief: Stages, Waves and Tasks

Clare Bidwell Smith has written a worthy essay on grief and anxiety, one that challenges Elizabeth Kübler-Ross‘s ‘bargaining’ stage:

Many of my clients immediately begin to assess their current state in terms of where they are with denial, anger, bargaining, depression, and acceptance. But while the stages were meant to be helpful, this is often where people begin to get confused. I don’t think I’m following the stages correctly, they’ll admit in a worried tone.

I don’t understand the bargaining part. I’ve been depressed for too long. I skipped the anger stage—is that okay? I don’t know where my anxiety fits in. These are the kinds of things I hear over and over again. In fact, I’ve heard them so often that I’ve now come to believe that when the five stages are applied to grief, bargaining should be replaced with anxiety.

Contemplating © 2013 by Anders Engelbøl

Not every mourner gets a soothing vista to grieve by.

Smith deserves kudos for drawing attention to anxiety’s role in grief. The loss of a loved one is a hole in our safety net. It reminds us of our own mortality. How does one not feel anxious about that? Her suggestion we make anxiety a stage of grief, on the other hand, propagates long-standing problems with the model.

For all of its cultural dominance, Kübler-Ross’s magnum opus has taken heavy fire. Bonnano, Wortman, et al (1)  found grief might take five different paths, including one of resilient recovery.  Maciejewski, Zhang et al (2) found symptoms of grief such as yearning, anger and depression rose and fell along overlapping curves, while acceptance rose along a steady upward slope.  Kübler-Ross herself freely admitted not everyone will experience each stage, the stages may not come in order, and that stages might recur once they’ve faded.  So, why describe grief in such terms?

A figure from Maciejewski and Zhang's research. While each psychological response peaks about a month apart, they all begin within three weeks of the loss and remain present throughout the process.

A figure from Maciejewski and Zhang’s research. While the first four ‘stages’ peak about a month apart, all begin within three weeks of the loss and continue nearly to the end. (see complete figure at the link)

James William Worden’s ‘task’ model drops the view of grief as a commuter ride on the Dysphoria Local.  Worden, professor at Biola University’s Rosemead School of Psychology, frames mourning as a set of chores:

  1. Accept the reality of the loss. Completely.
  2. Work through all of the emotions tied to the loss. All of them.
  3. Make all the adjustments needed to function without that person – inside and out.
  4. Find a way to maintain a link to the loved one, while you move on with your life.

Each task can be worked on a bit at a time. They don’t need to be completed in order. Anxiety, yearning, anger, depression? Each fits each task. No one needs to wonder why they still feel angry after being depressed for so long.  Worden’s model empowers our clients, because it makes grief a mission to complete, not a storm to be weathered.

The flaw in Smith’s plan to substitute ‘anxiety’ for ‘bargaining’ is the same that undermines Kübler-Ross’ model.  Symptoms like anger and anxiety rise and fall, but they don’t come in stages. They pervade the process. Let’s reassure our clients the loss of a loved one can be terrifying. Let’s not shoehorn that anxiety into an misfired concept like ‘stage’.

Citations:

1: Resilience to loss and chronic grief: A prospective study from preloss to 18-months postloss. Bonanno, George A.; Wortman, Camille B.; Lehman, Darrin R.; Tweed, Roger G.; Haring, Michelle; Sonnega, John; Carr, Deborah; Nesse, Randolph M. Journal of Personality and Social Psychology, Vol 83(5), Nov 2002, 1150-1164. doi: 10.1037/0022-3514.83.5.1150

2: Maciejewski PK, Zhang B, Block SD, Prigerson HG. An Empirical Examination of the Stage Theory of Grief. JAMA. 2007;297(7):716-723. doi:10.1001/jama.297.7.716.

@ 2013 Jonathan Miller All Rights Reserved

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Diluted DBT Still Effective for Bipolar Disorder

University of Washington psychologist Marsha Linehan has a strict definition of her ground-breaking Dialectical Behavioral Therapy (DBT). If a client doesn’t …

  • attend a DBT skills group and …
  • receive individual therapy from a DBT-trained therapist …
  • who attends a weekly DBT consultation group and …
  • offers phone coaching,

… they aren’t really in DBT. The full program is what she researched; she won’t vouch for anything less.  A new study by Van Dijk, Jeffrey and Katz of the Southlake Regional Health Centre in Ontario, Canada suggests even a cherry-picked form of ‘adherent’ DBT may still help those with Bipolar Disorder.

T-shirts like this are why I love the internet

T-shirts like this are why I love the internet

The researchers enrolled twenty-six adults with Bipolar I or II Disorder in a psychoeducational group. The clients learned about their diagnosis, but were also trained in mindfulness practice and DBT’s emotional-regulation, interpersonal-effectiveness and distress-tolerance skills. After twelve weeks of ninety-minute group sessions, the clients scored higher on Beck Depression Inventory, reported greater awareness of their emotional states and less fear of the same. Six months later, they also had fewer emergency-room visits and hospitalizations. These findings echo other studies that found DBT skills group training – by itself – can be effective for depressive symptoms.

It’s tempting and dangerous to conclude DBT can be treated like a toolbox, instead of a unified whole.  Tempting, because DBT is a comprehensive therapy for challenging clients. That makes it dauntingly complex. Becoming fully versed is like learning another language. With all of its’ useful techniques, attitudes and approaches, it’s almost too simple to cherry-pick a few and call it DBT.

It’s dangerous because Linehan’s therapy depends so much on movement, speed and flow – rapidly shifting around all of those techniques, attitudes and approaches to meet a client’s needs.  Practitioners’ mailing lists often feature tales of clients firmly uninterested in DBT because of their previous experience – with non-adherent therapists whose treatment had some of the features, but none of the integrity of Linehan’s.

Carl Rogers’ use of reflective listening and Alfred Adler’s focus on the here-and-now were subsumed into the basic practice of therapy. Linehan’s DBT skills could be mindlessly assimilated the same way. Let’s have more research on how much and how little can be dropped before you no longer have an effective therapy.

Citation:

Sheri Van Dijk, Janet Jeffrey, Mark R. Katz. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Journal of Affective Disorders 5 March 2013 (volume 145 issue 3 Pages 386-393 DOI: 10.1016/j.jad.2012.05.054)

@ 2013 Jonathan Miller All Rights Reserved

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Russell Barkley: AD/HD is No Gift

Russell Barkley, PhD  is professor at the Medical University of South Carolina, and author of more than 200 scientific articles and book chapters on Attention-Deficit/Hyperactivity Disorder. Here, he has a few words for the overzealous:

… Many people may be gifted and talented in various aspects of these other human abilities, but never attribute that giftedness or that success to the AD/HD itself … I want people to understand that while people might be gifted and talented and successful in spite of their AD/HD, it is not because of their AD/HD. The AD/HD itself may, in fact, make you less effective than other people who have equally talented areas in those human abilities.

He’s addressing the Center for AD/HD Awareness, Canada, but he aims fire at all who suggest the disorder brings talents and blessings.

Some writers propose innate distractibility is just the thing for a multi-tasking world.  Sadly, it’s not enough to shift attention rapidly among tasks. You also have to return to those tasks to finish them; difficulty doing so is criterion 1D for the disorder. Lara Honos-Webb, PhD has written several books suggesting AD/HD may bring such vague, unverified capacities as, “attunement to nature,”  and “emotional sensitivity.”  In The Gift of Adult AD/HD, she asks, “Are mistakes and sloppiness anything less than perceiving the world in a way that opens up possibilities?” The answer is yes – much less.  Creativity can involve serendipity. Mistakes and sloppiness are failures to perceive you’ve forgotten to unplug the iron or to add the most important ingredient to a dish. Her books provide helpful coping techniques, but they fall flat when they claim AD/HD is a boon. Consider its’ co-morbidity with  depressive and anxiety disorders and it  appears much more of a curse.

Funny t-shirt. See if you can find the gift in this flow of thought.

Funny t-shirt. See if you can find the gift in this flow of thought.

Barkley’s criticism isn’t aimed at optimists, but those who leave the facts behind. This blogger writes of how he loves (!) his AD/HD. Not because there is anything to love about it, but because nothing is worse than negative thinking.  Barbara Ehrenreich would disagree. In her 2009 book Bright-Sided, she uses America’s vulnerability to the Sept. 11th attacks to show how positive thinking can have drastically negative consequences:

There had already been a terrorist attack on the World Trade Center in 1993; there were ample warnings, in the summer of 2001, about a possible attack by airplane, and flight schools reported suspicious students like the one who wanted to learn how to “fly a plane but didn’t care about landing and takeoff.” The fact that no one — the FBI, the INS, (President George W.) Bush, or (national security advisor Condoleeza) Rice — heeded these disturbing cues was later attributed to a “failure of imagination.” But actually there was plenty of imagination at work — imagining an invulnerable nation and an ever-booming economy — there was simply no ability or inclination to imagine the worst.

Positive thinking encourages people to feel good about themselves, but as Ehrenreich points out, it inevitably carries  harsh, invalidating personal judgments. Are you feeling depressed, angry or uncertain because neurology makes you look like a screw-up? Drop the ‘victim mentality’, ya whiner!

‘Positive’ is nice. ‘Realistic’ is far more important. As Dr. Barkley said to patient advocates at the conference:

It’s going to be very hard for society to take you all seriously if you continue to trumpet this disorder as a gift. There is no way that we can go to Ottawa and walk the halls of Parliament arguing for accommodations, entitlements, funding of AD/HD medications on the one hand, while rah-rah cheering AD/HD as this wonderful giftedness that we have and you don’t.

What’s worse than negative thinking? Falsely boosting people’s self-esteem with unsubstantiated claims that skew public understanding of the disorder. There’s a real danger that attitudes on AD/HD could go from, “There’s no such thing,” directly to, “Why should we make accommodations for your son? Doesn’t he has the gift of AD/HD?”

@ 2013 Jonathan Miller All Rights Reserved

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