Very far.
Note to clients: ethical therapists will not ask you to undress.
(thanks to V. Valenti)
@ 2012 Jonathan Miller All Rights Reserved
Sleep Apnea: Depression’s subtle sidekick.
A client presents with irritability, drowsiness, lack of energy, and hypersomnia. You’d suspect depression, possibly Bipolar Disorder, and you’d likely be correct. It might also be something more.
Just over a year ago, Texas governor Rick Perry was hailed as the Republican party’s best choice to win the White House in 2012. Poor debate performances sank his candidacy, most notably when he couldn’t remember a third government department he planned to eliminate. In his new book “Oops“, Texas Tribune correspondent Jay Root claims Perry’s lapses were due to a sleep disorder:
“…by early October, days after the Florida fiasco, (Perry) had urgently consulted sleep specialists. After conducting overnight tests on Perry, they produced a rather startling diagnosis: He had sleep apnea, and it had gone undetected for years, probably decades.”
Rick Perry’s doctors: “Oops.”
Sleep apnea causes sleepers to stop breathing. These pauses can last several minutes and occur thirty times or more per hour. Unknowingly, sufferers’ wake dozens of times per night. This sleep disruption can slip past diagnosticians because it shares so many symptoms with depression. When a client presents with fatigue, forgetfulness and lack of motivation, a family doctor might refer them to counseling instead of a sleep study. The assessing therapist might ask the person if they ever wake up gasping for air. More likely, they’ll focus on all of the mental health questions we have to squeeze into an assessment session.
Along with serious physical risks, sleep apnea can cause depression and memory troubles, via sleep deprivation.With depressed clients who report fatigue, but no trouble sleeping, it’s smart to ask about the following:
- Morning headaches
- Memory or learning problems and not being able to concentrate
- Waking up frequently to urinate
- Dry mouth or sore throat when you wake up
- Snoring
- Reports from bedmates that you stop breathing in the night.
Two years ago, I started to encourage clients to report such symptoms to their family doctors. An impressive percentage have returned with a positive diagnosis for sleep apnea. So far, each who pursued treatment have reported improved mood and energy. Each was genuinely depressed; disrupted sleep made each’s depression significantly worse. With sleep apnea, sleep deprivation can hamper therapy even when a client believes they sleep all too well.
@ 2012 Jonathan Miller All Rights Reserved
Filed under depression, Diagnosis
Graham Greene on Antisocial Personality Disorder
In the postwar classic The Third Man, novelist Graham Greene’s protagonist, Holly Martins, confronts racketeer Harry Lime about his black-market sales of worthless, diluted penicillin. Atop a ferris wheel, he asks his old friend, “Have you ever seen any of your victims?” Lime’s response is telling:
Orson Welles as Harry Lime in The Third Man (1949)
“Victims? Don’t be melodramatic. Look down there. Tell me. Would you really feel any pity if one of those dots stopped moving forever? If I offered you twenty thousand pounds for every dot that stopped, would you really, old man, tell me to keep my money, or would you calculate how many dots you could afford to spare?
…Nobody thinks in terms of human beings. Governments don’t. Why should we? They talk about the people and the proletariat, I talk about the suckers and the mugs – it’s the same thing. They have their five-year plans, so have I …
… in Italy for 30 years under the Borgias they had warfare, terror, murder, and bloodshed, but they produced Michelangelo, Leonardo da Vinci, and the Renaissance. In Switzerland, they had brotherly love. They had 500 years of democracy and peace, and what did that produce? The cuckoo clock.”
(Rabid cinéastes will point out Orson Welles added the lines about Italy and Switzerland himself.)
@ 2012 Jonathan Miller All Rights Reserved
Filed under The Client's Side
Trauma, Addiction and Ouroboros
Therapists are often reluctant to see clients who just kicked their addiction. We know therapy can be wrenchingly difficult. We worry we’ll trigger a relapse if we see someone before they’re firmly grounded in sobriety. Maybe we shouldn’t.
A new study from University of South Wales researcher Katherine L Mills and her team tested their program, COPE: Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure. As the name makes clear, COPE combines addiction treatment with prolonged exposure therapy for post-traumatic stress disorder. Most would fear the grueling exposure process would cause the clients to relapse. It didn’t. After nine months, the COPE group and an addiction-treatment-only control group both saw the same decline in substance dependence. Among those who were still addicted, both groups’ members saw their addiction grow less intense by roughly the same amount. The only statistically significant difference between groups? Those in the COPE group had significantly lower rates of post-traumatic symptoms.
Ouroboros, in a medieval engraving.
Critics have rapped the study for comparatively small effect-sizes. One would suggest they’ve missed the point. Dually-diagnosed clients can feel like Ouroboros – the mythical serpent forever swallowing its’ own tail. Alcohol and other drugs might be their only way to cope with emotional problems, even while their addiction makes those problems worse. Emotional pain and the struggles of recovery may be the right choice, but it’s a hard choice when the option is to get wasted one more time. In this study, even those clients who weren’t fully abstinent saw their PTSD symptoms dwindle.
Ouroboros, as experienced by many dually-diagnosed clients.
The authors are clear that a client can’t get blotto every day and still get somewhere in therapy. They do say:
“These findings challenge the widely held view that patients need to be abstinent before any trauma work, let alone prolonged exposure therapy, is commenced. Although we agree that patients need to show some improvement in their substance use and an ability to use alternative coping strategies before prolonged exposure therapy is initiated, findings from the present study demonstrate that abstinence is not required.”
The fact these clients improved without firmly-established sobriety, some without even being fully abstinent, is more significant than the extent to which they recovered. More studies on therapy with the recently-sober, please.
Citation:
Mills KL, Teesson M, Back SE, Brady KT, Baker AL, Hopwood S, Sannibale C, Barrett EL, Merz S, Rosenfeld J, Ewer PL Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: a randomized controlled trial. [Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov’t] JAMA 2012 Aug 15; 308(7):690-9.
@ 2012 Jonathan Miller All Rights Reserved
Filed under Post-Traumatic Stress Disorder
Where Borderlines Excel
If you’ve worked with clients who have borderline personality disorder (BPD), you’ve probably had a conversation like this:
Therapist: How did that make you feel?
Client: I dunno.
Therapist: How do you think that might have made someone else feel?
Client: I dunno.
Therapist: Take a look at that list of feeling words and see if there’s anything that fits.
Client: Oh God. I can’t face that list today.
Therapist: Well… hm.
Client: You’re getting worried. You’re thinking about referring me, aren’t you?
Can people really be so oblivious to their emotions when they’re so well-attuned to yours?
Carina Frick, Simone Lang, et al answer at least half of that question in their new study. They asked clients with BPD to receive an MRI while guessing the emotions others displayed in photographs. The BPD clients out-guessed the control group of healthy subjects. The fMRIs showed they actually used different parts of the brain. They were so skilled at identifying what others feel that the mentalization term ‘mind-reading’ seems eerily appropriate.
The researchers suggest this serves as empirical evidence for Alan Krohn’s 1974 paradoxical theory. Krohn noted people with these issues usually grew up with unpredictable parents and inconsistent rules; what Marsha Linehan would later dub the invalidating environment. The clients he studied had to hide their feelings and read their guardian’s mood quickly to avoid punishment. Clients with BPD are often alert to your emotions and blind to their own, because that kept them safe through childhood.
Neurologists will be titillated by the differences in the brain activity. The fMRIs showed BPD clients’ amygdala, medial frontal gyrus, left temporal pole and the middle temporal gyrus were more active when guessing others’ emotions. The members of the control group lit up in the insula and the superior temporal gyri. Therapists will be excited that even very low-functioning clients with these issues have a common strength to build on. Two possibilities:
- Clients with BPD often feel hopeless about their abilities. We can validate and encourage them by reminding them of this skill, and how useful it is in the work world.
- When clients talk about times where it was obvious what someone else felt, I’m going to ask just what they saw. What posture did that person take? How did their face look? What tone was in their voice? What happens in the client’s throat and mouth when they reproduce that tone?
Here’s to the hope these ‘mind-reading’ abilities can be reverse-engineered towards greater self-awareness.
n.b.: If you’d like to test yourself on ‘mind-reading’, Simon Baron-Cohen‘s “Reading the Mind in the Eyes” test is available here.
Citation:
Frick C, Lang S, Kotchoubey B, Sieswerda S, Dinu-Biringer R, et al. (2012) Hypersensitivity in Borderline Personality Disorder during Mindreading. PLoS ONE 7(8) e41650. doi:10.1371/journal.pone.0041650
@ 2012 Jonathan Miller All Rights Reserved
Filed under Borderline Personality Disorder
“It’s All in Your Head”
LicensedMentalHealthCounselor has a thoughtful post on parents’ denial of their children’s mental health problems. It reminded me of a pet peeve: family members who ask clients, “What wrong with you?” then dismiss the answer with, “That’s all in your head.”
What does “It’s all in your head” mean? “You’re incorrect”? “You’re making excuses”? “You’re lying”? It might mean, “Please don’t talk about this.” Talk about mental health problems can trigger others many ways. For example,
1. Not everyone with problems is in treatment. If a client admits they are vulnerable to emotion, others remember they’re vulnerable, too.
2. “I can’t,” isn’t in our vocabulary. Our culture values hard work, personal responsibility and triumph over adversity. Only the most severe mental health issues are visible to others. Most skeptics have long experience with The Jitters and The Blahs. They can have a hard time understanding what separates those from Panic Disorder or Major Depressive Disorder.
3. As a culture, we don’t talk about emotional problems. If we talk about them at all, we do so in an understated, hesitating way. When someone explains they have mental health issues, the other person is left to guess how much understatement just occurred. Does, “My nerves make it hard to go outside,” mean they have a moderate case of agoraphobia? Or does it mean the entire family will be murdered in their sleep? Much easier to sweep the entire topic aside by saying, “That’s all in your head.”
In fairness, “It’s all in your head,” often means, “You can do it.” It can come from the same well-meaning and wholly-useless intentions as, “Don’t worry about it,” “Relax,” and, “Just cheer up.” It can also channel condemnation those other tips don’t. Clients say this disregard is worse than insensitive – it’s invalidating. Even when their family hopes they’ll feel empowered, the client is often to wonder, “Do I actually have problems, or am I just a lazy coward?”
Different clients have handled dismissive relatives differently. Shrill didactic lectures haven’t always been the answer. When a pithy conversation-ender seems appropriate, I’ve suggested, “Sure it’s all in my head. And your diabetes is all in your pancreas.”
@ 2012 Jonathan Miller All Rights Reserved
Filed under The Client's Side
New love, limits for behaviorism
Gregory A. Fabiano and Rebecca Vujnovic posted interesting results in improving special-education classroom behavior in children diagnosed with AD/HD and ODD. Teachers rated the kids’ behavior on daily report cards tailored to each child, based on their individualized educational plan.These cards went home to the parents, who were asked to reinforce good reports with privileges. End results? These rapid feedback-and-reinforcement loops moved the kids up their percentile ranks by an average of 14%.
Daily report cards have been used since the late 1990s, and this particular study dates to 2010. If it’s not new, it’s still exciting, because of what it says about behaviorism.
On task longer, but is she learning more?
People forget how much operant conditioning was once feared. As this story from The Atlantic tells, the excitable claimed B.F. Skinner was an Orwellian fascist pushing Clockwork Orange-style mind control. In my mid-1990s grad school program, the professors snubbed behaviorism as a three-legged dog of a modality; respectable, certainly not useless, but limited. We got the message it was the playground of cranks – real therapists did CBT. Today, operant conditioning is the central axis in integrative therapies such as Dialectical Behavioral Therapy and Acceptance & Commitment Therapy. A short tour of the Apple store will show it’s the algorithm behind a hundred apps for weight loss, reducing wasteful spending, and the like.
New theories tend to be viewed as cure-alls, and behaviorism is receiving the buzz of a rousingly new idea. Given parent’s reluctance to medicate children with AD/HD, there’s considerable push for behavioral interventions in place of meds. Fabiano, et al’s findings hint where behaviorism’s limits may lie.
Despite the improvements in the children’s behavior (including the rate at which they completed homework), their grades stayed largely the same. Early behaviorists like John B. Watson defined behavior solely in terms of what an organism does that can be observed. B.F. Skinner expanded that definition to include thoughts and feelings – anything an organism does. Given that the kids’ behavior improved but grades didn’t, “anything” may not include neurological processes, such as absorbing, retaining and recovering information.
Follow-up please – does ‘staying on task longer’ correlate to ‘paying attention more’, or just ‘elongated staring at the paper’?
citations:
Fabiano, G.A., Vujnovic, R., Pelham, W.E., Waschbusch, D.A., Massetti, G.M., Yu, J., Pariseau, M.E., Naylor, J., Robins, M.L., Carnefix, T., Greiner, A.R., Volker, M. (2010). Enhancing the effectiveness of special education programming for children with ADHD using a daily report card. School Psychology Review, 39,219-239.
@ 2012 Jonathan Miller All Rights Reserved
Filed under AD/HD, Behaviorism
CBT by phone: Shorter-lasting effects for more.
There’s one kind of client no therapist can help – the one that doesn’t come in. David C. Mohr, Ph.D, of the of the Northwestern University Feinberg School of Medicine, Chicago, IL, has a new study that suggests they may not have to.
Alexander Graham Bell, inventor of the telephone.
In 2008, Mohr found clients will stick with therapy conducted over the phone longer than with therapy provided face-to-face. His latest study found that cognitive-behavioral therapy (CBT) for depression delivered over the phone was just as effective as the same therapy delivered face to face. Six months after treatment, all the clients were still improved.
There was one catch: the clients who met their therapists face-to-face were doing better at the follow-up than those who telephoned. 32% of those who came to their therapist’s office were depression-free compared to 19% of those who phoned. Click the mp3 link on this page, and around the four-minute mark, you’ll hear Dr. Mohr describe the face-to-face clients as, “slightly better off.” This is an unnecessary understatement, considering the increased numbers who finished therapy. Estimates of the drop-out rate in face-to-face therapy have ranged as high at 60%. Researchers have developed simplified feedback forms, helping some therapists reduce their attrition to around 18%. Mohr’s 2008 meta-analysis found the mean attrition rate for telephone psychotherapy was just 7.6%.
Sigmund Freud, father of modern psychology
Could coming to a therapist’s office for treatment increase the risk that a client will drop out? Consider another industry whose consumers keep their customer status private: pornography. Reliable stats are rare, but it’s believed porn consumption exploded in the early 1980s, and did so again in the 2000s. Changes in technology led the way. With the rise of the VCR, consumers could get their obscenity without visiting the seedy part of town. Once internet access spread, they didn’t even have to leave their home. There’s little reason to doubt most folks feel shame about going to a mental health center, just as they would about a grimy peepshow or massage parlor. Providing therapy by telephone would not only simplify clients’s busy lives, it would also remove low-level fears about being recognized at a therapist’s office.
Larry Flynt, pornographer. (Photo by David Livingston/Getty Images for COPE Health Solutions)
One can’t blame Mohr and Co. for trumpeting the effectiveness findings. Counseling someone you can’t see? There have been long silences where I was grateful I could see my client quietly weeping or mulling things over. But Mohr’s findings, and the number of successful blind therapists suggest visual contact’s importance may be overrated. Alexander Graham Bell invented the telephone in 1874. Sigmund Freud coined the term ‘psychoanalysis’ in 1894. In 2012, mental health therapy is still mostly conducted face-to-face in therapist’s office. If combining Freud and Bell’s inventions would help more people, with only some decrease in the length of therapy’s effect, one is forced to ask, “Why not?”
@ 2012 Jonathan Miller All Rights Reserved
Filed under Uncategorized
Making therapy offices therapeutic
An interesting photo gallery here, where therapists muse on their offices. More than just decorating tips, they explore the thought process that went into creating a therapeutic space. Author Jose Ribas MD explains:
An examination room in a North Carolina hospital or clinic probably appears quite similar to an examination room in a hospital or clinic in New York, South Dakota or Texas. Where this model departs is in Psychiatry, where the room itself plays an important role, as it becomes the physical “holding environment” where the therapist conveys to the patient that he or she is safe to explore those areas within him/herself that are threatening or causing distress.
My Tuesday-Friday office. The architects added on to the building some years ago, giving my clients and I a view of the billing area. (photo credit: Mrs. ‘Sphere)
Designing my own space, the aim was to balance professionalism and homeyness; to be colorful but not gaudy and warm without being oppressive. I realize now that all three posters show scenes from Europe. We Americans associate the continent with intelligentsia – perhaps it’s saying, “I’m smart enough to help you solve your problem.”
@ 2012 Jonathan Miller All Rights Reserved
Filed under Uncategorized
PsychotherapySphere 