Sunday, January 29, 2017

Better Friends

[Note: I wrote this post awhile back and have decided to re-publish it with some edits] Friendship is important. A lack of social supports has been linked to poor physical and mental health. Here are some tips on making, keeping and being better friends:


1. Good friends keep confidences.  This doesn't mean that friends don't ever gossip about each other. Some gossip is harmless. Two friends talking about how they don't like another friend's hairstyle or boyfriend is harmless gossip; it's just the sharing of opinions between two people. On the other hand, repetition of a secret told by one friend to another is a betrayal of confidence. Such people should not be kept as friends; but, it's important to remember that if you don't expressly say "this is not to be repeated," the other person may not know that he/she is hearing a secret. Different people have different opinions on what should be private and confidential. Don't assume your friends view secrets the same way you do.  If you want to speak in confidence with someone, you must make it clear that confidentiality is your expectation.

2. Friendship requires effort just as a romantic relationship does. Someone who expects his/her  friends to take the initiative and make the social plans is not a good friend. All relationships involve mutual obligations and responsibilities. If someone you have been considering a friend never initiates social activities with you, drop that person. She or he may be responding to your social overtures due to enjoying the attention, a symptom of narcissism. Or, the person may be a passive personality and in a crisis, these people cannot be relied on--which leads to my next point:

3. A real friend is someone who is there in a crisis. Many people are party friends or what used to be called "fair weather" friends. Unfortunately it's often difficult to know who these people are until a crisis occurs. A real friend is someone who would take you to the hospital in an emergency, and who will ask you what you need if you are sick or in a crisis.

4. A good friend takes your side in a conflict but also tells you the truth when you're wrong. A sad and not uncommon situation is when someone who's getting a divorce is abandoned by "friends." An advantage that single people have over married people is that single people never have to question whether someone socializes with them because the person likes their spouse.
 Real friends also tell friends when they are wrong. Sadly, this sometimes leads to the end of a friendship, because we are living in an age of entitlement in which many people don't believe that they are ever wrong and react with rage when the possibility is mentioned (see my previous post on Narcissistic Personality Disorder). But, there can be an upside to this:  Telling friends your honest opinion when you strongly believe the person is making a bad decision is a good way to get rid of friends with pathological narcissism. Ultimately these people don't make good friends, so it's best to get rid of them sooner rather than later. On the other hand--

5. Offering a lot of unsolicited advice is a good way to annoy your friends and may eventually lead to the loss of friendships. Although it's important to warn friends about bad decisions--as I mentioned in point #4--friends who are subjected to repeated unsolicited advice may feel condescended to or may experience the friend as "bossy." Sometimes a good way to offer "advice" is to relate a personal experience: "When I was in that type of situation what I did was..." This sounds a lot better than "You should...."  The fact you have had a similar experience lends credibility to your advice and sounds more genuine. Similarly one could say "If it were me in that situation what I would do is..."

6. Good friends aren't leeches. Borrowing money from social connections isn't as common as it once was, perhaps because today, as compared to previous generations, debt through credit cards, home equity loans etc. is more common. Today's leech is more likely to be someone who asks professional friends for extensive professional advice. As a health care professional I have been subjected from time to time to requests for feedback on extensively detailed personal problems from people who I would call social acquaintances. I don't do therapy with friends or social acquaintances, as it would be inappropriate. (On the other hand, I can give general advice on where and how to seek help). Similarly, stockbrokers and other financial professionals are often pestered in social situations for stock tips and free investing advice, and lawyers may be asked for free legal advice. The message this behavior gives is that the person is trying to leverage a social situation to get something for free that ordinarily costs significant money. A better way to benefit from friends with professional expertise is to ask them for a referral to a trusted colleague or to another type of resource. 

7. Conversation is a give-and-take. Friends who are  "good listeners" might actually be wondering when you're going to pause for breath or ask them what they think.  On the other hand, someone who never shares his/her thoughts and experiences may be viewed by others as aloof, boring, passive, or possibly hiding something.

8. Friends don't invest the same feelings into your personal accomplishments and daily triumphs as you do. A patient told me a funny story once about a friend who wanted his friends to "attend" a virtual ceremony involving his new baby. Of course many people want to go to baby showers and similar events.  because those are parties that often involve food and drink as well as socialization. That's quite a different experience from watching your friend's ceremony on your cell phone. Many people today are confused about the differences between actual socialization and exhibitionism/voyeurism accomplished via technology.

9. Good friends are on time, most of the time. Constant lateness is a sign of disrespect for other people. Even people with ADHD can learn to be on time. 

10. Good friends can both give and accept gifts, but don't judge relationships by materialism. Someone who has difficulty accepting gifts may have a cynical or even paranoid outlook on life, believing that gifts are only given to obligate the recipient to reciprocate or do something else. It's true that there are some people who give gifts for such reasons, but those people usually make themselves obvious in other ways. Someone who doesn't give gifts on occasions that demand them may be immature or self-centered. On the other hand, narcissists sometimes give very expensive or ostentatious gifts to prove their status, and some people give expensive or excessive gifts because deep down they don't believe they are loveable, and instead believe that they are only appreciated for material things.  The best people give ordinary gifts out of genuine affection without expecting anything in return, and likewise, accept gifts without seeing agendas behind them or believing that an exact reciprocation must be made.

Saturday, January 14, 2017

Winter Blues

Some people get depressed in the winter, and in the 1980s this was identified as an illness called Seasonal Affective Disorder. Today SAD isn't used as a diagnosis per se, but is described as an aspect of a mood disorder for some people. It's been theorized that reduced exposure to light in wintertime triggers depression for some people (perhaps by increasing sleep?).  But could there be other reasons  why people get depressed during wintertime?

Another possible reason for winter blues could be wintertime respiratory infections. Being sick isn't fun, and also, the body's immune response involves inflammation, and inflammation has been linked to depression (see my post "Can Vitamin D Improve Your Mood" from June 29, 2013).

Many people don't pay attention to infection control, and in a city like New York, this can be dangerous. It's important to wash your hands after taking public transportation--or, wear gloves. 

The most recent issue of Eating Well magazine suggests a few dietary tricks to reduce wintertime colds: Cinnamon has a property that inactivates viruses according to one study.  Try putting it in coffee instead of sugar, and mix it with unsweetened applesauce. The article also recommends Shiitake mushrooms, which have been found to improve immune cells (possibly because they contain selenium and other minerals and vitamins). If you don't like mushrooms, you could take supplements.  Probiotics may also be helpful, so regular yogurt is a good idea.

Perhaps another reason for wintertime blues is that people spend more time indoors during cold weather. Exposure to nature has been found to be beneficial to mental health. The Japanese sometimes practice a therapy they call "Forest Bathing"--which just means spending time in the woods (a wooded park is probably just as good). It's been found to reduce stress. This makes sense, because for millions of years before modern humans evolved, our ancestors found safety in trees. In addition, trees may give off organic compounds that promote health.

The way we live in New York City isn't  natural. Dark apartments, fluorescent lighting, overcrowded public transportation and lack of contact with nature all promote ill health. But infection control measures, good dietary habits, and perhaps taking a winter vacation to someplace like a national park in a warmer state or a Caribbean or Latin American rainforest could help.

Sunday, December 11, 2016

Forgiveness v. Moving On

Often I come across statements from members of the clergy, politicians, and ordinary people quoted in the media, linking "forgiveness" with "healing." Forgiveness isn't a concept from mental health treatment. It's a concept from religion, and in particular, from Christianity. A religious concept has utility for religious persons. For those seeking mental health, a better concept is "moving on."

The purpose of forgiveness in the monotheistic religions is to become more godly or pious.  As a psychotherapist, my goal is to help people feel and function better. No psychotherapist should suggest to a patient that he or she forgive those who have hurt them, because such a statement implies that the patient adopt the therapist's religious views. In addition, such a statement could be heard as minimizing the patient's trauma and emotions.

"Forgiveness" implies a change in attitude from the victim toward the offender, and is a statement that the victim no longer seeks retribution. "Moving on" simply means that the victim no longer obsesses or dwells on the offense and seeks to live a normal life unencumbered by emotions generated by the trauma. It is possible to move on without "forgiving" the offender. It is even possible to move on while still seeking retribution in the form of criminal justice or civil law, depending on the amount of time and energy required to pursue justice.

Obsessing over past hurts contributes to depression and PTSD symptoms. The obsession may cause the offender to loom large in the victim's mind and this can contribute to feelings of disempowerment. A saying I heard often when I was a substance abuse counselor--often from one recovering patient to another--was "You're letting him rent space in your head!" Actually this is a generous interpretation, because the perpetrator isn't paying any rent to live in the victim's head.

"Moving on" means practicing the old adage "Living well is the best revenge." Psychotherapy for trauma can involve many different techniques, but the ultimate goal should be a better life for the victim. This involves empowering the patient and helping him or her put the past in the past. Many different techniques can help traumatized persons accomplish this. They include various forms of cognitive and behavioral therapy, EMDR, insight-oriented therapy to help the person gain self-understanding and supportive therapy to help the person focus on current goals.

If it's important for you to forgive because of your religious beliefs, then by all means do so. But forgiveness is not a requirement for healing and mental health.






Friday, October 21, 2016

Rapists Old and New

NOTE: This has been edited since initially published.The accusations against Donald Trump have ignited a moment we haven't seen since 1992 when Anita Hill ripped the veil of denial from people's eyes about sexual harassment on the job.

What has been coming out all over the media and in my office are stories about rape that people never reported, perhaps because they didn't think anyone would listen, or because they just preferred not to think about it. It's always easier to pretend something unpleasant just didn't happen. But when people start hearing other people's similar stories, it's more difficult to ignore the past

I believe the dynamics of social rape have changed (I've decided to use the term social rape because "date rape" and "acquaintance rape" don't describe rape by boyfriends and friends). There were rapes on campus in the 1980s--while I was in college I heard stories about fellow students being  raped by athletes at parties. It hadn't occurred to these women that if a man they didn't know well invited them to his room for a beer, it could be a dangerous situation.  I also heard stories about people being raped by their boyfriends. What was the same in all of the stories I heard in the 1980s was that afterward, the women were traumatized and they did not wish to see or interact with these men again. But lately I've come across a phenomenon I have never seen or heard of before: A woman is raped by a man she is dating and she continues to date him. Perhaps this was the scenario of the "mattress woman" at Columbia University--who knows. I am beginning to think this scenario is far more common than  most people want to acknowledge.

Why would a woman continue to date a man who raped her? I've been hearing interesting rationalizations. These have included "I like sex so I decided it was ok" and "I wasn't sure if I felt bad about it because of my own issues about sex." There seem to be underlying beliefs that sex is fun and you're supposed to like it, and if you don't like it, it's because of your "issues." In fact this nonsense has been a common manipulation tactic of rapists throughout the decades, and also of harassers on the job, who have perennially tried to shame women as "prudes" to get them to comply.

In my era of youth sex was considered a variable experience for heterosexual women. It was considered only good if a man was "good in bed" and it was considered normal for a women to refuse sex fairly often. None of us considered an occasional lack of interest in sex to be evidence of our "issues." If sex was bad, we typically blamed our partners, not ourselves. A quick glance at the covers of women's magazines and men's magazines and popular movies shows that times have changed. Women are now mysteriously supposed to be responsible for making sex fun, when making sex fun was supposed to be the man's job and he was supposed to feel grateful that he found a woman who actually was willing to sleep with him.

In my opinion there is only one logical explanation for this strange turn of events, and that is what has often been called the pornographication or pornification of society, which covers not just the ubiquity of online porn, but also an increasing use of porn talk  in the general media and an overall degradation of women in the media that is getting worse. In porn, women are the sexual servants of men, yet in all but the worst porn they are also supposedly liking it.

Unfortunately the contemporary version of feminism--sometimes called "Third Wave" feminism--isn't tackling this issue or even discussing it. This is a far cry from the radical feminism of the 1970s and 1980s, in which the degradation of women in the media, from pornography to advertising to literary works, was frequently discussed.

Young women are living in a dishonest and dangerous time. Although laws have changed to encourage the prosecution of rapists, this doesn't help young women who blame themselves or even believe that they couldn't have been raped because it wasn't that bad; it was sex. Young men are encouraged to rape by the pornographic media they consume, but also because they know that many of the young women they are meeting have been brainwashed by a popular culture that has reduced them to sexual servants and entertainers of men. They are seeing women as their entertainers and caretakers, and as  rapeable objects who won't complain.
ADDENDUM 11/20: This post has attracted more views by far than anything else I have written for this blog. I would like to get feedback. If you have read this post please post a comment or send me a message at annerettenberg@msn.com.

Sunday, June 26, 2016

Truth v. Fads Part One: Dating Advice for Heterosexual Women

Recently I suggested to one of my patients who's having some dating issues that she read the 1990s bestseller "The Rules." I noted that although the book contains some advice that might seem superficial about makeup and other trivialities,  the basic theme is about setting boundaries and limits with people--something that many people, especially women, often have difficulty doing.  She read the book and found it useful, but told me that when she told her friends she was reading "The Rules," they were shocked because, they claim, the book is anti-feminist.

I'm a feminist. The definition of feminist in the popular imagination seems to have changed in the past 20 years, but I don't think the actual definition of feminism has changed. A feminist from 20 years ago (or 40 years ago) and a feminist today presumably agree that feminism is about equal rights under the law and a belief that men and women are intrinsically equal, that men are not superior to women.

There were arguments starting in the 1970s in favor of the interpretation that feminism implied that men didn't have to pay for women on dates and that women should feel free to ask men out on dates. However, until fairly recently I had been under the impression that those arguments never really caught on and the they were finally tossed out after "The Rules" explained how these social gestures had nothing to do with feminism. Apparently I was wrong. From what I've heard from several patients in their 20s and early 30s as well as what I've been reading in the popular media, there remains an interpretation of feminism that has less to do with equal rights and more to do with a promotion of the idea that women should adopt  male behaviors in dating, such as asking men on dates and even proposing marriage. Copying other people's behavior doesn't have much to do with equal rights. If women and men are equal, then why should women be told to act more like men? Telling women to act like men carries an implication that women are doing something wrong. This fits in with a tendency women have to blame themselves, a probable factor in the higher rates of depression among women compared to men. Many feminist philosophers have argued that society overvalues male behavior and undervalues female behavior.

Anyone who has studied biology or even just watched nature programs and documentaries from time to time is aware that most animals engage in elaborate courtship and mating rituals. In many species of birds, males must court females through helping them build nests or by putting on elaborate displays. Male deer fight each other to prove who is the dominant male who should mate. Males have been proving themselves for the right to mate for tens if not hundreds of millions of years--how could humans think that  popular fads can overrule Nature's rules? They don't. Evolution has decided that females should select males based on the male's efforts at winning over females, because this ensures survival of the fittest. Nature doesn't think that males are superior to females. Nature has simply developed a set of rules--Rules--to ensure survival of the fittest. Expecting a man to pay on the first date doesn't mean you're not a feminist woman--it means you are following a rule that has been tested and proven by Nature for a hundred million years.

Some in the popular media seem to argue that biological mating isn't relevant to contemporary dating because contemporary dating is about having fun and lots of casual sex. In reality, most women want to find a mate. The notion that what women seek is lots of casual sex with various friends, acquaintances and strangers is something that has been promoted by self-styled opinionators, many of whom are not women. These individuals may have agendas that have nothing to do with promoting health and happiness for women.

Making a man prove himself means not asking men out on romantic dates, not asking a man to marry you, and expecting that on a first date the man will offer to pay for the expenses. Because if a man can't take the initiative and responsibility to pursue the woman he wants, he isn't worth your time, and, as another book said, he might "just not be that into you." Men have a tendency to know what they want and to pursue what they want in romantic and sexual relationships. If they don't pursue, it can mean they don't want the other person that much, but are just going with the flow, because why not? It's not uncommon for a man to allow a sexual relationship to go on even if he doesn't want to marry, doesn't respect and/or doesn't even like the other person. Trust me--I've had a lot of male patients and I've been able to directly hear statements to this effect.

 Men and women aren't the same. There are biochemical/genetic/psychological differences between the genders that do not imply a difference in equality but do mean difference. Equal doesn't mean identical. Women are genetically engineered to become more emotionally invested in relationships over time (although men may develop dependency for different reasons).  Women are also more likely to be infected with STDs by their partners and are the only gender that can get pregnant. These are some of  the reasons why women should be cautious about romantic and sexual relationships and should set high standards for mates.

If you want to find the truth about any subject, don't look to what some trendy website says. Try looking at the evidence that has been proven over time, and the more time, the better. I plan to write more following this theme.

Sunday, June 19, 2016

Psychopaths Among Us

As the number of mass shootings seems to be on the increase, many have wondered what types of people commit these acts. As I noted in my June 20, 2015 post,  some of those who are racially motivated may have Delusional Disorder. I noted in my May 31, 2014 post, some may have Narcissistic Personality Disorder and/or Bipolar Disorder perhaps exacerbated by the wrong type of medication. But the diagnosis most often correlated with violent behavior is Antisocial Personality Disorder, which is better known by its earlier terms, sociopathy and psychopathy. All three terms refer to the same condition.

It used to be believed that psychopathy (I'll use that term for this blog post) was a rare condition. It isn't a rare condition. Studies referenced in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-V) indicate the rate of Antisocial Personality Disorder, or psychopathy, is somewhere between .2 and 3.3 percent of the population.

It is commonly and inaccurately believed--including by some members of my profession--that psychopaths are found mostly in the criminal justice population. I used to work with people paroled from state prison, in the 1990s, and I have seen a rate of psychopathy in my private practice that is about the same as what I saw in my job with the parolees. Most of the parolees weren't arrested for crimes committed to gain psychopathic thrills; most were arrested for selling drugs or committing burglaries or robberies in order to support heroin addiction or addiction to crack cocaine. Our prisons aren't overcrowded with psychopaths.

Psychopaths have come to my private practice for a variety of reasons including having been arrested, having committed a serious crime that did not result in arrest but resulted in interpersonal problems, and because of job problems, educational problems, addiction, and depression.

It is commonly believed that psychopathy is untreatable or barely treatable. Some therapists like to say that "the only reason psychopaths come to therapy is to learn how to be better psychopaths." Is this true?  The psychopathic persons who came to see me who were struggling with depression or early recovery from addiction definitely wanted help for those problems. I do believe that I helped them, but the underlying personality disorder remained more or less intact. The persons who came to treatment due to outside pressure were less treatable, but I do believe we were able to work on some issues when the patient was being honest with me. I only recall one psychopathic patient who I became convinced was simply making up stories, perhaps in order to get a thrill out of manipulating someone.

Psychopathy, or Anti-Social Personality Disorder, is usually characterized by difficulty following rules and social norms, deceitfulness, lack of empathy, impulsivity and aggression. It is thought to be more common among men, but I question that statistic, because half the psychopaths who have come to my private practice have been women. But perhaps female psychopaths are more likely to seek treatment.

The best treatment, as it is in many disorders, is prevention. The DSM-V notes "Adoption studies indicate that both genetic and environmental factors contribute to the risk of developing antisocial personality disorder." Past studies have correlated psychopathic behavior with childhood abuse and neglect and with inconsistent parenting (parents who disagree over rules or a parent whose discipline seems arbitrary). Ideologies that provide a rationale for violence help psychopaths commit violent acts. Societal alienation may exacerbate the characterological lack of empathy. Anyone who sees him or herself as having little to lose is more likely to commit a violent act that ends in his or her own death or arrest. This last factor indicates that depression may exacerbate psychopathic behavior, although I am unaware of any scientific research on this subject.

The DSM specifies that for antisocial personality disorder to be diagnosed, the person must have had some symptoms starting before age 15. Perhaps if we did better screening, referral and treatment of children and teens exhibiting psychopathic behaviors we would not see so many acts of mass violence. Treatment should include treatment for parents or other significant family members as well as parent training to teach appropriate discipline. In some cases, removal of the child from the home may be necessary, but because such removals are usually done long after the damage is done, and because foster and adoptive homes are also often not optimal, this may not result in prevention of violent acts.

Many factors contribute to psychopathic behavior. To prevent acts of mass violence, reasonable gun control laws should be combined with early intervention for children exhibiting serious conduct problems and lack of empathy for others.

Sunday, June 5, 2016

Obesity and Depression

Are there links between obesity and depression?

People used to think that the link between obesity and depression was that fat people were depressed because they didn't like how they looked.  Later it was theorized that some people overeat because they're depressed--although depression often makes people lose their appetite.  I believe there may be a biological link between obesity and depression: Depression has been linked to inflammation (see my June 29, 2013 post on Vitamin D and mood) and obesity can increase inflammation. Therefore, it is possible that obesity can biologically contribute to depression by increasing inflammation.

There are other negative psychological effects from obesity. It can make people give up (or never try) activities that might make them feel better, such as exercise. It can make people self-conscious, which can lead to social withdrawal. 

It's possible, although not easy, to lose weight. Unfortunately, I come across misinformation about weight loss in the media: Recently I read a news article that implied losing weight is next to impossible. It was based on the experiences of contestants in "The Biggest Loser" who gained most or all of their weight back. The reason was that their metabolism slowed to a crawl after they lost weight. I don't think "The Biggest Loser" is a model for weight loss, because the weight loss program it advocates, extreme exercise, probably isn't feasible for many people and may not even be healthy. The show also uses public humiliation as a tool, and that doesn't help people.

It is possible to lose weight and keep it off.  I've worked with several persons who lost large amounts of weight that they managed to keep off--and none went to a weight loss camp. The most important elements in weight loss may be motivation and the taking of personal responsibility (which could be undermined by reliance on a trainer). 

Several persons who came to see me had already begun or completed their weight loss program before coming to therapy--perhaps change in one area motivates change in another. Here are some of the various methods with which they lost weight:

1. Weight Watchers--50 lb weight loss (I also knew someone in school who lost 100 lbs through Weight Watchers). Weight Watchers teaches portion control and healthy eating while providing social support.

2. Nutritional Counseling--60 lb weight loss. The nutritionist provided education as well as support.

3. Daily gym workouts (no trainer involved!) combined with eating only a Greek salad for dinner--100 lb weight loss. Exercise not only burns calories but also relieves stress. Exercising while listening to music may be especially effective and may provide a "safe space" where one escapes the stresses of daily life.(The person's main exercise was the elliptical machine, which avoids excess stress on the feet)


Therapy can help. I helped someone lose weight  by having her write in a journal everything she ate, along with when she ate it and other relevant information. We would discuss what she wrote, in our sessions. This method allows for the analysis of emotions and thought patterns that trigger overeating. Hypnotherapy may also be helpful for some people. 

I believe overeating is an addictive behavior no different in its psychological basis than addiction to alcohol or cocaine. Obese persons who aren't interested in losing weight can be observed to use the same sorts of denial and minimizing statements that one hears from active alcoholics and drug addicts. Behaviors such as secret use/bingeing, arranging social activities around the substance  and avoidance of others or activities that interfere with use, can be seen in both chronic drug users/alcoholics and the obese. Both drug addicts and morbidly obese persons have higher than average rates of childhood trauma according to some studies and many grew up in households in which addictive behaviors were common. After giving up drugs or alcohol, some people turn to food, and there's been some evidence that people who have had weight loss surgery are at increased risk for  problem drinking.

Given the similarities between overeating and alcohol/drug addiction, can a 12-step group help? I've heard mixed reports of Overeaters Anonymous, the 12-step program for food addicts. The 12-step  model was originally based on abstinence, and abstinence from food isn't possible. However, some may benefit from the support in OA.

Obesity isn't a problem because of how it makes you look. It is a serious health condition that not only raises one's risk for fatal conditions including diabetes, heart attack and stroke, but also can increase depression through increasing inflammation and reducing recreational and social activities.