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--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.

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 crack cocaine addiction. 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.

Tuesday, May 17, 2016

Preventing Suicide

In the past year or so, the news media have reported on a couple of disturbing research studies that showed rising suicide rates. The latest study reported that suicide has been increasing in every age group except the elderly. What is prompting this increase and what can be done about it?

Many have speculated that economic hard times are behind increasing suicides. This could certainly be a possibility for the increasing rates of suicide in middle-aged people, many of whom lost retirement savings and jobs, or lost homes, during and after the crash of 2008.

Increased suicides among girls age 10-14 is more of a puzzle. One theory is that increased social media bullying is the cause. If this is true, an easy way to decrease these suicides is to not give your daughter a smartphone until she is old enough to tolerate or stand up against bullying. That kind of personal strength is unusual in people under age 15. Facebook supposedly doesn't allow accounts for people under age 13, but I don't know if this is enforced at all. It's really up to parents to protect their children. Likewise, it's important to ask your child about bullying and take steps to address it if it occurs, including speaking with the school principal, switching schools and/or taking legal action. Harassment and stalking are against the law regardless if the perpetrator is a teen, and Title IX of the Civil Rights Act forbids sex discrimination in education, which could make sexually-related bullying a federal violation if it is tolerated by the school.

Teen girls are now subjected to more degradation than ever before. Besides social media harassment, they also now have male peers who view internet pornography, and who may as a result view girls and women as subservient or degraded sex objects. Some girls may be pressured into sex acts as a result, and viewing of some types of pornography is a trauma for a young person. Pop music stars such as Beyonce and Miley Cyrus perform burlesque acts that may confuse 11 and 12 year old girls, who are told that these sexually objectifying performances are acts of empowerment, while at the same time they are derided as "sluts" if they dress the wrong way or date boys. Overweight girls are teased, but thin girls are also derided in popular culture--take a look at Meaghan Trainor's hit video "All About That Bass," a profane, vicious, bullying rant that is promoted as "happy" music on Amazon. Trainor's songs are marketed to young teen girls.

The more I think about it, are we really surprised that suicide is on the rise? Perhaps the reason the suicide rate of the elderly is not rising (despite the fact it historically has been higher than for other age groups) is because elderly people are more likely to have assets that weren't as affected by the 2008 crash, Social Security incomes, and a lack of involvement in degrading aspects of popular culture.

In terms of specific risk factors and prevention, something that we know about suicide is that it is often an impulsive act and often based on cognitive distortions. Even when times are bad, most people are able to recognize that things can get better. People commit suicide because they don't see a way out. They develop a narrow way of thinking that blocks out options. They also often don't believe that others can or will help them. They don't "reach out" for help. These thought patterns and behaviors are referred to as "hopelessness and helplessness," and mental health professions screen for suicide risk not just through asking patients how depressed they feel and whether they have had thoughts about suicide, but also by assessing whether the patient has any plans for the future and whether the patient has a social support network. People can be very depressed and feel like they don't want to live, but if they feel connected to others they are less likely to commit suicide. Someone who does not have anyone in whom to confide is far more likely to commit suicide than a depressed person who reaches out for help. This brings up another possible reason why suicide is on the increase--some studies have found that more people are reporting few or no close friends, in comparison to previous decades.

If we want to live in a society with a low rate of suicide, we need to have a stable economy that provides some security for everyone, we need to encourage friendship and mutual trusting  relationships,  and we need to protect vulnerable persons such as young girls from degradation via the internet. 

Thursday, April 28, 2016

Why I Left the Aetna Panel

In February, I made a decision to terminate my relationship with Aetna, the health insurance company, and also decided to terminate my relationship with the 1199 National Benefit Fund. Some patients have asked me why I did this. The truth is that I'd come to the realization that I was in abusive relationships with these entities, and the only way to deal with being in an abusive relationship is to leave that relationship.

Aetna does pay providers a bit more than some other insurers, but in every other way they demonstrate contempt for the providers who actually do the work for which Aetna takes the profit. Aetna messed up my credentialing twice, first when I initially applied in 2008, then again in 2014 when I changed my tax ID number. These screw-ups meant I wasn't paid for months and that I wasted hours of my time on the phone and writing emails as well as resubmitting claims, in order to resolve the problems. Aetna also denied claims for bogus reasons, such as in one memorable case when they told me my patient's auto insurance might have already paid the claim. The patient didn't own a car. I eventually spoke to someone at Aetna who was as puzzled as I was by this bizarre statement. She resolved the issue, but only after both I and the patient wasted time trying to resolve the unpaid claim.

The last straw for me with Aetna was in early February, when I received a phone call from a third party, "ArroHealth," saying that I needed to turn over case records on four patients. I inquired as to the reason and was told "it's the annual risk assessment."  I'd been credentialed with Aetna for almost 8 years and had never heard of an annual risk assessment. Moreover, all of the cases were closed, so a risk assessment was beside the point. I don't turn over confidential health records without a good reason. I informed "ArroHealth" that the cases were closed, I was no longer in touch with the patients, and their confidentiality waivers for Aetna were now out-of-date. Of course, what many people don't know is that when you sign up for health insurance you sign a statement allowing the insurance company to look at all your health records. Regardless, this is never something I would do without consulting with the patient. I found out later some of my colleagues dealt with this by asking patients to write letters to Aetna or to ArroHealth saying they were refusing the release of their records. But I didn't want to involve former patients at all. Moreover, because of the consulting work I do as an auditor, I know that payors are capable of finding bogus reasons to take back money from providers. I am not giving back one cent of any money paid for work that I have done. I told ArroHealth that I wasn't going to release the records. Within one week I had decided that if I maintained my relationship with Aetna, I would be subject to more of the same, so I faxed them a termination letter.

As for the 1199 National Benefit Fund, which ironically is a plan for health and hospital workers in New York, they processed by tax ID change application by immediately eliminating my old tax ID number, but waiting six weeks to instate my new tax ID number. This meant that I was listed as an "out of network" provider for six weeks. I don't know if this was extreme incompetence or done deliberately, but the end result is that they owe me hundreds of dollars for a patient's incorrectly processed claim. Although I filed an appeal, I have not been paid.

I counsel my patients not to tolerate abuse and disrespect and I would be a poor role model if I allowed myself to continue to be mistreated by these organizations.

Tuesday, April 5, 2016

How Music Helps Your Brain

I was intrigued by this article in Guitar Player, and more so by the TED video that is embedded in the article:

According to the article and video, listening to music stimulates the brain, but playing a musical instrument enhances brain functioning even more. It makes sense--music is both emotional and logical, expressive and structured, mathematical and sensually stimulating. It links the brain's two hemispheres, and the brain's "executive functioning" would be enhanced by the processing of the large amount of linked information. ("Executive functioning" refers to mental processes of ordering, sorting, linking and prioritizing information).

Does music help prevent dementia? The article and video imply that it could. I'm wondering if there's a possibility learning a musical instrument might also help persons with  ADHD, although, as far as I know, there is no research regarding this. (People with ADHD have difficulty with "executive functioning.")

Although music may be especially helpful in improving brain functioning and stimulating the brain's reward centers, any artistic activity can improve focus and involve what psychotherapists are currently calling "mindfulness"--a state of focus that relieves anxiety and stress.

Performing one artistic activity can also stimulate activity in other artistic areas  ("Violon D'Ingres"). My favorite example is William Blake, one of the greatest English poets, who was by trade an illustrator and graphic artist. Although he didn't achieve renown as a visual artist, anyone who reads his poetry  is struck by its vivid imagery, especially in his most famous poem, "The Tiger."

There are multiple benefits to engagement in artistic activities.

Friday, March 25, 2016

Before Saying 'I Do"

I thought this was a pretty good list of issues to discuss and consider before getting married:

(I'm sorry that I can no longer figure out how to put in links on this blogging platform)

Monday, January 18, 2016

How Frequently Should Therapy Sessions Be?

When people come to see me, they usually assume I'll be scheduling them for a weekly appointment, probably because this is the norm for psychotherapy these days. But is this really the best format?

When psychotherapy first began, as psychoanalysis, patients attended sessions 4 to 6 days a week. It was thought that this was necessary to allow for the "free association" to reveal the patient's unconscious material. On the other hand, no one came to psychotherapy for 10 years, as happened later. Patients who were suffering wanted to be cured as quickly as possible.The original purpose of treatment was to cure neurosis, and once cured, it was thought it would not re-occur.

As I've outlined in previous posts, these days people come to therapy for a variety of reasons and some  people have personality disorders that are chronic. I believe the format of therapy should fit the individual patient. I see most people weekly, a few people every other week or in rare cases less frequently, and occasionally I have scheduled people for twice weekly sessions. 

I pick the format that seems to fit the individual patient and I expect that therapy could last anywhere from a few sessions to a few years, depending on the individual. 

 I generally start out with weekly sessions because this is usually enough to start therapy and fits most people's schedules. Some people ask to be seen less often and I evaluate this on a case-by-case basis, but I rarely agree to see people less than once a week within the first couple of months. I have found that some persons who ask for infrequent sessions at the start of therapy have intimacy issues or are afraid of making changes. Although fear is to be respected, it may be important to discuss the source of this fear rather than simply acquiescing to it. I've also found that people who request right away to be seen less frequently than once a week are often people who don't want to come to therapy at all but are being pressured by someone else, or for another reason not related to wanting to be in therapy. Change can occur in therapy at any frequency, however.

I have had a few cases in which I moved the patient to twice weekly sessions because I thought we were stuck and weren't getting to something important. Increasing the frequency of sessions can lead to a breakthrough in some cases. Psychoanalysts believe that therapy at least twice a week is necessary to generate something called "transference," which is really just a jargon term for the emotional relationship between the patient and the therapist (although technically it means the patient transfers a relationship from childhood onto the therapist).  I'm not sure this belief is true, as transference can occur in the very first session. But some people may achieve breakthroughs in more frequent therapy because they need the more consistent presence of the therapist to feel safe in making changes or dealing with difficult material.

In a few cases I have reduced the frequency of therapy because I thought the patient felt pressured to make changes he or she wasn't capable of. It's important for the therapist to respect the patient's limits. The more experienced that I have become as a therapist, the more clearly and rapidly I can see a patient's problems, but that doesn't mean the patient is ready to see what I see.

In general, people improve more quickly if they attend therapy sessions more frequently, but it is possible for some people to benefit from infrequent sessions.