Wednesday, November 15, 2017

Some Thoughts on Our Addiction Epidemics

Newspapers are full of stories about the U.S.'s opioid epidemic. It's only one of several addiction epidemics that are ravaging the country, although it's the one that is getting the most attention from politicians and the media. The root cause of all these epidemics is profits.

Approximately 10 percent of the population is thought to be predisposed to addiction, from a combination of genetic and early environmental factors. Such persons can become addicted to anything--drugs, food, sex, shopping. Persons without this predisposition can abuse substances, and will develop a physical dependence to a substance with certain chemical properties if they use it regularly enough--but it's a matter of opinion whether these persons can truly be called "addicts." But even if only 10 percent of the population are truly addictive personalities, that's enough, more than enough, to create an epidemic. Since that percentage doesn't change, why do addiction epidemics appear and disappear in societies?

When evaluating any phenomenon, it's important to ask the question "Who benefits?" The current  identified culprit for the opioid epidemic is the pharmaceutical industry. Some states are suing pharmaceutical companies for engaging in allegedly deceptive marketing practices. This may be a valid allegation, and it makes for good politics, but the main culprit is doctors. Medical training includes extensive study of anatomy and physiology. There is no way a licensed M.D. doesn't know that an opioid is addictive. I don't believe for one second that any M.D. was bamboozled by a pharmaceutical company into believing that a new opioid wasn't addictive. Doctors prescribed these pills because they wanted happy consumers.

There are many ways to manage or cure pain--physical therapy, surgery, acupuncture, massage therapy, ergonomics, nutritional counseling to lose weight and yes, psychotherapy (because mental pain increases physical pain). But there's an old saying, "If your only tool is a hammer, every problem looks like a nail." Only M.D.s and a couple of other professions are licensed to prescribe pills, so that is what they do. They don't do physical therapy or acupuncture, and even among psychiatrists, few do psychotherapy anymore--they leave that job to non-medical therapists, because prescribing pills is more profitable. Primary care physicians and psychiatrists increasingly use only one tool--pills.

A good primary care physician refers patients to necessary adjunctive treatments, but many do not do these referrals, partly because insurance often doesn't pay for them, but also because many doctors want to believe that what they do is the "real" treatment. It's also what is profitable for them.

Opioids aren't the only substance causing an addiction epidemic. There has been a worldwide plague of addiction to benzodiazepines that has flown under the radar because it seemingly has not caused an epidemic of overdoses or crimes. But that's probably because there's no illegal alternative to "benzos." People don't overuse benzos and turn to an injectable street drug because such a drug doesn't exist. They also don't necessarily think of themselves as "high" on benzos. Although a  drug is classifiable as "addictive" based on whether it is likely to cause tolerance and dependence, the general public and perhaps some doctors identify addictive substances by whether they cause a "high." But life experiences can cause "highs." In the field of prescribing, the issue of concern should be whether the substance causes physical tolerance and dependence. What pills am I talking about? Benzodiazepines include Xanax, Klonopin and other commonly prescribed anti-anxiety medications. Other sedating drugs that aren't benzos, such as Ambien, may also induce tolerance and dependence.

A few years back I saw a new patient who appeared "strung out." She denied illegal drug use. I took a look at her list of prescribed medications, and saw that it included daily Xanax. I suggested she talk to her doctor about discontinuing this medication, and she told me that she had done so but that her doctor had advised against it, because, he told her, it would take her a year to taper off the medication. I've learned that this is indeed true, it takes patients months or years to detox/taper off such medications (detox from heroin takes about 8 days in an inpatient facility). Is such use of these medications, originally developed to treat severe anxiety, justified? I do not believe so. Panic disorder is often well-controlled with SSRI anti-depressants or a combination of SSRIs and psychotherapy. SSRIs may become less effective over a very long period of use, but do not create the kind of tolerance and dependence created by controlled substances.

But the worst epidemic of our time is the obesity epidemic. The culprit is the food and beverage industry, and few politicians have the courage to attack this industry. Junk food is more popular than opioids. The media directly benefits from advertising by the food and beverage industry, not from advertising for controlled substances (it may be illegal; I'm not sure). Yet the obesity epidemic kills millions more people than the opioid epidemic.

Other addiction epidemics of our time include video game addiction and online pornography addiction (a subset of sex addiction). The Wall Street Journal and other publications recently reported  about a study that found that a main reason for declining participation in the workforce by young males was video game addiction. Other studies have found evidence for sexual dysfunction caused by online pornography, and there's no question in my mind that online porn has contributed to a general cultural misogyny, stories of which I hear in my practice. I don't see any political crusades against video games or online porn. So far the general public seems to believe that these are harmless activities, and the companies that produce these products--some of which are multinational, powerful corporations--don't appear to answer to anyone.

Tuesday, October 31, 2017

Brainwashed!

Over the past year I had been experiencing the pervasive sense that large numbers of people in the US were going crazy. From neighbors, colleagues, patients and random persons on the internet I heard statements that sounded extreme in their despair, fear and rage. At times the statements entered the realm of clinical paranoia. I was told by left-of-center persons that America was full of Nazis, and by persons to the right that the "Left" was engaged in a purposeful campaign to destroy the Constitution and install a totalitarian regime. I blamed the media and our two main political parties for the incessant drumbeat of hysterical "news" stories, inflammatory language and demonization of others that fed this mass hysteria. But it turns out that the real story is even weirder: It was the Russians.

Why do people succumb to propaganda and why can't they see that they are being manipulated? There are many factors:

Conformism: Humans are social animals and want to "belong." If a group of people with whom someone wants to associate insists on a shared belief system, many people will adopt the beliefs even though those beliefs have no basis in fact. The strong need to "belong" will override logical thought processes.

Displacement: Persons with histories of abuse or neglect in childhood deal with anxiety, anger and even outrage, but may be unable to connect those emotions with their childhood experiences due to wanting to protect the images of their family members. Instead, they direct their fear and outrage toward public figures or groups or imagined groups. It is emotionally convenient to fear and hate those you don't personally know.

Self-esteem: Many people revel in a belief in their own moral superiority. By aligning themselves with what they see as a virtuous or righteous position and condemning others who disagree, they feel better about themselves.

What can counter these dangerous tendencies? Here are some tips:

1. Learn history. The better educated and older people I know demonstrated less susceptibility to the propaganda, and not just because they don't use Twitter. It's that they (we) have seen it all before, and what we haven't seen personally we have read about. Propaganda and popular hysteria are nothing new. There have been waves of mass hysteria throughout history, often with atrocious, catastrophic or genocidal results.

2. Use logical analysis to assess claims made by groups, including established groups. It doesn't matter who made the argument or published the news story if it doesn't make sense.

3. Listen to your gut instincts. If something seems fishy, it probably is. If you can't put the pieces together, maybe it's because they don't fit. Ask yourself: Is something missing from the story? Does the story seem too bad or too good to be real?

4. Live a healthier lifestyle: Acknowledge your childhood traumas, build your self-esteem in healthy ways and seek friends who don't demand that you agree with their political beliefs. Talk to different types of people and listen to them.




Tuesday, October 24, 2017

Harvey Weinstein Heads to Rehab

Yesterday I read that Harvey Weinstein is checking into a facility for treatment of "sex addiction." Is repetitive sexual harassment or sexual assault a form of sex addiction? 

Sex addiction, like any addiction, is a repetitive, compulsive behavior. The hallmark of any addictive behavior is that it is experienced as being outside of the person's control. A common self-test for addiction is to try to stop the behavior for a period of time. If you find that you are engaging in the behavior after you told yourself you wouldn't, this could be a sign of an addictive disorder. Simply making something a habit is not itself  a sign of addiction. If the behavior is under the person's control, an addiction has not been established regardless of how dysfunctional the behavior is.

Sex addicts typically either frequent prostitutes, pick up random strangers for sex on a regular basis, or spend hours masturbating to online pornography. Some also compulsively attend peep shows and strip clubs. Eventually they start to realize that they are spending enormous amounts of time or money (or both) on their sexual activities, and perhaps endangering their health or even their lives. At this point an addiction has been established, and sometimes, people seek help.

Based on the publicly reported evidence, Weinstein appears to have exercised great control and planning in his harassment activities. Subterfuge and the assistance of allies appear to have been involved in the various scenarios that have been reported. The cost of hiding the behavior appears to have been calculated. This type of planning and execution is rare in addictive behaviors, because, as I said, the hallmark of addiction is that the behavior has spun out of control. In addition, on a deeper psychological level, addiction is about a regression in which the person unconsciously grants power to a substance or behavior, enacting a dominance/submission dynamic in which the addict is the submissive. In Weinstein's case, it's obvious that the dynamic went the other way in his encounters with young actresses and models.

If it's not an addictive disorder, is it possible that Weinstein has a different clinical disorder? It's possible and perhaps likely, but it may be one that it is extremely difficult to treat. Pleasure in exercising control and dominance over others is sadism, a psychological phenomenon that is rarely treated because sadists don't seek help. I'm not aware of any standard treatment protocols for sadism except perhaps psychoanalytic therapy to resolve early childhood traumas and conflicts, but, as sadists are rarely interested in such treatment, there isn't a lot of evidence regarding outcomes. Sadism is often a component of antisocial personality disorder (also called sociopathy or psychopathy) and this disorder is notoriously difficult to treat. Confrontation and limit-setting may be the only ways to address sociopathic behavior. People, like other animals, respond to negative consequences for behavior.

Wednesday, October 18, 2017

Mass Culture and the Normalization of Pathology


Yesterday I wrote a post about the psychological defense mechanisms often used by trauma survivors and others, and how these defense mechanisms might prevent awareness of traumas and crimes. But are psychological defense mechanisms the only reason why people don't address sexual harassment, sexual assault, and related issues? Of course not. Our culture supports the minimization and rationalization of sexual harassment and violence against women and normalizes the oppression of women People don't complain about, or sometimes don't even notice, what they consider "normal."


Repetitive presentations of violent or degrading images in tv shows, movies, video games and in online pornography trigger the use of the defense mechanisms I noted in yesterday's post. Today's youth (I'm using "youth" expansively to mean persons under 45) have grown up with pornography, reality tv shows in which people are deliberately humiliated, and violent imagery in television that wasn't permitted or just didn't exist 40 years ago.  Repetitive viewings trigger dissociation, separating the viewer from his or her emotions. The viewer stops experiencing the normal feelings of disgust and fear that these images would otherwise generate.  Unfortunately, the use of these defenses then becomes a habit. The individual who routinely uses dissociation in order to view tv, video games or pornography without disgust and fear then becomes unable to recognize violence and humiliation perpetrated on others in real life. Violence and humiliation become "normal." The dissociation doesn't just destroy empathy for others; it can also lead individuals to deny their own victimization, because they are dissociated from (disconnected from) their own emotions.

The notion that women's bodies are a commodity for men's entertainment has been normalized, including in persons who don't view online pornography or violent films. The commodification of women is an old practice and has only gotten worse in recent decades as it has become more generally acceptable and out in the open. As a psychotherapist who works with men and women, I hear things that most people don't, and have come across more than a few examples of how people who would generally be considered liberal or worldly or even feminist still can accept the notion that women's bodies are for men's entertainment. Here are some vignettes, all from the past 8 years:

1. A man who worked in sales told me team meetings were sometimes held in strip clubs. I pointed out to him that this was done to exclude women or make them feel uncomfortable. He looked surprised. This hadn't occurred to him. He didn't disagree with me; he simply hadn't thought about this possibility.

2. I was working with a man who I thought might have a problem with online pornography. I decided it might be important to find out what type of porn he was viewing. It turned out he mostly looked at women giving men blow jobs. I pointed out that these images represented a woman doing something for a man. A look of horror came over the man's face; he considered himself a feminist and didn't want to think of himself as someone who thought women should serve men. Yet he hadn't noticed the pattern in his choice of pornography and pondered what it might mean.

3. A man told me workers at the social service agency where he was employed had a get-together at a local Hooter's. I found this odd considering that many women work in the social services field. Apparently, women are now so dissociated from their own femaleness that they can watch other women degrade themselves in a low-wage job to obtain tips, and not feel uncomfortable.



The reality of women's oppression is also obfuscated by the invention of euphemistic phrases or new definitions of words. "Casting couch" and "sleeping her way to the top" have now been revealed to mean "raped and silenced with job offers." For decades women and men alike have been brainwashed by these euphemisms to believe that women initiated these encounters or at the least agreed to them in advance.

More recently, the word "choice" has been confused with the word "empowerment." The words aren't synonymous, as many choices are not empowering. I find that when I point out examples of internalized oppression or capitulation to oppressive systems, the person to whom I am speaking sometimes will tell me that the behavior can't be an expression of internalized oppression or defeat because the person "chose" to engage in the behavior. But people also "choose" to commit suicide. They choose to shoot heroin. These aren't examples of empowerment. In addition, many so-called choices are not made freely. The 12-year-old girl in East Africa who "agrees" to be genitally mutilated is not making a "choice." And yet, I found out recently that the ACLU--supposedly an organization that supports freedom--supports the "right" of persons in the US to "practice" this form of torture and disablement because it is their cultural "choice." We are well into the realm of Orwell's "1984" with this type of re-definition.

The overwhelming presence of mass media and entertainment media in people's lives has been a boon to those who want to entrench sexist notions. Media and entertainment companies are still mostly run by men, and these men have used media to shape and alter people's emotions and perceptions. Through the control of images and the manipulation of language, violence and oppression have been normalized.




Tuesday, October 17, 2017

Normalization of Pathological Behavior, Part One: Psychological Defense Mechanisms

Since the Harvey Weinstein revelations, I've been thinking about the normalization of pathological behavior. This is a common phenomenon in our society and in most societies.

This article in The New York Times summarizes the reasons why women often don't report sexual harassment--mainly, that they fear retaliation. There are other factors, however, that make people in general turn a blind eye to harmful and pathological behaviors. These include psychological defense mechanisms such as denial, rationalization and dissociation, effects of mass culture, and deliberate propaganda by vested interests that uses rhetorical tricks to minimize atrocities. I'll address psychological defense mechanisms today.

Psychological defense mechanisms serve to ward off anxiety by distorting reality. In rationalization, the mind invents "reasons" why something happens that aren't really logical, but serve to distract from an unpleasant or frightening reality. In dissociation, consciousness is altered so that an experience isn't perceived at all in daily consciousness, but may be acted out unconsciously, or remembered while in an altered state (such as hypnosis). Denial is a phenomenon in which "the existence of unpleasant realities is disavowed; [it] refers to keeping out of conscious awareness any aspects of external reality that, if acknowledged, would produce anxiety" (Kaplan and Sadock, "Synopsis of Psychiatry," 2007 edition). Denial and dissociation are closely related.

The mind resorts to defensive maneuvers in order to preserve physical health. Overwhelming stress can cause great damage to the body--altering hormones, damaging the immune system, interfering with sleep and worse. The survival instinct will undermine the mind's ability to accurately perceive reality in order to avoid the physically damaging effects of overwhelming fear.

People who have been victims of rape or other traumas not infrequently experience dissociation. Aspects of the trauma may be blocked from conscious awareness.

Sometimes trauma survivors invent "reasons" why the incident occurred (rationalization). As the general population is made aware of behavior such as Weinstein's, others may also engage in denial or rationalization. People don't want to believe that another human could be that horrible, and perhaps especially, when that human is the same gender as they are. It's too frightening.

The way to overcome denial, dissociation and rationalization is to speak about the crimes and traumas. Overwhelming evidence eventually destroys the use of distorting defense mechanisms, in all but the psychotic.



Wednesday, October 11, 2017

Raising Resilient Children

There have been a plethora of books and articles written in the past few years about the lack of "resilience" among members of "Generation Y" (people born from approximately 1985 to 2000), what has caused it and what to do about it. But now, the millenials are starting to have their own children. How can they avoid the mistakes of their parents? Here are some tips:

1. Have more than one child and make sure that siblings aren't more than 3 or 4 years apart in age. I know this might not be feasible for all parents, but it is worth mentioning, because the advantages of siblings outweigh the negatives, and the advantages are significant.

 Although some studies in the past indicated that only children have higher achievement, some studies also found a greater incidence of drug addiction among only children.

People who grow up with siblings learn crucial skills of negotiating, sharing, advocating and taking turns, earlier and more consistently than only children do. More importantly, a sibling close in age is a "buddy" who provides peer identification, which is important for personality development. Only children often feel lonely because school friends and play dates aren't a substitute for a sibling, and worse, when the parental marriage is dysfunctional, an only child can become a parent's best friend, an unnatural situation that interferes with personality development and in the worst cases leads to incest.

Although I've heard stories of dysfunctional sibling relationships (including abuse), the majority of my patients who have siblings have benefitted from those relationships. Siblings too far apart in age often don't function as siblings, however, with the older sibling often taking on a quasi-parental role that may not be appropriate.

2. Allow your child to engage in unstructured, unsupervised play. It really is true that hovering parents interfere with a child's developing sense of autonomy. Let young children play by themselves (or with siblings) in their rooms, and let school age children play by themselves in the backyard, if you have one.

3. Send your child to sleep-away camp if you can afford it. Do this when your child is 11 or 12 years old. Sleep-away camp can be a way for only children to get some of the benefits that children with siblings get. A good sleep-away camp offers challenging outdoor activities that build confidence.

4. Remember that academic achievement alone doesn't guarantee success in life. The Unabomber went to Harvard. Prestigious academic degrees don't guarantee mental health or social functioning. I have found that many of my patients who are the children of immigrants were kept home after school to study, study, study. The end result is often anxiety disorders and worse. Just today I read an article in The New York Times about the skyrocketing rate of adolescent anxiety disorders, with one teen profiled  taking 3 Advanced Placement classes as a high school junior. I don't understand why this is allowed by the school, much less by the parents.

5. Be a role model of mental health. The best way to be a good parent is to be a healthy parent. Parents with untreated depression or those who engage in substance abuse tend to have emotionally disturbed children. Nine times out of ten, when I worked with children, I found that there was either abuse or neglect going on or a parent had an untreated disorder. Unfortunately the media sometimes give the impression that children's emotional disorders are purely genetic, purely socially constructed,  or unfathomable, and this isn't true.

Sunday, September 24, 2017

What is Co-Dependency?

I've discovered many people do not know what the word "co-dependency" means.  It's a somewhat complex clinical term.

"Co-dependency" was coined in the addiction treatment field to describe a phenomenon observed among family members of alcoholics and addicts. Treatment professionals and others noticed that spouses of addicts and alcoholics frequently were high-functioning individuals, but that they often helped the addict/alcoholic cover up their addiction and "enabled" the addiction through "caretaking." These "enabling" and "caretaking" behaviors sometimes allowed the addict/alcoholic to continue their addictive behaviors past the point where they might have been forced to change, had they been on their own. These observations led to a belief among treatment professionals and others that family members of addicts needed their own treatment.

"Enabling" and "caretaking" can take a variety of forms. The spouse/partner might make excuses for the addict/alcoholic to employers, "explaining" that the person is "sick" and can't come to work, for example. If the addict/alcoholic is fired from employment, the co-dependent may take on additional work to make up the difference, instead of demanding that the addict/alcoholic stop the addictive behaviors and find a job.  The co-dependent in some cases may even facilitate the addiction by keeping alcohol in the home or by driving the addict/alcoholic to social events or perhaps even the liquor store. Why do people engage in these behaviors?

A theory began to emerge that the co-dependent was "dependent" on the spouse's addiction the same way that the addict/alcoholic was dependent on the substance. By comparing her/himself to the addict/alcoholic, the co-dependent could feel superior. The care-taking behavior was seen as making the co-dependent feel important. In some cases, the co-dependent behavior led to a "martyr complex," in which the co-dependent believed that he/she was a valiant and long-suffering individual. Underneath  these behaviors and beliefs there is typically a lack of self-esteem. Treatment for the co-dependent involves helping the person get in touch with his/her feelings of low self-worth, and guiding the person to finding productive ways to raise their self-esteem instead of through comparing themselves to a dysfunctional person whom they need to remain dysfunctional in order to fulfill this purpose.

Because so many alcoholics and addicts are men, for a long time the stereotype of the co-dependent was that of a wife. However, it's been my observation that more men than women have co-dependent traits, and that these traits are often normalized in men--the "White Knight" who rescues a damsel in distress, or the man searching for an "Angel with a Broken Wing." We are so familiar with these characterizations that we may think of this as normal male behavior. Needing to feel superior is a sign of low self-esteem, and just because it may be common in men doesn't mean it isn't pathological.

Even though the co-dependent may "help" the dysfunctional partner or family member, the relationship doesn't serve anyone's interests. It enables the dysfunction and stresses the co-dependent. The dysfunctional person often starts to resent the co-dependent, sometimes sensing consciously or unconsciously that the care-taking behaviors are a form of control.

Anyone who has a close relationship with an alcoholic or addict should seek their own counseling. Any man who searches for an "Angel with a Broken Wing" as a partner should take a serious look at his own feelings of insecurity and inadequacy.

Tuesday, August 8, 2017

If Psychotherapists Ran the World

If psychotherapists ran the world, it would look a lot different.

Let's start with the U.S. We would have universal healthcare, because all psychotherapists know that the patchwork system we have doesn't work and isn't fair. We work every day, in one capacity or another, with the healthcare system, and as most of us are self-employed, we know from personal experience that the current system is unworkable for self-employed individuals. Obamacare helped many people, but didn't resolve many of the underlying problems.

We would require large businesses to have onsite daycare, because psychotherapists know that there's no substitute for an early parent-child bond. All businesses would be required to offer both maternity and paternity leave.

We would have a different foreign policy. All psychotherapists who have worked with children or with dysfunctional families (all of us) know that the cardinal rule of behavior modification is "ignore the negative behavior." Paying attention to negative behavior rewards the behavior, and the child (or adult) is encouraged to continue or even to escalate the behavior. Responding to provocative behavior and threats from other world leaders by making threats in kind and engaging in provocative rhetoric is exactly the opposite of what you want to do.

Should I run for office?

Saturday, July 22, 2017

When You "Assume"...

There used to be an old saying about assumptions: "Never assume; it makes an "ass" of "you" and "me."" This piece of wisdom seems to have fallen by the wayside.

Assuming can lead to social bloopers. But it has worse effects: It can lead one into dangerous situations. One of the most common assumptions, in my observation, is the one held by many women that if a man seems like a nice person, he is a nice person.

Women are socially trained to be "nice" and accommodating and to not be "critical." Although many women don't adhere to these norms and stereotypes, all women are to some degree affected by this social conditioning.

Even with my decades of professional experience and training, I don't always know in the first session that a patient I'm working with is a sociopath or a dangerous person. Sometimes such individuals reveal themselves quickly, but others mask their dangerous traits--in a psychotherapist's office, the disguise is in the form of other symptoms. In real life, the disguise is in the form of charm, sociability or verbal skills.

Both men and women can be sociopaths. In women, being pretty can be the "disguise" (disguises aren't necessarily deliberate). There's been research showing that physically attractive people are assumed by many people to be morally superior. This assumption--like most assumptions-- isn't based on facts.

Making assumptions won't make you popular with other people. It might sound like a compliment to say to someone, "But I thought you were much younger!" but depending on the person, it might not be heard as a compliment. It might also make you look like you're not very observant or that you are being dishonest.

People respond more positively to  questions and interest in the responses. Most people, particularly women, are attracted to others who show interest in finding out who they really are. The generic compliments some men give women on dates might puff up the self esteem of a woman who is insecure, but a woman with better self esteem responds more positively to questions about who she is and what she likes.

Professionals, including mental health professionals, aren't immune to assumptions. An amusing (or not) example is the following experience I had while working in a residential treatment program for men with mental health and substance abuse problems, in the 1990s: One of my tasks was to write up summaries for patients' post-discharge housing resources. I scanned the initial assessments of one such patient, and saw that the psychiatrist and other professionals had consistently described the patient as "white" or "Caucasian" in their assessments. I didn't know the patient well as I didn't do individual counseling at that job, but I had been trained to never make assumptions and to never go by another clinician's assessment. "How would you describe your ethnic or racial background?" I asked him. He looked confused. "I'm black," he responded. I decided not tell him that he had been assumed to be white by numerous persons.

I don't assume I know people's race, their age, or even their gender, unless the facts are extremely obvious. I certainly don't assume I know their personalites just by looking at them. It's always better to act from the standpoint that you don't know than to assume you know things about people based on outward appearances.

Sunday, June 25, 2017

Snappy Answers to Stupid Questions (or Comments). Or, How to Defuse Conflicts Without Really Trying

When I was 10 years old, my favorite reading material was MAD Magazine. For those of you who don't know, it was (is?) a humor magazine that's somewhat lowbrow, although nothing I read in it in those days was offensive. One of my favorite features was called "Snappy Answers to Stupid Questions." Unfortunately, I can't remember any of the snappy answers I read in MAD more than 40 years ago. But, I've come across gems of snappy answers over the years. These type of retorts serve to defuse potential conflict through humor, a useful skill.

Probably the best snappy answer to a stupid question of all time was voiced by Mohandas ("Mahatma") Gandhi, India's national liberation leader: A journalist once asked him: "What do you think of Western civilisation?" He replied "I think it would be a good idea!" (For those of you who don't understand this, read up on the history of the British Empire).

Another of my favorites comes from Pablo Casals, the famous cellist. When in his 90s, he mentioned that he still played the cello, and someone (another journalist, I think) asked him: "Why are you still practicing at this age?" which is an ageist and clueless remark. Casals replied,  "Because I think I'm making progress!"

Obese people have told me that they've had experiences of being in a fast food restaurant when another customer said to them something like "You shouldn't be eating those fries." A standard retort: "It's true I'm fat, but I could lose weight. Unfortunately there's no cure for stupidity/bad manners." (That may not be completely true, as people can learn better manners, but they usually don't).

A sense of humor is considered an important psychological strength by psychotherapists. In fact it is classified as an adaptive defense mechanism.

I've noticed that despite a plethora of comedy on tv and in movies, many people today are taking themselves too seriously, are easily offended, and at the same time are often afraid to use the type of snappy answers I've cited above because they are wary of offending others. But snappy answers can be a way to put people in their place so that you are standing up for yourself without arguing or throwing a temper tantrum. They are more likely to be heard than direct reprimands or lectures.

There are times when it's best to hold one's tongue, such as when dealing with your boss at work. But in most cases it is better for one's mental health to respond to offensive remarks. Practice some snappy answers to the type of insults that you encounter so you'll be prepared for the next time.

Addendum 7/15: And for my patients who work in media, I found the following:
https://www.mcsweeneys.net/articles/greeting-cards-for-your-online-trolls






Sunday, May 28, 2017

How to Argue

After last November's election, I saw a number of media articles about disastrous arguments that had erupted among family members and even between couples. There used to be an old saying, "Never discuss religion and politics" in conversation. But today, people sometimes have difficulty finding non-controversial subjects to discuss, partly because the media likes to enhance controversy and division, and partly because entertainment has become so splintered many people aren't watching the same tv shows or movies as their friends or family. To make matters worse, many people today don't know the rules of debate. The rules of what used to be called rhetoric certainly are not modeled by our politicians or  by the media. Here are some of the basic rules:

1. Arguments must be supported by facts. Facts are pieces of information that are demonstrably true. Something isn't true based on the number of people who believe it. A billion people could believe something and it could still be false. Many beliefs throughout history have been believed by the majority of the population of a country or region yet were found later to be utterly false. Truth is supported by observable evidence. The evidence might only be observable with an electron microscope, or it might only be indirectly observable (psychotherapists can observe the workings of psychological defense mechanisms, even though the mechanisms themselves are caused by brain patterns that we haven't yet been able to pinpoint, for example) but there must be observable evidence to support the argument.

2. Arguments and positions must be evaluated on their own merits, rather than being judged by who did the arguing or who holds the position. This is the classic distinction between an "ad jure" and an "ad hominem" attack. An ad hominem attack is a personal attack. For example: Sen. Smith supports a controversial bill. Someone argues against his position by saying "Sen. Smith cheated on his wife who divorced him." This is an ad hominem attack. The problem isn't so much that the attack is personal, the problem is that it is irrelevant. Sen. Smith's marital history is only important if one is planning on dating him or marrying him. It has no relevancy to the legislation he supports, even if the legislation concerns marriage. The validity of the legislation has to stand (or not) on its own merits. The personal attributes of its sponsors have no relationship to the validity of the legislation.

3. Guilt by Association is a smear tactic and should not be used. Guilt by association is often used as part of an insinuation or innuendo. For example: "I saw Sen. Smith talking in a parking lot with the Grand Wizard of the Ku Klux Klan." Unless we know what transpired in this conversation, this is an irrelevancy. Even if the Grand Wizard of the Ku Klux Klan endorsed Sen. Smith for public office, this does not mean that Sen. Smith holds the same views as the Klan, unless Sen. Smith asked for an endorsement from the organization or its leader. Although one might assume that an endorsement is done because of similar beliefs held by the endorser and endorsee, that may not be true. The important question is what does Sen. Smith believe and support? Sen. Smith's political positions have to be evaluated based on their own merits or lack thereof.

4. A "Straw Man" argument is an innuendo/insinuation that manufactures a controversy; it is a dishonest tactic that should not be used. Wikipedia has a good entry about Straw Man arguments:
https://en.wikipedia.org/wiki/Straw_man

5. Sources cited must be credible. Here are some basic rules for sources that I learned as a journalist in the 1980s, before the profession sank into the mud: a) Information should come from more than one source, especially information that is politically sensitive, incendiary etc. The standard rule for reporting sensitive stories is that the same information must come from two independent sources, in other words, two sources who aren't in collusion with each other  b) Sources must lack bias. In other words, they cannot have an ulterior motive. c) Sources cited as experts must actually be experts. Having an opinion does not make one an expert. Experts are persons with extensive training and/or professional experience in a given field.

If one reads many of today's news outlets (many of which are not actually newspapers or magazines but agenda-driven websites) one can find stories written based on only one source or based on sources with bias. The most notorious recent example was the Rolling Stone magazine campus rape story that was retracted. It was almost entirely based on the account of the victim with no corroboration. For other examples, look for news stories that quote agenda-based organizations on the same topic that the organization promotes or attacks. Anything such sources claim should be taken with the proverbial grain of salt. Just because their spokesperson is being quoted in a newspaper does not mean that what the spokesperson says is credible.  In fact their bias discredits them. Many news stories try to sidestep this rule by printing "opposing views." They publish (or broadcast) two persons' views that are in opposition to each other. But both viewpoints could be false, if they aren't based on facts. If the subject is technical or scientific or requires professional expertise to understand, the viewpoint is only credible if the person is an expert.

Many ordinary people when arguing a point will base their argument on what they read in the media. Unless the media source you are citing follows the above rules, your argument may be based on false information.

If ordinary people followed all five rules I've cited above, arguments would be less volatile. Because they would be fact-based, the opponent may catch on that listening is an opportunity to learn. If the opponent has no facts, he or she may discontinue the argument and head to the library to find some. Both parties might learn to have more respect for each other, because we tend to respect people who know facts and who avoid insinuations and personal attacks.

Saturday, May 13, 2017

Reading Fiction for Better Mental Health

Does reading improve mental health? There's evidence that it does.

It's long been known that reading improves overall cognitive ability. Studies have shown that there's a correlation between early literacy in children and higher IQ scores later in life, and that reading in older adulthood delays cognitive decline to some extent. Reading involves the decoding of symbols (letters) and forces the brain to interpret words in context--perhaps the brain requires this exercise to stay fit. Pictures don't have the same effect, because understanding them doesn't use the same brain functions.

But what about emotional health? There are several ways reading may improve emotional well-being. This rather long article in The New Yorker
on bibliotherapy cites some studies indicating that reading fiction improves the capacity for empathy and also, can be a "mindfulness" activity (see my previous post on mindfulness).

This brings up the issue of what type of reading we're talking about: Any type of reading may increase general cognitive function, but reading fiction, particularly the best fiction, may have special benefits: Good fiction convinces the reader, temporarily, of the "realness" of the characters, setting and events (thus inducing a trance state that removes the reader from his/her real-life troubles). Good fiction also includes well-developed, multi-dimensional characters and immerses the reader in the character or characters' inner and outer worlds, helping the reader see through their eyes. It's easy to see how this could increase the capacity for empathy.

The best writers portray villains who perhaps weren't always evil, and heroes who are flawed. These nuanced explorations of human nature may especially help readers with personality disorders. Persons with Borderline Personality Disorder in particular typically divide the world into polar opposites: Good v. Bad people, and simplistic or extreme interpretations of events. These tendencies are found in people with Borderline Personality Disorder even when the person has a high IQ, because these distortions are caused by dysfunctional ego defenses, not by low intelligence (see my previous post on Borderline Personality Disorder from Oct. 14, 2015 ).

Reading fiction might also help persons with depression: The characters in the best fiction grapple with conflicts and make mistakes, even when they are the novel's "heroes."  Reading about their struggles might help self-critical persons moderate their self-criticism.

In short, reading is important, but it matters what you read. Many of the opinion essays,  Facebook posts etc. that I come across on the internet are nothing but recitations of popular slogans and catchphrases. They often demonize opponents by using hyperbolic language. They often promote a code of "correct" language that is remarkably reminiscent of the "newspeak" of Orwell's classic dystopian speculative fiction novel "1984." The purpose seems to be to increase fear and hatred of opponents,  as well groupthink and submission to self-promoted "authorities." These are the tools of authoritarianism and totalitarianism. This type of reading can have a negative effect on mental health by increasing anger. It might even negatively impact overall cognitive functioning by encouraging simplification.

I've noticed over the years that although reading complex novels doesn't prevent mental illness, my patients who read fiction often seem to cope better with their disorders, including serious disorders.

To increase general knowledge, I recommend reading reputable non-fiction books written by academic experts or by reputable journalists who are basing their works on facts and research, not on opinions. To increase emotional well-being, I recommend reading  fiction (in any genre) that includes multi-dimensional characters. Maybe a book club is a therapy group!





Wednesday, April 12, 2017

Mindfulness

The word "mindfulness" is coming up more and more in the popular vocabulary. What does it mean?

"Mindfulness" means simply a state of being aware. The practice of mindfulness is an element of Zen Buddhism that has been incorporated into some Western treatment programs, especially Dialectical Behavior Therapy. I can't comment on mindfulness as a spiritual practice because I am not Buddhist, but I can explain the ways it works psychotherapeutically: Focusing your attention on something stops anxious ruminations. Focusing for a prolonged period of time can induce a trance state, which is relaxing  and also is a component of hypnotherapy. In addition, mindfulness can increase appreciation for the world around you.

Mindfulness is an essential part of meditation.

Marsha Linehan, the founder of Dialectical Behavior Therapy, developed a series of mindfulness exercises to help persons with Borderline Personality Disorder manage their emotions. Mindfulness is a component of DBT, along with interpersonal skills training and elements of cognitive therapy. Since Linehan developed DBT in the early 1990s its use has expanded and DBT is now  used to treat people with anxiety, depression and PTSD. Here's an excerpt of a mindfulness exercise from Linehan's DBT workbook:

" `Awareness Exercises' 1. Awareness of the Positions of the Body: This can be practiced in any time and place. Begin to focus your attention on your breath. Breathe quietly and more deeply than usual. Be mindful of the position of your body, whether you are walking, standing, lying, or sitting down. Know where you walk, stand, lie, or sit. Be aware of the purpose of your position. For example, you might be conscious that you are standing on a green hillside in order to refresh yourself, to practice breathing, or just to stand. If there is no purpose, be aware that there is no purpose."

Another excerpt: "Awareness While Making Tea or Coffee: Prepare a pot of tea or coffee to serve a guest or to drink by yourself. Do each movement slowly, in awareness. Do not let one detail of your movements go by without being aware of it. Know that your hand lifts the pot by its handle. Know that you are pouring the fragrant, warm tea or coffee into the cup. Follow each step in awareness. Breathe gently and more deeply than usual. Take hold of your breath if your mind strays."

Mindfulness can help anxious or depressed persons get out of their inner world in which they may be dwelling on negative thoughts. Obsessive preoccupations are common in anxiety disorders and also for some persons with depression. These internal experiences often become disconnected from external reality. Mindfulness exercises can help re-connect the anxious or depressed person with the greater context of the world around them.

People who play sports or engage in artistic activities often practice mindfulness without realizing it. Perhaps that's why those activities are referred to as "recreation" (re-creation).

Too often we mindlessly engage in our daily activities. Eating mindlessly not only leads to weight gain but also denies oneself the pleasure of flavor, aroma and other sensory experiences of food. Many people walk through parks without fully appreciating the natural world around them.

On a vacation last year in Vermont I spent an hour in the afternoon doing nothing except sitting in a grassy area by the woods. I focused on the touch of the grass, the dark mystery of the woods, the blue sky, some unidentified plants and an occasional butterfly. I sat alone, which allowed me to experience the natural world without the distraction of conversation. I had the sensation of being in a timeless place in existence apart from daily life. In hypnotherapy, we often teach people to mentally escape to a "safe place" in their minds. But I believe real-life experiences may be necessary for many people to be able to imagine a safe place.

Anyone can benefit from mindfulness exercises and perhaps we all need them as an antidote to our frantic, distracted contemporary lifestyles.

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.