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Archive for the ‘mental health’ Category

There’s been a lot of noise lately about how awful the new version of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association is going to be. Virtually none of this drive-by criticism appears to be the least bit informed as to the goals of the DSM-V, much less the process by which it has been developed.

A recent critical article: Why Many Mental Health Professionals Are Ditching the DSM-V ‘Bible’. There are SO many problems with this article, yet most will completely elude detection by readers.

1. The title asserts that “many” MHPs (Mental Health Professionals) are abandoning the DSM-V. Absolutely NO evidence is given for this assertion. A cheap shot, nothing more.

2. The title refers to the DSM as a “Bible”, which it is not. The Bible is considered to be a revelatory document (by believers) or a historical document (by non-believer scholars). The DSM is neither. It’s a data driven, clinically validated, periodically updated classification scheme, and nothing more. That’s all it’s designed to be.

3. “major players in the mental health community say the book needs more research”. Who are these “major players”? The NIMH is mentioned, but that’s now old news, and not immediately relevant, anyway (see #4 below). Unnamed academics from Columbia and Rutgers are also referenced – complaining about the DMS’s lack of epidemiological perspective, and insufficient consideration of ancillary causal factors. As usual, these non-clinician critics want the DSM to be the kind of research review it never was intended to be. It’s for working clinicians, not researchers. It USES research, in several ways, but is NOT a research report, review, or even summary. Once again we see non-clinicians simply failing to understand what we in clinical mental health are actually doing in our work.

4. NIMH director Thomas Insel is paraphrased (correctly, I think) as saying the DSM lacks validity because it classifies disorders solely by their symptoms. Pray tell, what is the alternative? The DSM, in recent iterations, derived from a desire to diagnose not according to theory (for which, by definition, there was little or no formal research support) but according to actual clinical presentation – yes, symptoms. WHAT ELSE DO WE HAVE? This isn’t a mistake, it’s a NECESSITY. We’re playing the only game we actually CAN play, at this point in the evolution of our knowledge of mental illness.

Insel’s project is a research strategy, for an agency with a very strong commitment to basic (i.e., physical science and medical) research. But don’t expect it to answer all questions; it simply can’t

There is a vast amount of research – from studies of morphology in biology to the famed “Minnesota twin studies” in psychology – which supports the idea that what one sees in the real world is about 50% derived from genetic factors and 50% derived from environmental factors. The conceit that any study of genetics+environment will allow us to account for the spectrum of depressive disorders, anxiety disorders, and most particularly trauma disorders is either phenomenally ill-informed or gratuitously over-optimistic. The further notion that the results of such a effort will properly be considered “medical” presupposes that psychology can be reduced to physiology, at the least. Yeah, and while you’re at it, let’s reduce computer programming to mere electronics. This is sort of “reductionist” logical error one is cautioned about as an undergraduate. Such decomposition of a higher order field to one or more lower order fields has never, to my best knowledge, happened – outside of the realm of theory, not is it ever going to.

For how many decades has the search been unfolding for a “gene for alcoholism”? And the results: still looking…

“Further evidence and an approximate estimate of heritability – crudely speaking how genetic a condition is – can be derived from twin studies that yield figures of 50% for males and 25% for females…” (Ball, D. (2004). “Genetic approaches to alcohol dependence”, The British Journal of Psychiatry
185: 449-451 doi: 10.1192/bjp.185.6.449)

What this should make clear is that “medical” approaches to such things will ever only get us part of the way to our goal. The rest of what it will take has to do with behavior, learning, and a causal model that will contain a number of non-physical factors. And alcoholism is EASY, compared to anxiety, depression, or trauma disorders.

It is fundamentally misguided to think that psychology can be reduced to physiology or medicine. Yet, if awareness of this thinking error is not much in the minds of the general public, it is also significantly lacking in the minds of too many mental health professionals. Insufficient awareness of this error is at the heart of much criticism of professional clinical psychology by non-clinicians outside of the field. They just don’t get it. Clinical work is NOT research any more than research is theory. Different areas of thoughtful activity – different goals – different processes – different rules – different outcomes. So shall it always be.

I appreciate that several rather subtle considerations are touched upon in my remarks above, of necessity. This is ALL about explanatory and prediction strategies, and THAT topic isn’t seriously taken up by most students until graduate school. If this were an easy topic, it’d be covered in high school.

Biology is still actively arguing about species delineation and classification (a fascinating topic, by the way). It’s hardly surprising that we are doing the same in the nosology of mental illness. It’s part of the process by which science improves itself. We’re NOT in trouble; we’re just doing our job.

[based on a 2013.05.14 post to the G+ Trauma and dissociation: education and advocacy community]

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Here it is short and sweet: If you eat fast food to any significant extent (you know who you are!), your risk of becoming depressed in the future increases (if you aren’t already depressed). If depression is a problem in your life, you should seriously consider reviewing your diet, eliminating any fast food you find and increasing your consumption of whole and fresh foods.

This is the major finding of yet another study on the relationship between diet and mood (depression in particular) – and here is a summary of the study, written for medial professionals: Junk Food Linked to Depression.

Here are the key points I see in this summary:

  • Using a “…prospective cohort design [which] affords the potential for investigating cause-effect relationships,” researchers followed a group of almost 9000 people over time, to look at the relationship between depression and consumption of “fast food” – quick take-out food, and commercial bakery items. At the beginning of the study, none “…of the participants had been diagnosed with depression or had taken antidepressants before the start of the study.”
  • ” Fast food consumption was defined as total consumption of hamburgers, pizza, and hot dogs/sausages. Commercial baked goods consumption was defined as total consumption of croissants, doughnuts, and muffins.”
  • A positive dose-response effect was found: The more food of this sort consumed, the greater the risk of becoming depressed in the future.
  • Consistent consumption of these foods produced an almost 40% increase in the chance of becoming depressed in the future.
  • “…the researchers note that even small quantities of fast food were linked to a significantly higher risk for depression.”
And from the article, here are some excellent summary statements:
  • “…the intake of this type of food should be controlled because of its implications on both health (obesity, cardiovascular disease) and mental well-being.”
  • “Limiting trans fatty acids content in several foods, avoiding the consumption of fast food and bakery, and increasing the consumption of other products such as vegetables, legumes, and fruits should be a primary goal for clinicians and public health makers…”
  • “…it is prudent for clinicians to assess and address the dietary as well as exercise habits of their patients, in addition to pharmacological and other established treatments.”

These findings are congruent with a number of previously published studies which document similar or related causal effects between diet and mood:

Trans-Fats Linked to Increased Depression Risk [2011.01.28] – “Consumption of trans-unsaturated fatty acids (TFAs or trans-fats) has been linked to a significantly increased risk for depression. On the other hand, olive oil, monounsaturated fatty acids (MUFAs), and polyunsaturated fatty acids (PUFAs) appear to have a protective effect and lower depression risk…”

More Evidence Confirms Diet’s Link to Mental Health [2011.10.14] – “…new studies from Australian investigators show that diet quality can have a significant effect on mental health outcomes and may potentially have a role in preventing and treating such common illnesses as depression and anxiety.” “…better diet quality was associated with better mental health in adolescents cross-sectionally and over time.” “…these findings suggest it may be possible to prevent teenage depression by ensuring adolescent diets are sufficiently nutritious, and improving diet quality may help treat depressive symptoms in this population.”

Clear Link Between Mood and Food [2012.03.20] – “New research shows there is a strong link between higher levels of nutrient intake and better mental health, thereby adding to the growing body of evidence demonstrating the critical role of diet in mood disorders.” A broad range of nutrients were monitored in the reviewed small-sample study of a clinical population (i.e., all individuals were adults living in the community and had been diagnosed with mood disorders), and consumption of all nutrients correlated positively with scores on the Global Assessment of Functioning scale very commonly used in psychiatric assessment.

Improvements in one’s diet are appropriately considered a significant preventive or treatment response with mood disorders – especially depression. Overall cost is likely to be less than that for other modes of response, and such action is ideal for self-management of mood. I do this myself (along with purposeful strenuous exercise – also validated by research as a highly appropriate response to risk or presence of mood disorders), as I want my mental function to be optimal at all times. I strongly urge others to consider doing it as well. It’s a smart move.

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All of us struggle with our sense of reality. Sometimes we cannot quite “see” what’s really happening. Other times we don’t question what we see so much as our ability to respond well to it.

In any case, a little thought clearly leads to the fact that our sense of our reality – encompassing both ourselves and what is around us – is something distinct from the reality itself. Unfortunately, it’s just not always easy to get a good sense of what’s really happening.

Consider for a moment, if this line of thought is a little murky for you, that all of science is simply an effort to address this problem – to get a better sense in our minds of what’s really happening “out there”. Science is hard work, which leads me to conclude that the problem it addresses is often not easily resolved.

I find that my own personal sense of reality and myself is subject to many distortions. Rarely do these mental errors help me live better, feel better, or like myself more, in the long run. In fact, such mental errors can often lead to short-term disaster!

In a recent email to a client, I addressed this issue, asking what they needed to remember about themselves and their situation in order to limit such mental distortions as much as possible.  I then offered the following ideas which I personally have found it very useful to remember.

  • I care about the people in my life, and this is good for me and them.
  • I can interact with them in ways that add value to their lives and mine.
  • Direct control of my feelings is not possible (because feelings are an automatic brain response), but indirect control, through attending my physical health, my thoughts, and where I choose to direct my attention, is actually easy, and usually has a powerful effect.
  • There are many aspects of my present situation which are evidence of great good fortune in my life. I am foolish to allow my attention to dwell too long on misfortunes which come my way, unless it is to learn something useful to carry forward in my life.
  • Investing a small amount of time in experiencing and expressing gratitude for what I have can lead to immediate substantial gains in the quality of my state of mind.
  • Progress in any area of my life is almost always possible, if I’m willing to accept the fact of my having limited power and knowledge. It can be difficult to be a mere human being, with all the limitations inherent in this status, but acceptance of my limitations can free me to work at reducing them, through patient, focused effort.
  • Good mental health is strikingly like good physical health: it usually doesn’t just happen, but rather results from intelligent, directed, repeated efforts. Children usually see and react; adults see, then plan, then act. They get better results. It’s better to be an adult.

To get these statements, I just asked myself what is true about my situation in life, and what I need to remember, given these descriptive truths, in order to function well. The set of “reminders” above are the result. They are not a final set, to be sure, but I note that just reading them improves my state of mind.

So…the question NOW is simply…what do YOU need to remember, about yourself and your life, to function well? I’ll predict that time spent with this question will be rewarding for you. I’d be interested to know what you discover…

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I just had an email exchange with a junior at a local college. Stress is a particular concern with this individual, and they’ve had both major challenges and major successes with stress in recent months. Today, they’re telling me that they are feeling “…a bit under the weather”. My response:

Yeah, used to happen to me a lot, too, in college. Why? Stress, pure and simple. It’s a high stress environment, which is one reason why you’ll be SO happy to be finished with it, eventually! Stress impacts our immune system negatively. Folks in college, where they’re exposed to all known pathogens in the universe (!), must be especially wary of this effect. Sooner or later it’ll “take ya down.”

While working one’s way through the college obstacle course, its wise to take the following recommendations as seriously as you can. I trust their effectiveness highly:

  • At any time need to lower your stress level, do a large sigh, in which you release as much muscle tension as possible. At the end of the sigh, sit in a little mental “quiet spot” for a few moments, being as still as possible internally. Practice not-doing for a few moments. Then return SLOWLY to the task at hand. Focus and move on. Repeat often, as this will train you brain to “settle down” more reflexively.
  • Sleep is the great healer. It “…knits up the raveled sleeve of care” – that’s how Shakespeare puts it. So, sleep MORE than you think you need. It’s putting money in the bank. Nap as often as you feel the need, and AT LEAST ONCE DAILY, preferably for 90 minutes. New research just out reports that people who do this LEARN MORE, recall more, etc., etc. A great payoff for something that also has distinct intrinsic rewards. I try to do this at least once daily. Lately, I’m getting up to 9.5 hours of sleep daily. I feel WAY better. Think I’m on to something? Care to try it yourself???
  • Exercise is the great normalizer, and second only to sleep (and proper eating) as a source of stress relief. By exercise I mean either aerobic (walking briskly or running or swimming, etc.) or resistance (weight room work or equivalent) exercise. Both give you simple tasks to do (“simple” is good), and an opportunity for a mental break. Probably more importantly, both cause fatigue in the large muscles of your body. Fatigued muscles relax, and relaxed muscles actually cause negative feelings in the brain to shut down. That’s stress relief of the most fundamental sort. But wait – there’s more: real exercise induces good, deep, healthy sleep. In college, when I started exercising right after finals, I stopped getting sick (which, until then, was highly likely).
  • Mind your mind: Remember your successes. You have many. You’ll have more. They’re what you’re working for. To get them, you MUST have some failures as well. Welcome then. They teach you what does NOT work – essential knowledge, and what you cannot (yet) do. If you’re not failing some of the time, you’re playing it safe or being lazy. So, work to accumulate those necessary failures, and the successes will come as sure as tomorrow’s sunrise.

For years, my own recipe for recovery or self-rescue from periods of intense stress has been very simple and quite fool-proof: eat, exercise, sleep. It simply always works.

Worth a try, eh?

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Since about November, 2008, I have been slowly working to improve the Posttraumatic stress disorder article at WikiPedia. It’s been fun, though at times inordinately time-intensive. Much of the article awaits my planned revisions, and I’m the only MHP (mental health professional) working on it, at the moment. As far as I can tell, I’m the only one who ever has. (More about that later…)

A few of the article’s sections are looking rather good. Medication (which took me 3 days!) is great, and Epidemiology is about 90% there. Other sections aren’t bad, but lack adequate references, or need their references checked (people can be incredibly sloppy). Some need a complete rewrite. Overall, the whole article needs some basic reorganization, which it’s about to get.

Wikipedia has enormous exposure on the Internet. It’s among the top 5 most-visited sites on the Internet. Of those, it’s the only one that’s non-profit. Its influence on a large segment of Internet users and various organizations and publications is truly impressive, and well surveyed here.

It’s also enormous. Nine years old, it currently has 14 million articles. Not words. Articles. Whew. Someone has a lot of free time, yes? In truth, I think it’s more about the passions of a small group of individuals, and the desire to share, than about free time.

It’s written collaboratively. You can go write there, if you like, but…you’ll have company. You’ll have to learn to work cooperatively, and to take the time to learn a little of the culture. There definitely are some rules and traditions you’re expected to play along with. Pretty much all good stuff, to be sure, but with some particulars you do need to know.

A certain amount of it appears overly influenced by popular culture, and an almost (heck – distinctly, at times!) adolescent point of view. But, for all that, there are reams of articles there which are very carefully written, meticulously documented, and flagrantly informative, if I may put it that way. A recently published study found its accuracy compared quite well with that of the Encyclopedia Britannica.[1]

When needing some quick information about some serious topic, Wikipedia is often the first place I turn. If nothing else, the references and links at the end of an article will quickly point me to some excellent information sources. But I usually get  much more than that.

Still, quality varies broadly, so it’s best that you know a little about your subject before reading a Wikipedia article, so you can filter the rocks out of the humus.

So, when I found that one of my clients with PTSD was reading about it there, I reviewed the article, and I was both intrigued and bothered. Some material in the article was excellent, but other major parts were poorly written, dubiously sourced (i.e., using shabby references), or simply irrelevant. I was annoyed. After some thought, I decided to try to fix it. But…I was totally new to Wikipedia, so I started slowly.

I hung out at the article’s Talk page for a while, and wrote some rather long and detailed answers to various questions. Suitably warmed up, I began contributing to the article itself. Slowly it dawned on me that I basically had no competition. There is only one other health care professional  involved with the article, at times, but he’s not a mental health professional, much less an anxiety disorders specialist. So, as it turns out, as long as I do my work according to accepted conventions (write clearly, make sense, and source major assertions with obvious authoritative references), I’m not challenged.  And, because of Wikipedia’s exposure and influence,  I’m feeling like I’m making a real contribution. At the very least, I can begin to stop worrying about what my clients might be learning about PTSD at Wikipedia!

So why am I so alone, as a major contributor to the article? I can only conjecture. In my personal experience, my MHP peers are a very caring, committed, and somewhat narrowly focused group of folks. Granted, work + family = little free time for many people, but that doesn’t tell the whole story. Many MHPs don’t write much, if anything at all. Many are not exactly enthralled by research-oriented psychotherapy. Few have much interest in community education or outreach issues. So, who’s left? Apparently, not many people at all.

I recently appealed for help on an Internet Discussion list I started some years ago. It has about 200 members, and a number of them are quite serious folks. I got no takers. OK…I guess I’m on my way to being the sole professional source for Wikipedia’s PTSD article. I do hope to have company at some point. It can only work to improve the article. However, I’ll stay with it until it meets my standards, which are definitely demanding. How demanding? Well, my Masters thesis in Counseling Psychology ran 385 pages, and I was told I’d written a dissertation. Didn’t get a Ph.D. for it, though.

Notes

1. Jim Giles (December 2005). “Internet encyclopedias go head to head”. Nature 438: 900–901. doi:10.1038/438900a. http://www.nature.com/nature/journal/v438/n7070/full/438900a.html.

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I recently added the following section (notes are at end of the post) to the Posttraumatic stress disorder article at WikiPedia (see my next post, for more on this). The information is completely up to date, and rather interesting – although probably only to other MHPs who treat significant numbers of clients with PTSD, which is my specialty –

Proposed changes to current DSM-IV criteria

(Note: the “DSM” is the Diagnostic and Statistical Manual of the American Psychiatric Association – the compendium of established mental illness diagnoses which mental health professionals in the USA, and a few other places, use. The fifth major revision is in preparation, and will be published soon. It’s a Big Deal, at least for some of us.)

On February 10, 2010, the American Psychiatric Association placed online for comment the draft diagnostic criteria for mental illness diagnoses which are proposed for the upcoming DSM-V. After a public comment period closes on April 20, 2010, the criteria will be field tested for two years, prior to final revisions and publication in May of 2013.[1]

The draft PTSD diagnostic criteria contain some noteworthy changes:[2]

  • Criteria A (prior exposure to traumatic events) is more specifically stated, and evaluation of an individual’s emotional response at the time (current criteria A2) is dropped.
  • Several items in Criteria B (intrusion symptoms) are rewritten to add or augment certain distinctions now considered important.
  • Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This is especially evident in the restated Criteria B – intrusion symptoms. Development of age-specific criteria for diagnosis of PTSD is ongoing at this time.
  • Criteria C (avoidance and numbing) has been split into “C” and “D”:
    • Criteria C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in descriptions.
    • New Criteria D focuses on negative alterations in cognition and mood associated with the traumatic event(s), and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria.
  • Criteria E (formerly “D”), which focuses on increased arousal and reactivity, contains one modestly revised, one entirely new, and four unchanged symptoms.
  • Criteria F (formerly “E”) still requires duration of symptoms to have been at least one month.
  • Criteria G (formerly “F”) stipulates symptom impact (“disturbance”) in the same way as before.
  • The “acute” vs “delayed” distinction is dropped; the “delayed” specifier is considered appropriate if clinical symptom onset is no sooner than 6 months after the traumatic event(s).

Finally, the inclusion in the DSM-V of a Developmental Trauma Disorder is still under discussion, at the time of the draft publication.[3]

Notes

1. Gever, John (10 February 2010). “DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses”. http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/18399. Retrieved 10 February 2010.

2. “309.81 Posttraumatic Stress Disorder – proposed revision – rationale”. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165#. Retrieved 11 February 2010.

3. “Conditions Proposed by Outside Sources”. http://www.dsm5.org/ProposedRevisions/Pages/ConditionsProposedbyOutsideSources.aspx. Retrieved 11 February 2010.

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I’ve been a vegetarian (meat – no, eggs and cheese – yes) for over 35 years, for well thought out moral, environmental, and health reasons. I very rarely talk about it. I basically do not proselytize on this subject. That changes, now, and here. I’m going to talk about it, and I want you to think about it. Suddenly, it matters, as you’ll see.

EATING AS A MENTAL HEALTH ISSUE?

A long time ago, someone who’d been born into luxury and comfort and safety discovered that no one can really escape the fact that life hurts. All of us come to sickness, pain, loss, and death. Or, as it is said that he put it: All of us come to unavoidable suffering. (This person, of course, was Siddhārtha Gautama, more commonly known as “the Buddha“, this being an honorific term translating approximately as “sage”, “wise one”, “enlightened one”.

One of the more interesting things about the Buddhist moral tradition is its concern for the suffering of all beings. In our own time, formal mental health intervention is one of the ways we deal with human suffering, along with medical/surgical interventions, etc. At various times, the tide of human suffering has advanced and retreated. It’s about to advance, again, it appears, and what we eat has something to do with this, as you’ll see.

CLIMATE CHANGE AND STRESS

The fast-approaching climate change crisis has already begun affecting people in the lowlands of Bangladesh and some of the island nations of Polynesia, due to threatened and actual rises in sea levels, and increased frequency of typhoons (we call them hurricanes in the USA).

Imagine the impact on your life if rising water chased you permanently from your home, without hope of return in your lifetime or that of your children. You’ll become a climate change refugee. Where will you go? What will happen to your way of life, to the hopes you had for your children?

At the purely human level, this is about exorbitant levels of stress. In sociology, it is well known that in stress-impacted families domestic violence rates go up, sexual abuse rates go up, divorce rates go up, mental illness rates go up. and so on. That’s quite an impact for something that can be traced to small changes in the percentages of certain gases in our planet’s atmosphere.

Now imagine that this mental health challenge is quite significantly related to what you eat, daily. As it turns out, this is true. It’s highly likely that the oceans will rise around four feet in the next century. That will impact coastlines all over the world, because it’s on coastlines where most of the world’s population lives. The impact of storms will be very much increased.

In the USA, large areas of Florida may become to dangerous to live in. New Orleans, Washington DC, New York City, and other major population centers will become at high risk for catastrophic storm damage. Many parts of the world, including in our own country, will have to deal with millions of climate change refugees.

A one meter rise (four feet) in ocean level is estimated to probably create 20 MILLION climate change refugees in Bangladesh. Where will they go?

THE RELATIONSHIP BETWEEN WHAT WE EAT AND CLIMATE CHANGE

Now, let’s talk about what we eat. To put it plainly, what you choose to eat can have a huge impact on the mental health of others (as well as your own health), through the mediating factor of climate change. I want you to understand the relationship better.

Here is an article in which a British Lord, a well-informed, well-placed fellow, says some things to say about the relation between industrial meat production and climate change, something about which we’re going to be hearing much more in the near future.

The point he makes is that among the lifestyle changes we need to seriously consider are some that have nothing directly to do with fossil fuel consumption. With industrial meat and milk production, methane gas is the problem, not carbon dioxide. (This is more generally known as “natural gas” – yeah, the stuff people can cook and heat with.)

This aspect of the climate change crisis – the methane produced by the meat/dairy industry – is not well known…yet. I’ve know about it for about a year.

METHANE IS NOT YOUR FRIEND!

Here are some basic facts you should know about methane as it relates to climate change, with some quality documentation:

  • Methane is lighter than air, and is naturally produced in a variety of ways, including the decay of organic matter in low- or no-oxygen environments. One of those environments is the digestive tracts of rumiant animals (cattle, etc.) Such animals produce “16% of the world’s annual methane emissions to the atmosphere”, [1]
  • “The livestock sector in general (primarily cattle, chickens, and pigs) produces 37% of all human-induced methane”. [2] (quoted in [1])
  • “Methane is a relatively potent greenhouse gas with a high global warming potential… Methane in the atmosphere is eventually oxidized, producing carbon dioxide and water. As a result, methane in the atmosphere has a half life of seven years.” [1] (The core reference used here is [3])

OTHERS DIE SO THAT YOU CAN EAT AS YOU LIKE

An additional aspect of this mess, which is worth mentioning, is that to produce one pound of edible protein from a cow, that cow must consume 22 to 26 pounds of vegetable matter. Feed that matter (or similar crops more suitable for human consumption) directly to people, and you can feed roughly 20 people instead of one. [4] Now you know one of the two reasons I stopped eating meat over 30 years ago.

This doesn’t matter, of course, if you think that the death of a little brown/black kid from nutritional inadequacy (it sounds so benign, yes?) doesn’t matter as much as the death of a little white child. Most people don’t have to think about this, of course, thanks to the blessings of the “out of sight, out of mind” phenomenon.

But…I’m asking you to think about it. At some point the relationship will become unavoidably obvious. Imagine the impact on your mental health if you have someday to realize that you could have done something about this problem, personally, but just walked on past the opportunity, as if it didn’t matter.

START SMALL…KEEP GOING

A final thought: It doesn’t have to be either/or. Simply reducing the amount of meat you eat will be helpful. You can walk slowly toward omitting it entirely from your diet. And you should know this: the concern expressed in Lappe’s book [4] for correct mixing of vegetable proteins to simulate meat protein turns out to be unnecessary. I gave that up a long time ago, and just eat a variety of vegetarian protein sources. My health is,  and has been, excellent. Dr. Andrew Weil confirms the legitimacy of this more relaxed view of the protein sufficiency of vegetarian diets. [5]

It’s easier than you think to do the right thing – for the health of your body, for your eventual mental health, and for the mental health of large numbers of people you’ll never meet. You can do this simple think yourself, and tell others about it. You might even send them here to read this.

References

[1] “Methane” (Wikipedia article). Downloaded 2009.10.26 from http://en.wikipedia.org/w/index.php?title=Methane&oldid=322309918 – mostly a chemistry article, but with some good summaries and references relevant to the industrial meat/methane issue.

[2] Livestock’s long shadow: environmental issues and options. Food and Agriculture Oorganization of the United Nations
Rome, 2006. Downloaded 2009.10.26 from http://www.fao.org/docrep/010/a0701e/a0701e00.HTM A PDF download version of this is available here: ftp://ftp.fao.org/docrep/fao/010/a0701e/A0701E.pdf (for broadband use only – it’s a large file).

[3] Chapter 2 of: Climate Change 2007: The Physical Science Basis. Contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. This is a section of the most recent publication of the Intergovernmental Panel on Climate Change of the United Nations Environment Program (UNEP) and the World Meteorological Organization (WMO). This group of 500+ scientists of international stature was established “… to provide the world with a clear scientific view on the current state of climate change and its potential environmental and socio-economic consequences.” (http://www.ipcc.ch/organization/organization.htm)

[4] Frances Moore Lappe. (1991). Diet for a Small Planet. New York: Ballentine. This is the book, originally published in 1971, which turned me into a vegetarian. I bought a copy on the way out of town, leaving the University of Colorado with a fellow graduate student to go deer hunting in Montana. I went along as a  “participant-observer”. I helped skin and dress 5 deer. The amount of sheer wastage we produced was staggering to me. I had no idea meat production involved such waste, and this was only in the butchering part of the process. It was an incandescent experience. The book gave me the rationale for my diet-change, but this experience gave me a good part of the motivation. I’ve never looked back, in 35+ years. What’s to miss?

[5] Weil, Andrew. (2001). Eating Well For Optimum Health: The Essential Guide to Bringing Health and Pleasure Back to Eating. New York: Harper.

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I wrote recently (A unique and shining moment…) of observing something very encouraging and informative – the positive effect on persons of color of the election of Barack Obama to the Presidency of the United States. Of course it’s had a positive effect of many of the rest of us as well, and I honestly believe that this effect will grow, over time. This is a man who exemplifies what can be accomplished when one marries vision, persistence, focus, and intelligence. This is a life from which we can all learn.

But how is that? How is that the life of another person can teach US something? In psychology, there has been considerable research and writing on something called Social Learning Theory. The research has largely supported the theory, and it all reduces to this: We learn from observing the actions of other people, and this effect is increased to the degree that we can see ourselves in them.

So, when a child, adolescent, or adult sees a human being with whom they can identify do something remarkable, it becomes easy to fantasize (the beginning of belief) that they also could do something remarkable.

Put differently, when we have models of functional normalacy, it becomes significantly easier for US to become functionally normal. Life really isn’t about the remarkable. Most of us will never be “remarkable”, and we don’t really need to be. We just need to have enough, do enough, be enough. This is hard to do when the most visible people in your culture clearly are NOT like you. There are many minority groups in our country who are negatively impacted by this problem. It injures them, and to that degree injures all of us.

I’m absolutely amazed and thrilled to observe, at this very moment, CNN reporters interviewing very ordinary kids walking on the Capital Mall today, the day before the Presidential Inauguaral, kids who are simply glowing with pride. I truly believe that for many of them it has never been easier to feel good about themselves, about their possibilities, and about the world in general. This is a very very good thing.

We all need vision, in our lives, and our minds. Some of us can provide vision for others of us, by what we do, especially in the public arena. Such role models most include ALL the people who comprise our remarkable nation, and world. President-Elect Obama’s remarkable achievement has given ALL of us a great gift, and its value is only beginning to manifest.

When I was eleven years old, I can recall seeing an article in the Reader’s Digest – a lead article at that – which went to great lengths to attempt to tie Martin Luther King and his associates to the International Communist movement. This was an idea actively promoted by the long term despotic Director of the US Federal Bureau of Investigation, Herbert Hoover, as has since been well documented.

My own parents, both raised in Texas, had always taken a clear position that persons of color (not the term in common use at that time) were as good as anyone else. They certainly didn’t see themselves as part of any movement, however, and nothing was said about that absurd article in the Reader’s Digest. And I can vividly recall going to Texas as a child and seeing “Black only” water fountains out in back of the service stations. It just looked strange. Still does, in  my mind’s eye – strange and frightening.

But today, and tomorrow, all of us – ALL of us – who wish to, can feel proud about how far we’ve come. And we need to remember that there are still very significant groups of people in our country who have great difficulty feeling proud about who they are. They need all the encouragement, and positive, affirmative, action, we can produce in our society. I’m thinking particularly at this moment of Native Americans and people in minority sexual/gender identities. But there are many other groups about whom we should be equally concerned. This is a social health issue, and most certainly a mental health issue.

Diversity is one fundamental aspect of humanity. People whose only distinction is that they are “different” are a fundamental asset for us all, and we need to cherish them, and help them to cherish themselves, so that they can achieve and maintain the essential pride which is the birthright of us all.

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By at least a ten to one margin, the most read and commented-upon post to this blog is my August 1, 2007 End times: Coming to the end of psychotherapy. I had not expected this, when I published the piece.

Originally written to help one of my clients sort out their thinking as they came to the end of their time working with me, I had posted it because I did think others might find it useful. It appears, now, that it addresses a real and persistent problem. Well, such problems are what we deal with in psychotherapy, and sometimes in our blogs as well.

So, “what’s the problem”? There appear to be two of them: psychotherapy clients, and their therapists. That’s simply what the data appear to support. Let me address each, in light of the continuing comments to the blog entry, and in relation to one in particular (which was withdrawn by its author, so you cannot find it there).

THERAPY CLIENTS AND THEIR ISSUES

Clients appear to have trouble with leaving for several reasons, among which are:

  • They cannot decide if it’s time or not. They don’t know how to arrive at  a decision they can feel comfortable with.
  • They have to leave, and don’t want to, and it’s disturbing them.
  • They’re ready to leave therapy, but don’t want to lose contact with their therapist.
  • They want to leave therapy, but their therapist is objecting, or advising against it.

I think you’ll agree that that covers a lot of ground.

THERAPISTS AND THEIR ISSUES

From the report of people writing comments to my blog entry, it appears that therapists also have trouble with therapy termination for a variety of reasons, among which are:

  • They think their client is making a poor decision, and really isn’t ready to leave.
  • They think their client is being “resistant” to therapy, and is basically “fleeing” therapy.
  • They appear committed to a long term relationship with their client, for reasons which (to me) appear suspicious, and object to a client’s attempts to break free.

I want in this post to comment about therapists and their problems, mostly, since the clients’ side of the picture has been commented upon by me extensively in my original post, and in my responses to readers’ comments.

When therapists think their client is making a poor decision, and really isn’t ready to leave. In a hospital, if the doctor treating you isn’t ready to discharge you and you leave anyway, which is certainly your right, unless you’re being held there under court order, you’re advised that it will be noted in your chart that you’re leaving “AMA” – again medical advice.

In other words, it is customary to tell you that we think (I used to work in a mental hospital) that you’re making an ill-advised decision. Partly this is to protect ourselves legally, but it’s also a last chance to ask you to think things over. Warning you about an “AMA” discharge seems good practice for both parties, and it’s usual and customary practice.

Such circumstances certainly occur in outpatient practice as well, and the same justifications for voicing and recording objections of the treating professional to the departure of the client hold weight in this context. In other words, we are almost certainly remiss if we DO NOT give this warning.

So, clients, you do well to consider the larger picture when you find that your therapist does not support your leaving. The disagreement likely has in it an element of real concern for your welfare.

Yet some clients come to therapy with the expectation (which can escalate to a demand) that their therapists “support” them, period. This is both unreasonable AND reasonable, in the following senses:

  • Reasonable: Our first obligation to you is to support the promotion of your health. It’s the oldest admonition in the healing arts. This means that we need to be able to offer you an informed opinion about your condition, AND that we actually make you that offer. But…
  • Unreasonable: There’s no guarantee that you’ll like what you hear  when we offer you this kind of support. Making you immediately happy is not the purpose of such support. Assisting you to be healthy in the long run IS.
  • Reasonable: “Support” is a favorite word women use in talking about their close social relationships, and with good reason (men seem not to talk about this). It’s a high value for most women, and by “support” they mean what I would call the offering of emotional congruence. That kind of support is appropriate in therapy as long as it supports (in the other sense!) your health. Such support can very meaningfully help a client learn to value their own feelings and viewpoints, for example. But…
  • Unreasonable: Do not expect us to support you emotionally while you make what appears to us to be a bad decision. That’s like praising you for staying on road while driving, as you drive across a washed out bridge.

So, can we do both at the same time? Can we support your “personhood” while disagreeing with your decision to leave? Of course, and I think we must.

I think that at all points in the therapy relationship we need to support our clients’ thinking for themselves. This, fundamentally, is about self respect. But, we also need to MODEL this behavior, which is what I do when I disagree with a client’s decision to leave. How can I advise you to respect your own thinking if I do not respect my own? Therapists are in many ways like parents: they cannot be, or act like, “friends” or “buddies”. We are coaches,  sources of expert opinion and intervention, and most definitely models. Any other understanding is almost always ill-informed and ill-advised.

Basically, our being both supportive and unsupportive of a client, when we find that that is our true position,  is asking a client to be an adult. We’re saying “It’s important that you make your own decision, and do what you think best. Nothing else will really work for you, howsoever scary it may be at the moment.” And then we may also say “And I do not agree with your decision to leave therapy at this time. I think it’s ill advised.” And then, finally we say (at least I say this, because I think it’s very important): “Now you have to make a lonely decision. I’ve given you my best thought, and the most important part of it is that it’s up to you to decide, just as it’s your fate to meet up with the consequences of your decision. This is the way life really is, and I’m here to help you with this little piece of it.”

Some clients have trouble with this, in large part, I think, because we therapists don’t work hard enough making clear what our purpose is: not to make life easy, but to make it better. Often, that means “no pain, no gain”. Some clients really kick and scream about this. I consider that a normal part of their life development. We’ve all done it at one time or another, believe me! And we therapists must remain adult, hold our ground, and hold out for the overall improvement of our clients. We, too, have a lonely decision to make: just as you have to do what you think best, and no one can really take over for you, so do we. It’s part of our ethical commitment to you.

(I’m laughing to myself right now…recalling how many times I know of parents who truthfully told their kids “You’ll thank me for this some day.” What a day of true joy THAT is – ha!)

When therapists think their client is being “resistant” to therapy, and is basically “fleeing” therapy. Well, some clients ARE resistant, and they do flee. The “resistance” is typically based either on a failure to understand what therapy is actually about (“What? I have to walk TOWARD my pain? Are you NUTS?”), or on fear, or both. The “fear” is more serious, more complex, and more difficult to deal with.

Just to give one example: a client I had once basically had never, as a child, had an emotionally supportive, protective relationship with an adult she could trust. I was probably the first person who’d ever invited her to trust herself (AND me) as we looked back at the painfulness of that childhood. She’d thought that therapy would be like a magic pill, and that we’d quickly and permanently anesthetize large parts of her memory.

When I advised her that that wasn’t quite accurate, she simply couldn’t trust that I knew what I was talking about. I think that she also couldn’t trust that she could survive contact with her feelings. She ran, against my advice and in spite of my best efforts to calm and reassure her. I believe her departure was due both to her mis-perceptions about how therapy works and her fear of herself and all other adults. A tough story, for both of us.

On the other hand, some therapists call any client who want to leave before the therapists deems them ready “resistant”. I strongly object to this. First, I don’t think it’s helpful in any way. Second, I think it a poor characterization of what’s actually happening.

Resistance can be a very good thing. I will resist your picking my pocket, for example. But it also can be a completely wrong word. If I resist having a perfectly good meal with you, because if I do so I’ll miss my train, “resisting” your invitation is simply rational. So is it rational if my client evaluates her situation, listens to me and anyone else she cares to listen to, then decides that what she want to do is leave? In that case, her leaving is the only sane, rational thing to do, and I would strongly support her leaving for that reason.

I have in fact most certainly told clients who I thought were leaving therapy prematurely (I do get a few!) that I thought all in all they simply had to go, that not to go would be wrong because it would be an act of self-disrespect. And I said this after telling them that I was convinced that therapy would be good for them, and  thought they needed it.

Again I say: I know this isn’t simple. But it IS true, and telling the truth is my first interest and first obligation. The challenge of understanding this truth is a completely separate issue.

WORKING TOGETHER TO MAKE THIS EASIER

From the moment I began addressing this topic, over a year ago, I knew that often it’s a difficult one for all concerned. I have, at all points, felt most concerned about the difficulties clients have with ending therapy. They are the more vulnerable, less informed, less experienced of the two individuals involved. I think we therapists need to help them with this issue just as we do with others.

Therapists get in trouble with this issue just as do their clients, sometimes for the same reasons! Sometimes their troubles are of their own making, and sometimes they are due simply to the nature of the problem. A fundamental objective of my writing on this topic is to raise awareness by both therapy clients and therapists both of the pervasive existence of this problem and of its nature.

We need to talk more with each other about this matter, preferably from an informed point of view. We certainly also need to respect each others difficulties in dealing with therapy termination. All in all, this problem isn’t going to go away, and isn’t likely to get much easier over time. It will just be there, waiting for us.

When therapy termination time comes, we need to do with this what we do with other problems in psychotherapy, turn toward it, look it in the eye, see its parts, feel our feelings, talk to each other, and, while as fully alive and functional as we can be, simply walk through the fire. It’s what we do, and it’s what we’re good at – or trying to get good at! It’s just another part of a life which isn’t always easy but which IS manageable.

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Tuesday, election day for us in the USA, I was barely able to get productive work accomplished. It wasn’t just a matter of being concerned that “my” candidate for President might lose. It was a mixture of many things, including:

  • the sense that our country stands at a unique moment – we either embrace the serious challenges facing us, or fall farther behind other countries who already are assuming a leadership position in the world relative to matters such as universal health care, a rational national energy policy, and an active commitment to economic, cultural, and social justice for all its citizens;
  • the sense that this long election campaign so much needed to end, for all our sakes, coupled by amazement at the apparently limitless energy of all four of the major national candidates, right until the final hour;
  • indescribable amazement at the fact that someone who was a state senator a mere four years ago appeared about to win the Presidency, someone whose intelligence, emotional balance, and capacity to organize his campaign in a manner never before seen has been commented upon by virtually everyone who wasn’t actually running against him (and at times even by them).
  • amazement every time I saw the Obama family on a public stage; when I was a child, and even a young adult, this family could simply not have been in such a position, running for a national office. Could we really have come this far?

And now that it’s all over, a new surprise: it seems that virtually everyone is celebrating. It appears nearly universal – that we recognize that as a nation we have turned a corner. This is a national Affirmative Action moment.

I say that because I can see the effect Obama’s election is already having on African Americans – there is an apparent sense of personal validation. THIS, for those who just don’t get it, is why we need people of all “flavors” in leadership positions. “Equal” mean equal access, and not just in theory. In actuality. Equality simply needs to be a visible reality, so that our children can see it. Now, in a sense that has never before been true, for African Americans, it is.

BUT…the caution: We still have a long way to go. The trans-generational effects of slavery, and of Jim Crow racism, are with us still, and will be for quite a while yet. The solution isn’t to make black people white, but to make our society brown – a mixture, at all levels. It simply has to be acceptable to appear, sound, and (even!) act black, at all levels. I can say this, as a Caucasian: too many white people simply don’t yet get this. And it isn’t just true for black people – tolerance for diversity remains one of our most central social challenges.

Now….to stay on topic – does any rational person doubt that social inequality has mental health consequences? It isn’t enough to have “equal access”. Only equal achievement will do the trick, and we have yet to achieve this, on so many fronts.

Social intolerance, and inequality of achievement affects everyone. What hurts one hurts us all. We cannot fail to care about our neighbors. We may well disagree about how to turn our caring into social policy, but about the goal there cannot rationally be disagreement. When one of us is injured by life, by social circumstance, by accident of birth, we all are injured.

This is a rare and shining moment we are having this week. We are not likely to pass this way again any time soon. I savor this moment, and seek to draw energy from it. There is a great deal of work to be done, by us all.

We really do need all hands on deck. I’d like to think that this week, “the crew” increased very meaningfully. I’m grateful to Obama, for who he is and what he has done, but I’m probably more grateful to my fellow citizens. As he said, we did this. It is our moment more than anything else – and no ones more than those folks who voted for the other candidate but still feel good about this moment. The last time we came together like this – and world drew close to us – we had just suffered a national terrorist attack. This time feels very much better, and will surely have more far-reaching consequences.

As we look at the challenges the whole world faces, in this and the next generation, we all need to believe “Yes, we can”. Then, we need to act on our belief.

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