Pain is inevitable, suffering is optional

I've been reading Rick Hanson's book Buddha's Brain, a fascinating and very readable presentation of the neuroscience behind mindfulness practices. Recently these practices, including relaxation and mindfulness meditation, have received support as viable treatments and, unlike medications, there are very few side effects.  I have been finding myself recommending mindfulness meditation to clients suffering from anxiety, depression and impulse control disorders.  It is a nice way to develop resilience and self-efficacy while enhancing health through decreased tension.  There is even a smartphone app called Mindfulness Meditation that can walk you through several basic meditation routines.  While not a panacea, mindfulness practice can be very helpful.

One quotation that I have found especially helpful in re-framing problems that we all struggle with is: "Pain is inevitable, suffering is optional." What I like about this quote is that it highlights the role the sufferer has in the creation of his or her misery.  Pain cannot be avoided.  It is an essential though unpleasant aspect of being alive.  We can, however, choose to accept this reality instead of engaging in the grandiose fantasy that pain can be avoided or negated.  We often find that the pain, once regarded as intolerable, is actually manageable once we let go of the delusion that it can be avoided.

So much of what my patients come to treatment for relief from is the by-product of frantically trying to avoid discomfort.  Alcohol, drugs, sex or compulsive shopping all promise relief from, or at least avoidance of pain but in the end they only create suffering.

Using mindfulness techniques can help us "sit with" and tolerate all of our feelings, painful or otherwise, and to function with resilience.  Our culture of immediate gratification and pursuit of the latest and greatest makes this hard but we can choose to exercise mindfulness just like any other muscle.  When we do, we live more intentional and satisfying lives.

Kentucky Psychology Board Moves to Censure Advice Columnist

In an interesting twist on protecting the public, the State Board of Psychology in Kentucky has filed suit against John Rosemond, a North Carolina licensed psychologist who writes a syndicated newspaper column, for practicing psychology in Kentucky without a license.  Rosemond's collumn appears in more than 200 newspapers according to a post on the Institute for Justice blog.

Each state has the authority to regulate the activities of professionals who offer services to citizens of the state. Each board is established by the legislature of the state and interprets the laws pertaining to professional practice in that state.  As a Pennsylvania licensed psychologist, I am required to adhere to the standards and regulations put forth by my state's licensing board.  If I do not, I risk sanction or the loss of my license to practice.  Anyone who wishes to practice psychology in Pennsylvania must apply to the board for permission to do so.

That's where the rub comes in the Kentucky case.  It seems that Rosemond, who has written 14 books on parenting, offered advice on parenting to which one retired psychologist in Kentucky took exception and wrote to the Kentucky board to complain.

The job of any professional board is to protect the public from harm and in this instance the Kentucky board reasoned that Rosemond's advice constituted the provision of psychological services for which he was not licensed in Kentucky.

Potentially, this opens a whole can of worms if one accepts that advice given in a syndicated column constitutes provision of psychological services.  Writers from a libertarian perspective cry foul because this would seem to limit first amendment rights to free speech.

It's hard to know exactly what argument was made in the Kentucky case but licensing boards are generally quite careful to deliberate fully before making a move.  They try to talk through the potential ramifications of various steps and to interpret the law as clearly as possible.

Another problematic situation that many state psychology boards are trying to work out is how to regulate the provision of counseling via electronic means.  For example, let's say you decide to start working with Dr. X who practices in California because he is an expert in the treatment of a disorder that you have.  Because he is in California and you are in, let's say Pennsylvania, you decide to conduct your sessions through Skype.

So what state regulates this professional service, California or Pennsylvania?  Who has jurisdiction to prosecute Dr. X if you feel that he has acted unethically or committed malpractice?  One suggestion is to have a national "passport" or universal certification but this may run afoul of state laws that prevent states from relinquishing regulatory authority.

Whatever the answer, this issue is likely to come up more frequently as consumers increasingly look to electronic sources for healthcare.  Some studies are even finding that internet based psychotherapy is as effective as face-to-face therapy.  There will be more to say about that later.

Evaluating Scientific Sounding Claims

Two stories on the radio this week got me thinking about the ways that we use science and how scientific discoveries are communicated to us. The first had to do with research on the toxoplasma parasite carried by cats (toxoplasma gondii). This parasite can cause toxoplasmosis in humans, an illness that can cause death in children and adults and birth defects in the fetus.  (If you have a cat litter box, wash your hands after cleaning it!) The argument went something like, toxoplasm is carried by cats. Cats began to be domesticated by humans and were very common at about the same time that rates of schizophrenia increased rapidly around the turn of the century, therefore there might be a relationship between keeping cats as pets and schizophrenia. The full episode of Radiolab, which aired the segment, can be found here.

Another story examined the role of microbes in human life.  Everything from the beneficial bacteria in our stomach to more esoteric microbes that can affect our behavior.  The point seemed to be that microbes could be the master controller of human behavior. The full NPR story is here.

Both stories are admittedly intriguing and the scientists interviewed are not crackpots.  So how do we really evaluate the science we hear and apply it sensibly in our lives?

One thing to keep foremost in our minds is that a relationship between two events does not tell us anything about the causality that may or may not link them.  Because schizophrenia increased when we started keeping cats as pets does not establish a causal relationship between cats and schizophrenia.  In fairness, the relationship between certain mental illnesses and toxoplasma has been reported elsewhere, I'm exaggerating somewhat to make a point.

The relationships between these issues is complex.  There is more interdependence, or what statisticians call covariance, than direct causal relationships among the variables.  It is more interesting to talk about the possibility of grand relationships and science fiction than to tackle the nuances of the relationships.  Who wants to read a dry science article when we can talk about protozoa taking over our minds.

So the point is to take science reporting at face value.  Dig deeper if a topic interests you and treat grandiose claims as what they are, bad science.

Tolerating Discomfort

"If some longing goes unmet, don't be astonished. We call that Life." - Anna Freud

This is essentially the argument for affect tolerance, the ability to tolerate all of our feelings and continue to function; being able to feel all our feelings without compulsively needing to anesthetize ourselves from them. There are always discomforts, disappointments and even tragedies in life. Our ability to bounce back from these experiences is resiliency. We can learn from our feelings, particularly the uncomfortable ones, so long as we are open to having them. If we choose to close ourselves off from these feelings we do so with the cost of impoverishing our genuine experience. 

So many of my patients come to me initially seeking relief from "anxiety" or "depression" by which they mean a subjective experience, a feeling, that is uncomfortable or unbearable. Our culture tells us that there is no need to tolerate an uncomfortable feeling. There are medications or new consumer products that can take these feelings away, banish them to the unknown.

But in doing so we flee the here and now for imagined comfort of somewhere else.  We trade our lived experience, the only true reality, for some imagined talisman that will end our suffering.

Michael Balint, a Hungarian psychoanalyst, argues that advertising, art, the longed for relationship, all depend upon our yearning for what he calls the transformational relationship. If we could possess that thing or relationship our lives would be transformed and made better. 

The hard sell in psychotherapy is that rather than taking uncomfortable feelings away, we work to increase the capacity to tolerate the full range of feelings, including the "bad" ones. So question is not "how can we take that feeling away?" but rather, "how much of that feeling can be tolerated?"

As you can imagine, not everybody wants to take that on. Why not just make the thing that causes discomfort go away? The point is that once a greater capacity to experience feelings without being overwhelmed is reached, greater emotional flexibility and resilience is attained, and that is the proper goal of growth oriented psychotherapy. 

Resilience from a psychoanalytic perspective

In 1932, addressing a gathering of medical students, Sigmund Freud made the famous and often quoted statement "where Id is, there ego shall be" (New Introductory Lectures). For a long time, before I read Freud more closely, I took this to mean that over time the ego could be trained to better dominate the unwieldy Id and that he was really talking about domination of the impulses.

As a review, the ego is that part of the mind with which we are most familiar. It is the seat of our conscious thoughts, sense of the here and now and the experience of the ourselves at any given moment.  The Id is the source of energy in the mind; all the instincts and drives as well as the parts of ourselves that we find uncomfortable or unacceptable. (As a side note, Freud's language was much more familiar and less scientific than the Latinized "ego" and "Id" suggest. Freud's translator, James Strachey, wanted the theory to sound more scientific and so dressed up the English translation using Latin terminology). 

At any rate, my initial understanding of this famous phrase could not have been more wrong. Freud was not suggesting that we increase our censorship and banish more of our experience to the Id, he meant the opposite; that as the ego grows stronger, more of the Id can be tolerated in our everyday lives. This enables us to benefit from all the energy of the Id and function more flexibly. 

Anger is a good example of this process. Many of us are uncomfortable feeling anger and even less comfortable expressing it directly. We are led to believe, through growing up, that it is impolite to express anger so we squelch it at every opportunity. The problem is, there is a lot of energy to be had in anger and anger can be an important signal that our needs are not being met. If we divert anger out of our awareness and into the Id, we loose this resource and impoverish our ego. 

This is not to say that we should be yelling at people all the time or making unreasonable demands. Rather, we should learn to tolerate anger (and all of out feelings) without resorting to defenses that negate reality and squelch anger. 

If the Ego can be strengthened so as to tolerate all our feelings, comfortable as well as ugly, then we expand the Ego and allow it occupy territory once claimed by the Id. We function more flexibly, get overwhelmed less easily, and experience life more fully.  That is resilience from an analytic perspective. 

A Brain Test for ADHD?

One the problems with psychiatric diagnosis is that we do not have "objective" measures that rule the diagnosis in or out in the same way that medical blood tests and the like do. I put "objective" in quotations because even blood tests are much more subjective than we might think.

A psychiatric diagnosis is made by identifying and categorizing behavioral symptoms.  For example, if a patient exhibits a certain number symptoms (five out of eight for example) listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) for a given duration, they qualify for the diagnosis. Absent from this schema is any real understanding of the reason for the symptom, it's function as a coping strategy. At the turn of the century Freud wrote of the need to understand the "sense" or meaning of symptoms rather than their mere existence (Freud, 1920. Introductory Lectures on Psychoanalysis). 

A new "objective" test has been approved by the FDA for the diagnosis of ADHD:

From the New York Times http://www.nytimes.com/2013/07/16/health/brain-test-to-diagnose-adhd-is-approved.html?partner=rss&emc=rss&smid=tw-nytimes&_r=0

"The test uses an electroencephalogram, or EEG, with sensors attached to a child’s head and hooked by wires to a computer to measure brain waves. It traces different types of electrical impulses given off by nerve cells in the brain and records how many times those impulses are given off each second.The test takes 15 to 20 minutes, and measures two kinds of brain waves — theta and beta. Certain combinations of those waves tend to be more prevalent in children with A.D.H.D., the Food and Drug Administration said in a news release."

 So will this eliminate our uncertainty when making a diagnosis of ADHD?  Probably not.  Our diagnostic system or nosology rests on a false belief in the reality of diagnostic categories.  In reality there is no such thing as "depression"or "ADHD."  I do not mean to imply that people do not suffer or that their lives are not impacted by these disorders, only that as an objective reality, these diagnoses are just constructs, ways of organizing phenomena into categories.

Without getting too philosophical (professors can get that way), suffice it to say that EEG's and medical tests exaggerate the certainty with which we draw conclusions.  We still do not know that a patient has ADHD even if they test positively on this new procedure.  What is more important is understanding the context and function of the symptoms so that we can help the patient.  As Freud pointed out, we need to make sense of the symptom and not just categorize them.

Stop Bullying Website

The following info graphic was posted on www.stopbullying.gov

Bullying: What You Need to Know