Mixing modalities

From the Flikr Stream of Emily Hoyer

 

 

 

    A little while ago I started getting trained in the fundamentals "Sand Tray" a particular tool of play therapy. It's very interesting and has more in common with art therapy than it does in what people consider "traditional" therapy where people sit around and talk.
    The set up is pretty simple, you have a container roughly the size of a storage bin filled 1/2-3/4 with sand, and a host of miniatures and a mental health professional. From there you essentially let people do what they want. Some people just push the sand around, others make simple, static scenes. Others make highly elaborate dynamic stories that fill, or even overflow from the container. What usually gets created is the person's head space in some way, shape or form.

    It's a very different way to engage with one's mind. Because it's so mailable, and those hard to articulate thoughts can be represented in the tray without words, a whole new way of working with one's inner life is possible. It's accessible for children and adults, average functioning people, those with disabilities and everyone in between.
    I'm really smitten with it :-) . Everyone's welcome to come and try it out!

Woo! Inflammatory article time!

So Mr. James Oliver at the Guardian has written an article on how current (lack of) genetic evidence for mental illness in populations is strong evidence that much of it is socially constructed, and there for, conservatives are dumb. Ie. Psychological challenges are much more prevalent in people who have a low socio-economic-status as opposed to those who enjoy a high SES regardless of genetic tendencies.

He goes on to talk about how, from a genetic perspective, south east Asia should have the highest rates of depression. While from psych testing it shows to have some of the lowest rates. He goes on to state that this is because they are much more collective society but he doesn’t site any peer-reviewed evidence to support this. Then he goes on to talk about how conservatives are echoing ideas of “Social  Darwinism” in the belief that the genetic sciences would back them up.

While I believe that SES, culture, and environment and quality of learned coping and interaction skills are probably the most important factors in mental health I’m reluctant to take the leap Mr. Oliver did. Correlation / causation are dangerous ideas to conflate, and the ad hominem attacks with it speak to me of major editorializing. Which strikes as a problem when presented in an article that is originally set up to be a fact based one.  

But still… more and more to think about…

It gets better

http://www.itgetsbetterproject.com/

I know I’m a few weeks behind the cutting edge, but I think for everyone who’s not familiar yet with Dan Savages amazing new support idea “It gets better” campaign I thought I’d fill ya in. The main focus is help prevent suicide among teens who identify as part of the LGBTQ community. Many LGBTQ teens commit suicide due to bulling and many other hardships they face as a teen out side the norm. People who identify as LGBTQ, particularly teens, are much much much more likely to use alcohol, other substances, harm themselves and kill themselves.

The youtube channel that he made is filled with videos of adults speaking about their teen years and many of the hardships they faced and that, in fact, life gets better. The bullying ends, they can move to better places, find friends, love and have futures. In hopes that it’ll give strength and solace to LGBTQ youth to make it through. It’s an extremely powerful set of videos and I recommend everyone watch it. Even if you’re not a youth questioning your sexual identity, or knowing that you’re a sexual minority you should watch it, and pass it along to anyone you know who could use some encouragement in life.

http://www.itgetsbetterproject.com/

New MHCA site!

Hi all!
I just completed and set up the new website for the Hudson Valley chapter of the New York Mental Health Counselors Association. Check it out! http://hudsonvalleynymhca.com

Interesting science, misleading reporting.

Science Daily just posted an article reporting on how a group have apparently developed a brain imaging technique to diagnose Autism in adults. This, however, is not really what the article published in "The Journal of Neuroscience" is saying.
I'm really annoyed at the implications that Science Daily is making. To me, their article has a flavor of "Now everyone can get tested!" To me, if you have sensory difficulties, social challenges or other features of Autism-Aspergers that are at a level to be distressing to you, then of course you should seek help. But since there's no real medical cure for ASD (besides one being developed for people with fragile X. And yes I know it's also from science daily, but there have been a few stories about it over the last year or so). So being diagnosed as an adult probably won't do tons for you, other than the relief some people find in having a label for a condition.
Personally I find the real message of the article to be much more interesting. Essentially the researchers found fairly strong evidence that a range of abnormalities in 5 different brain regions seem to be found consistently in people with Autism (sample size was only 20 though, and the control population were people with ADHD) may contribute to autism as a whole. This lends weight to pre-existing ideas that the range in variations in physical neurological abnormalities leads to the cluster of spectrum features that "make up" autism. If anything it helps further research into how these regions working in concert can be distruptive to neuro-typical functioning.

...Just remember, the brain is extremely elastic. People with hydrocephally and people who do not have this condition can have totally different looking brain scans, but have relatively the same functioning and IQ level, it all depends on if/how the brain adapts.

I'm a sucker for a good podcast

I just got around to listening to this weeks episode from “The Moth,” an event where people tell true stories on stage live without notes. Over the year or so I’ve been listening I’ve heard stories about people who think they were being haunted, doctors trying to save lives, famous actresses saying how they went psycho on ex-boyfriends. This weeks was particularly striking to me as it focused on a man talking about a Cambodian woman’s experiences during and after the Khmer Rouge. After surviving the atrocities she played a major role in helping a large number of women with PTSD who had seemingly entered a vegetative depression once they reached the relative safety of refugee camps. She spoke about a three-part method for this. Helping people speak about their experiences and letting them learn to “forget” so they could move on, having them do life skills so that they could feel some accomplishment, purpose and maintain themselves more. Lastly, she taught them to do manicures and pedicures. She did this she says so they could have physical contact with others again, and learn to trust and build a community. It’s very interesting to me how universal particular types of responses are to particular types of events, and how often the “treatments” are really focused on community building, rapport building, and allowing people the space to derive meaning from their lives. It seems like I’d be put of the job pretty quickly with some social reforms :-)

Bullies and their victims

Ohh, I love Science daily. It’s like reader’s digest for PsycInfo (I wish I still had access to that, anyone who hooks me up will get a plate of cookies!) …. Anyway… I really like the article they just covered on the correlations between skill sets and bully/victim behavior. Dr. Clayton Cook of LSU did a meta-study on 153 different studies that examined which traits, or lack there of, went a long being a bully or a victim with interesting results. It seems that the main commonalities are that both groups have poor social-problem resolution skills, perform poorly in school, experience social isolation, have negative views of themselves and others, and possibly have challenging homes lives.


A lot of this may fall into a “chicken or the egg” question, but it I think it highlights very important information in how to handle it. Like most American “corrections” policy, a lot of anti-bullying policy focuses on chastisement and isolation of the perpetrator. Nietzsche would probably argue that this mostly does little more than let the victims feel a little schadenfreude (I think spreading activation theory clicked my brain over into German mode…). Instead of suspending a person, which would further isolate them and probably cause more challenges for them in school, wouldn’t it make more sense to view behaviors on both ends as an expression of need? Working on academic and social skill building, hopefully early on, would probably do much for everyone involved. Maybe I’ve read too much Buddhism, but it really does seem that all human cruelty springs from a lacking or pain in one form or another. Solving that seems to me to be the best way to end the cruelties.

They might really not understand…

New research by Dr. Dabrowska and James Street summarized by Science Daily sheds interesting light on parts of communication that was until now, seemingly taken for granted.

A lot of linguistic theory assumes that people are hardwired for language (which does seem to have merit) but, Chomsky, and many of his followers argue that there is “fundamental grammar” that all people understand language parts in the same way.  There’s been some controversial indications that this might not be true such as the book “Don’t sleep there are snakes” where a missionary to the amazon says he worked with a tribe that doesn’t use recursive language. Which basically means that their language doesn’t allow for sentences that would have two commas in them. Recursion is/was assumed to a part of all human language.

The new research shows that many native adult English speakers may not understand “passive” sentence construction ie. “The soldier was hit by the sailor.” As opposed to “active” sentence construction, “The sailor hit the soldier.” Understanding passive sentences was another aspect of language that was assumed to be a universal. These contrary findings have many implications.

The one that jumps out to me is that co-workers, children, parents and really anyone else you might speak with literally may not understand you, or get the opposite meaning out of your words. Maybe those people who seem to actively contradict others are really trying to please. At the core of this frustrating behavior may actually be the result of incomplete language processing.

It’s simply to get around though, and is used throughout the mental health world. Repeating back the speakers statements in one’s own words allows for corrections to be made, and ensures that both parties are understood.

I still wonder though how many times I’ve been mad at people thinking they want to frustrate me when all it was, was a break down in communication.

Who saw this one coming?

So, remember how that health reform bill got passed and a lot of stuff got gutted from it as a concession to the health insurance industry? I guess it wasn’t enough. I had heard through the grape vine of a few instances where insurance companies were acting like they weren’t up to speed with the new regulations. Looks like what’s really happening is they’re trying to get around a whole bunch of laws.

Quick history lesson for those of you who’ve never really dealt with mental health managed care. Insurance companies treat mental health and physical health very differently. You can go to an M.D. as much as you want, stay in a hospital for as long as medically necessary and the health insurance folk don’t have too much say in it. In the mental health and addiction recovery worlds however, there are session limits, need for continuing care requests, pain in the butt treatment plans  and all kinds of crazy different co-pay rates which don’t exist in the M.D. side of insurance.

This causes problems because therapy isn’t like going to the doctor for an annual checkup and maybe a follow up a few weeks later when the tests come back. Therapy is usually a weekly visit, and it often takes a few months. I used to work for a site that only could provide ultra-brief therapy with an 8 session limit. People usually don’t get really into the really deep parts of therapy until session 5 or 6 anyway.

The new laws passed as part of the bill say that physical and mental health insurance needs to work the same. So if you have unlimited M.D. visits, you also get unlimited visits with a mental health worker, same co-pays etc.

The insurance companies don’t like that their profit margins would lower a little as a result of having to cover cost of care for people. So it looks like from this article that many insurance companies are trying to back slide and continue not to provide adequate levels of mental health care. Guess I’m just a little bitter about the whole thing. Still, I strongly encourage everyone to call their representatives, and let them know if you feel this is a problem. Hopefully with enough noise they’ll stand up to the companies for us and require them to do what is expected of them: To cover the cost of health needs.

Approximately 321,711,000 Rx’s for psychotropic meds were written last year.

Psychcentral just put up this article, Top 25 Psychiatric Prescriptions, giving a break down of number of prescriptions written for different kinds of psychiatric meds written last year. 9 of the top 10 meds on the list are primarily for anxiety and depression,

I’m not really sure how to interpret these numbers. They’re a lot, and not a lot, and it probably means both good, and not such good things about our society.

Some things to consider off the start are that many people are on more than one med, and on average you need to get your script refilled once every few months. If you break it into the most conservative estimate, lets say that people are taking a cocktail of 3 meds (which would be a pretty high number of meds to be on) and that they get their prescription refilled once a month you’re left you’re left with 8,936,416,67 or roughly 9 million people on medication. One million more people than live in NYC. That is a pretty sizeable number of people to have on meds, but it’s a lot lower than the number of people suffering form a mental disorder in a given year according to NIMH. They say they’re basing their numbers on the WHO estimates, but I wasn’t able to find out how they’re basing their numbers.

So how can you look at this? The upside is probably that the stigma of taking meds has significantly decreased, so more people who need help are likely to seek it out. At the same time, what does this mean about the kind of social and psychological conditions that our society lives under? The meds in the top 10 really aren’t targeting things like delusions, hallucinations, mania, or anything like that. They’re for people who feel sad and worried.

Depression and anxiety do have chemical basis, but they’re also strongly affected by the kinds of social contact, supports and coping skills people have, where things like schizophrenia and mania which are much less driven by social contact. It doesn’t really matter how good you are at handling life and how many true friends you have when you KNOW that the tv is sending you coded messages about how you’re the next messiah.

The hypothesis that rings truest for me (as opposed to its acceptance, marketing, increased genetic predisposition, etc.) is that maybe our society is currently not set up to provide the right kinds of social interactions that people need, or that no ones thinks they should be distressed as an indication that an important event has happened or something is amiss in their life. I think about how many people I interact with in the world at large that are mostly motivated by fear, which spins into isolation, in both knowing others, and knowing one’s self. In my experience as a counselor having both of kinds of knowledge are key to finding one’s way out of depression and anxiety in the long run, and maybe with the help of some good psycho-pharmacology.

Complexes from complex complexes

    I just finished reading “Are Prisons Obsolete?” by Angela Davis and found notes from a few weeks ago on statements that Tom Ricks made on Fresh Air and it got me thinking. First off, these two people might have the most opposite histories you can imagine. Some highlights from Ms. Davis’ past are: ties to the Black Panthers, was nominated twice to run as the vice presidential candidate the communist party, the 3rd woman ever on the FBI’s most wanted list for reasons related to the kidnapping and murdering of a superior court judge, and, you know, a professorship at U.C. Santa Cruze. Tom Ricks on the other hand is a Pulitzer prize winning journalist specializing in military reporting for the Wall Street Journal. He grew up in Scarsdale, NY (my home town) and Afghanistan (not my home town) and is currently a member of a defense policy think tank.
    I can hear you asking, where the poop do these two people’s thoughts and ideologies cross, and how on earth could this be related to psychology? I’ll tell you! It’s all about their ideas on the need to reform massive coercion based systems into humanistic systems to actually meet the goals they say they’re reaching for! Ha!
    Angela Davis makes a very strong case for illustrating how modern prisons are essentially based off a 100+ year old idea that wasn’t very good to start with and in its continuing incarnations really serves to continue racism, classism and misogyny with its main aim to control minorities and provide cheep labor. Tom Ricks argued that a main problem with the military is that it was currently using strategies based on English and French colonial strategies used to put down uprisings, but maintain the dependence on mother country also for easy control.
     What’s the problem with both? Control. As both systems currently stand in opposition to helping people learn better ways to meet their needs. In essence they perpetuate and increase the dissidence that people feel by not listening to the needs they are expressing causing more crime, hatred, and violence instead of making the world a safer place.
       Interestingly, both thinkers have very similar solutions to these problems, at least from a humanistic psych perspective. Tom Ricks related an change in style where officers used active listening (he described this psych skill set to a T with out using the words) with the locals which resulted in the people being heard, and a much more successful campaign towards helping them reclaim their country and be less dependent on the U.S. military.
    Angela Davis argues that abolishing prisons and using large scale active listening to focus on the social ills that cause crime and solving them work better. Controlling criminal behavior in a cell block does nothing. Going for “reparation instead of retribution” helping violent offenders meet their needs for better social integration, allowing them to make amends, grow and continue on with their life to help the their communities grow which is the core of humanism.
     All of this was pretty glib, but really, its pretty powerful to me that both these people, probably without formal training in humanism, have independently come to see it as the answers to such different problems with such different scales.

Dx's and Rx's for kids...

Children Labled as "Bipolar" up 4000%

     Articles like this one on diagnosing (Dx) and the changes that come from it are often unsettling to me. For every one true case of childhood bi-polar, conduct disorder, ADHD, and the other “hot” childhood psych disorders, there seem to be thousands of others who just the same label without merit.
     This article hints at that it helped many doctors prescribe meds for the children (I’m hoping they mean psychiatrists, and not just general practitioners). That’s truly disturbing as well. Psychotropic meds aren’t like Advil. These drugs have major, long lasting side effects and, unless there’s a true chemical imbalance, can be very harmful.  There’s often many other causes for why some acts the way they do, besides poor brain chemistry.
     I can’t tell you how many charts I’ve looked at that have a wrong Dx, a mutually exclusive Dx, or a list so long of Dxs that it took up half a page.  This often happens so that people can get reimbursed for treatment. Insurance companies don’t like paying for preventative psych services, or psych services that will take a long time.
     It often seems like they’re much more willing to pay lots of money for extremely strong meds that lead to other health problems to deal with underlying issues, rather than spending a little more at the beginning to help the person learn to cope and eventually get off the meds. So essentially mopping up the water on the floor and turning off the running faucet at the same time as opposed to just putting lots of paper towels down.

How to get your [co-worker, neighbor family member, pet, significant other] to do what you want – Part 3

I’m a drug dealer. You’re a drug dealer. The fix we give is so good people will work hard for it, people will literally clamor over each other for it, some commit crimes for a fix, and babies die without it. What’s the fix? Attention.

In part one and two I talked about planned ignoring, and positive reinforcement, here’s how to tie them together via selective attention, a very powerful tool.

Part of being social animals means we all crave attention and praise. Sure the level varies from person to person. We all know people who want it all the time.  They’re the ones always trying to be in the spot light, and all but the most reclusive hermits want at least a little attention.

This is part of what makes therapy such a unique experience for people. In theory, therapists are expert attention payers, we listen, processes and respond to you. It’s often very Fight Club-esc, “…They really listen to you instead of just...Instead of just waiting for their turn to speak.”

Since attention and praise is so powerful, giving out a little extra here and there can work wonders in shaping someone’s behavior in all kinds of environments. Stopping a kvetch? Easy. Constant complaining is one way of scoring some attention, although it also usually repels people shortly after. Now remember, you’re the person who handing out their fix, so give it out on your terms.

You- ::look them in the eye and give your full attention:: “Hi Bob! What’d you do this weekend?”

Bob- “Ehh, nothing really, it was too short, now back to the grind of data entry for our terrible boss, I think she knows how looking at the screen gives me migraines…”
You- ::go back to doing paper work as soon as the complaining starts::

Bob- “Yeah, but no migraines this weekend, just nice and quite with the wife and kids.”
You – ::look them in the eye and give your full attention when hearing the little positive things:: “Sounds Nice! How are the little one’s doing?”

If you keep going like this, pretty soon Bob’s behavior will change to get the most attention possible. Just keep giving Bob a fix of attention when he’s acting positively and don’t pay him any mind when he’s not.

Same thing works for getting work done on time, or ahead of schedule. Improving organization, phone habits and anything else really. Once you get the basics of this down, you can use Shaping and Chaining to get just the kind of behavior you want from people, even if they’ve never done it before.

Mind, Body, Stim.

According to a new journal article, we move our bodies forwarded when thinking about the future, and lean back when recalling the past is a great. I’m always amazed how strongly thought, stimulation and body are tied together. Thought I shouldn’t be. There are lots of articles about how people’s thoughts that things are harming them make, them ill. Airport security screeners think that honey is a bio weapon and make themselves sick enough to go the hospital. And "ElectroSensitives" get better over night once they're told a radio tower is off, even though it's really been off for a month already....

The reverse is true too. NPR’s Radiolab recently did an excellent show on placebo affect (scroll down on the show panel on the right hand side for the podcast) the final segment, on how even doctors wearing white coats has been shown to help their patients get better is.

Stimulation is also so key, but so few people every think about it explicitly.
ARC’s Snoezelen room does amazing things for people. While it was developed to work with adults on the autism-aspergers spectrum, everyone loves it.

Most people regulate their stimulation level from different senses implicitly. Choosing clothes with a fabric you like (tactile), tapping your foot or spinning a pen (proprioceptive), choosing a scent (olfactory), going for a walk or a run (vestibular). Those are just a few ways we modulate our stim level, and one of the main features of people on the autism-aspergers spectrum is marked difficulty in managing their own stim levels. Have you ever been somewhere and the lighting was to high or too low? The music was too much, or not enough? You felt bored or much too stimulation? Makes you feel gross right?

A Snoezelen room is the exact opposite. The person running the room changes all the aspects of stimulation in the room (and there are toys, and a chair that makes you feel weightless, and different areas and textures and a little alcove and…and…and…) so that you can find exactly the correct amount of stimulation you want and it does amazing things. Your muscles relax, your head clears and often develop this great sense of well being. It’s a lot like waking up from the best nap ever.

Our thoughts, our environment, and our bodies all play off one another. It’s almost comical to me how people organize school, work and sometimes even out own homes in ways that our culture says is appropriate and the “best way” to get things done, and then everyone in there fights against it all day.

Anyone want to help me make the world be more ergonomic?

So Quick To Punish...

One of the major issues I saw while working with people who have intellectual disabilities is how often the people around them, who are there to support them, and help them make the most out of their lives, are so quick to chastise and “correct.”

This seems to be the ruling thought for our penile system, school management and other traditionally institutional systems. They all seem focused on stopping the end disruptive behavior, but seem to invest so few resources in analyzing the precipitating causes. It’s kind of like cleaning up the mess from an over flowing sink, without bothering to turn off the tap.

Does punishment work? Sometimes, but not often. Numerous articles and other work has been written illustrating the failures of the American prison system, a few things get found over and over again, longer, stiffer prison sentences do not reduce crime. What does? Rehabilitation and working on the initial causes that create the problems in the first place.

This works from an economic standpoint as well. Removing drug dealers from the streets doesn’t make drugs go away (unless you get all of the dealers) it just make the drugs that are there more expensive. So what you end up with are addicts going greater lengths to get the cash to buy them. What does remove drugs? Making people not need, or not want them. If there’s no market for drugs, they won’t be profitable and no one will bother to sell them.

Think even closer to home. Think about the last time someone yelled at you. Did it make you think positively of the person? Did it really make you want to change your behavior, or just figure out how to do things so you wouldn’t get yelled at next time?

All behavior is communication, misbehaving is communicating that there is a need that isn’t being addressed. Either there’s a lack of understanding, resources, or ability in being able to meet the need in a better way. Fix that need, replace it with a “better” behavior and there’ll be no more need to yell.