I’ve been kicking around the idea for a site like this for years. Since my introduction to the internet in 1994 or so, I have been fascinated by it and the way it can improve our lives. I did my doctoral dissertation on the internet – specifically, trying to tailor a marital intervention for delivery over the ‘net. That was in 2003 and I had to do a lot of the coding myself. It was a long and sometimes tedious process. Now, 8 years later, things are much easier to do.

As a licensed psychologist, I’ve got an interest in making sure that I stay current on what’s out there, both in the popular press and in the research literature. I believe that a central purpose of the internet is in helping everyone get information about anything they want. Call it “democratization of information” if you want. I love the internet for that. I’m much more informed now than I think I could ever be without the internet.

The problem with many sites about mental health these days, though, is that information tends to be one way. It’s “top down”, if you will. That is, researchers or reporters give information to end users and that’s the extent of the information sharing. There is some “bottom up” communication in the form of comments, etc., but I don’t think that’s as effective as it could be.

I am (re)launching this site to facilitate more bottom up communication. My hope for the site is to have people participate in sharing articles and techniques that relate to their own mental health. What they found to work, what they found useful or informative, what they felt was insightful or even revelatory. I don’t want to dwell on what doesn’t work or how ridiculous a particular article or point of view is unless we’re providing actual feedback about what to do to make it better.

Respect for our users, contributors and readers is the utmost priority. I want this site to help end the stigma associated with mental health problems and I want it to be a resource for everyone. Call it a “crowd sourced resource for mental health”.

My son has a birthday card he got from his grandparents. It’s one of those annoying singing birthday cards that have no audio fidelity at all but makes a 4 year-old crack up. The song is I like to move it. (by a band I’ve never heard of called “Reel 2 Real”.) Whatever the band’s name is or the degree of annoyance of the song, it’s a catchy tune and an apt title for this post.

The NYT reports:

Each volunteer exercised for four months, while continuing to take an antidepressant. At the end of that time, according to the study published recently in The Journal of Clinical Psychiatry, 29.5 percent had achieved remission, “which is a very robust result,” Dr. Trivedi said, equal to or better than the remission rates achieved using drugs as a back-up treatment. “I think that our results indicate that exercise is a very valid treatment option” for people whose depression hasn’t yielded to S.S.R.I.’s, he said.

I like to think of early depression treatment as targeting one or more of the areas affected by Major Depressive Disorder:

1. Cognitive
2. Somatic (physical/energy levels)
3. Sleep
4. Emotional
5. Motivational

There are others things that need to be targeted but the majority of patients in early treatment for depression have a lot of work to do one one or more of those areas and it’s extremely relevant to their situation. It’s nice to see something so clearly affected by depression, yet so incredibly simple to do, gets continued attention in the press and research literature.

If there’s one thing we’re sure about when it comes to addiction – of all types – it’s that we have a tendency to resort to our addictive substance when we’re feeling more emotional than we’re comfortable with. It’s just a fact of the way addiction works that we go to it in times of need. Briefly, addiction is maintained, from a psychological/learning perspective by negative reinforcement. That is, the removal of something unpleasant (negative) results in the increase in a behavior (e.g., taking of the substance of choice: behavior that is reinforced).

What is often neglected is the ways in which we become our own worst enemies in recovery because we create our own stress. We manufacture issues when there aren’t any or we make big deals out of not so big deals. We put ourselves in situations that become significant so we have to resort to our addictions. Or we interpret interactions in a way that makes us feel more stressed.

When dealing with clients with addiction, it’s often a given that they will struggle more and have more relapses when they have been stressed. It’s certainly not acceptable behavior as far it treatment for their addictions go but it is not unexpected. But the ways a stressful situation develops is often left unexplored. In DBT, we refer to the circumstances that could lead up to problem behavior “apparently irrelevant behavior”. The behavior seems like it might be irrelevant and could be but it might not and that’s an issue that needs to be explored.

What I’m referring to here is a specific type of apparently irrelevant behavior. It might not be irrelevant but it might be. Are you creating your own stress to give yourself a reason to use? If you find that you’re feeling extra stressed out these days, ask yourself what’s really going on and see if it’s not your addiction trying to get out.

Dr. Linehan has been an inspiration to many, including me, in trying to figure out how to deal with borderline personality disorder. I count myself among the fortunate few who have had an opportunity to be trained by Dr. Linehan and her “children” during my own training to be a DBT therapist. Does this revelation that she, herself, has struggled with borderline personality disorder change the way I think of her? Yes, but only in the most positive ways: I knew that she talked the talk, but now I know that she walks the walk.

When I teach skills to my clients, I often use personal examples as illustrative. I don’t have any illusions that my own personal struggles match in intensity their own, but I do think it’s helpful to share how the skills I’m teaching have helped me. The stigma associated with chronic mental illness is real and difficult to deal with. Even more for those who already struggle with emotion regulation.

The NYT reports:

“That did it,” said Dr. Linehan, 68, who told her story in public for the first time last week before an audience of friends, family and doctors at the Institute of Living, the Hartford clinic where she was first treated for extreme social withdrawal at age 17. “So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward.”

You are no coward, Marsha. Thank you for your courage and your story.

One of the most maddening things to hear as a therapist is the idea that people should just change the way they think so they can feel better. If it were only a matter of changing thoughts, I’m sure that most people would choose to feel better. The myth here is partly the fault of Cognitive Behavioral Therapy. While I’m sure that Aaron Beck didn’t mean to reduce emotional suffering into a series of “just” statements, CBT has been watered down by popular press to the statement above.

To be sure, any good CBT therapist will be able to help you deal with your automatic thoughts to make good use of thought challenging techniques and I can, and do, use “straight” CBT with clients for whom its appropriate. But for a number of clients, I find that an approach that provides an understanding of where emotion comes from to be the most validating way to teach and make significant progress.

Internal Physiological Experience

Emotion is, at its heart, a physiological reaction to stimuli. Without being too reductive, stimuli occur and brain chemicals are released. These brain chemicals create a physiological change. Muscle tense or relax. Heart rate increases or decreases. Pupils dilate, breathing quickens.

Each type of emotion has an attending physiological reaction. Some of these reactions may be mild and unnoticed and in these cases, but in the situations that you’re trying to deal with maladaptive emotion, you’re probably going to notice it.

External Physical Expression

Each emotion also comes with some behavior that we might engage in. Now we might not choose to engage in those behaviors but we probably want to. You might run, hit, hide, yell. These are all external physical expressions of an emotional experience.

Our heart rate increases when we’re afraid. We have the urge to run when we’re afraid. Now, you’ll notice that when you run, you’re heart rate increases. There is a feedback loop between the physiological experience and the behavior we engage in. We have to make sure we don’t inadvertently amplify our emotion when dealing with a situation.

Dealing with emotion

Each emotion has both the internal physiological experience and the external expression, in addition to potential thoughts/interpretations. We know that there is some benefit to challenging distorted thoughts. All of CBT is based around this notion. But also notice that there is benefit to dealing with your physiological reactions and working to change them through behavior. The corollary also follows: that if you don’t have success dealing with your emotion through one of those interventions, maybe there’s something else keeping it around.

Pay attention to more than just your thoughts and realize that there’s no guarantee that just changing your thinking will change how you feel.

A while back, I bookmarked an interesting article (pdf link) that I’ve been meaning to write about. As I haven’t had a chance to really digest the material and compose a longer entry, I thought I just get it up on the site for wider consumption. The gist of the research highlighted therein is that Tai Chi Chih seems to have a positive impact on geriatric depression.

Given the relative reluctance some geriatric patients have to psychotherapy and the complicating factors of drug interactions, anything we can do to help that doesn’t involve traditional medication management and/or psychotherapy is welcomed. The question remains what is the mechanism of change for this particular intervention. I suspect that it’s a result of the increased ability to focus on an activity and the consequent ability to focus away from unwanted ruminations that helps, but that’s just my slightly biased-towards-mindfulness explanation.

As I was digging through the articles I’ve collected to read and post about, I came across this one. The study described in the article was a large multi-site data analysis in which adolescents with a Major Depressive Episode were followed-up over the course of several years after treatment.

The researchers found that:

• recovery rates were good, with 96.4% of participants recovering during the follow-up period, with over two-thirds recovering during the first year of treatment.
• treatment modality was unrelated to recovery.[1]
• nearly half of those who recovered had a recurrence of symptoms within 5 years.

We’ve long known that a past major depressive episode predicts a future one. As a result, this finding is not surprising. What is interesting about the research here is that there is a predictive factor of both gender and co-occuring anxiety disorder.

As far as clinical implications go, this finding highlights the importance of skills acquistion for self-recovery after the completion of therapy by a trained professional. In addition, the should focus not just on the management of the depression symptoms but also of the anxiety features present. I’d like to see more follow-up on specific types of therapy and the longevity of their effects, but longitudinal study is hard and expensive, so we may never get to see that clinical application of these findings.

Depression isn’t forever, but like an unwelcome houseguest, it finds its way back. Be ready.

Footnotes:
[1] This was not a study looking at the efficacy of various types of treatment, just a look at the efficacy of all treatments. The treatment options for participants in this study received either Cognitive Behavioral Therapy, fluoxetine (prozac), a combination or a placebo.

Self-restraint can be hard to effectively manage. There’s been an ongoing debate about the notion of catharthis and whether it works to help us relieve emotions or not, for example. A recent article in Wired.com discusses the issue a bit more:

My favorite experiment involved movies. Two hundred and thirty nine subjects were given a choice between a virtuous apple and a hedonistic chocolate bar. (A slim majority chose the apple.) Then, they were offered a selection of movies to watch, from Anger Management (an anger themed film) to Billy Madison (a non-anger themed film.) Interestingly, students were significantly more likely to choose the angry films if they’d first chosen the apple. And it wasn’t just films: another experiment found that people who exercised financial restraint – they chose a gift certificate for groceries over one for spa services – were more interested in looking at angry faces.

But just because practicing self-restraint can lead to some anger-related experiences, it doesn’t mean that we should forgo self-restraint entirely. Over time, not succumbing to urges will weaken the power of those urges. The implication is that if we can practice self-restraint consistently, we’ll be reducing how often we feel angry and/or seek out anger-related stimuli.

Living in a mid-sized city has a few benefits: we get a lot of the culture of a place that’s diverse, and we are able to escape much of the violence that plagues larger cities. There are times I wish that I could raise my kids in an even more urban environment but then I’m reminded about the very real dangers of a big city — gun violence not the least amongst them. Even if kids aren’t directly exposed to violence, if they know kids who are, there can be a ripple effect.

NPR reports on one adolescent in Chicago who has exposed to gun violence:

Despite the violence that engulfed her, Hatter says she’s not worried about her safety or afraid of the streets. But she doesn’t believe the violence will ever stop. “No, [because] people don’t care,” she says. “They don’t have no feelings.”

Hatter’s experience with gun violence and the ways in which she expresses her hopeless should be cause for alarm. The after effects of being victimized in this way are far reaching:

common aftereffects are aggression, depression, anxiety and post-traumatic stress. He [University of Chicago researcher Dexter Voisin] believes schools should teach students appropriate ways to cope with violence — especially in neighborhoods where exposure to shooting, fighting and other violence is so high.

We have long known that kids are resilient and that there are ways to help foster that natural resilience but even the most quick to recover kids can be worn down by repeated exposure to violence. We should do what we can to help. To paraphrase a well-worn saying, “help early, help often.”

Chicago has a program called CeaseFire that has as its mission to help kids dealing with gun violence and prevent retaliation. Their results have been outstanding:

The Department of Justice report validates the CeaseFire model as an evidence-based intervention that reduces shooting and killings and makes communities safer. The report found the program “effective” with “significant” and “moderate to large impact,” and with effects that are “immediate.”

There is definitely hope. If only we could continue fund important initiatives like this one in all communities that need it.

“When reminded of an immoral deed, people are motivated to experience physical pain.”

This is the opening line of the discussion section in a recent article published in Psychological Science. The hook is alluring, isn’t it? Thinking about times that you were “bad” makes you want to punish yourself. I was attracted to this article for review because of my interest in working with self-injurious patients. There are two predominant reasons people engage in self-injurious behavior (SIB):

1. He/She wants to regulate his/her emotions through distraction or
2. He/She wants to punish him/herself for some perceived wrong or defect.

As a starting point in understanding SIB, these two perspectives are helpful. They give us a framework to begin to explain possible motivations and the function of that particular SIB. In other words, how do we get those needs met without having to engage in SIB?

The Article

Getting back to the article, the authors engaged in a simple experimental manipulation in which participants were assigned to either the recall of “immoral”[1] interpersonal behavior or more generic interpersonal behavior. Participants rated their affect using the PANAS[2] and then engaged in the pain part of the study. Following the painful/non-painful experience, their level of “guilt” was measured by completing the PANAS again.[3]

The researchers found that participants in the guilt inducing/pain condition expressed lower levels of guilty feelings after the manipulation, leading them to conclude that the painful experience caused a drop in guilt ratings.[4]

The participants in the guilt/pain condition also perceived more physical pain during the manipulation than those in the non-guilt/pain condition.[5]

Reading the Tea Leaves

The authors go on to claim that the motivation for causing pain is to reduce guilt. I believe they’ve got their conclusions backwards. Guilt is reduced because of the pain, not the other way around. Getting into divining motivation is a specious area at best. Unfortunately, I don’t see how the results of their study supports that explanation. This reading of the data is basically saying that the second of my two reasons for SIB listed above is the reason for engaging in the behavior. However, I believe that emotion regulation aspect of painful experience is not to be understated.

Pain as Emotion Regulation

The explanation of this article is a long way around to talk about my favorite therapeutic technique — mindfulness. Specifically, using mindfulness as a way to stop thinking about particular experiences can help reduce the intensity of those thoughts and the subsequent emotion. Rumination on particular misdeeds fires off a host of strong emotions and breaking into that ruminative cycle prevents continued emotional experience. In this particular case, the ice was an unavoidable mental focus and we can see support for this supposition in the subjective experience of the pain.

To further draw out the supposition, without too much of a stretch, we can say that people actively avoid thinking about times they did something “wrong”. When the participants were presented with a mental “out”, they took it. Ice is painful and it’s relatively easy to focus on pain. Focus on the physical pain increases the subjective experience of the pain. Two conclusions can be drawn from this:

*For those who were suffering from emotional pain as a result of the manipulation — those in the “guilt” condition — this physical pain was deemed to be less intense, so they focused on the ice.

For those in the non-guilt — those without emotional pain — the physical pain was more uncomfortable to they focused *away from it, leading to subjectively less pain.

Mindfulness as Emotion Regulation

The revealing thing about this article is that a mindful experience can be emotionally regulating. In DBT, we talk about using ice as a distress tolerance skill. This research, coming from a non-DBT perspective, corroborates that belief. I don’t believe that you necessarily need to subject yourself to physical pain to get the same sense of relief — you don’t need to punish yourself to feel better, at least all the time — you just need to be able to mindfully turn away from your rumination.

The process isn’t as easy as it sounds since being able to turn away from your ruminative thoughts is work. Our minds have a tendency to stick to things that we least like them to stick to. Cultivating mental control through regular practice and developing a sense of forgiveness and genuine caring for yourself can help. You should not let yourself violate your values if you can avoid it, but if you have, make up for it and then move on.

Footnotes

[1] The authors defined “immoral” behavior as ostracizing someone. I’d buy that as a particularly embarrassing experience.

[2] The PANAS is a well-validated measure of affect. I’m not sure how well it measures guilt, but since this is a peer-reviewed article, I’m going to give the authors the benefit of the doubt.

[3]This type of within subject/repeated measure design is common in psychological research. It’s designed to measure change across time or via experimental manipulation and has much theoretical support. It’s an especially powerful design because each subject is his/her own control.

[4]Given that this was an experimental design, causal conclusions are warranted.

[5]This finding, I believe, is particularly salient.