About this Blog

Integrative Medicine and Psychology

Sun, 1 Sep 2013 17:55:22 -0400

In addition to my private practice, I provide psychotherapy and psychological testing at the Tao Institute of Integrative Medicine at its offices in Bryn Mawr, Pennsylvania in the Philadelphia Main Line area, and in the Cherry Hill/Marlton area of New Jersey.

In recent years, research on brain functioning, mind-body interactions and the effects of trauma and abuse have contributed to a growing realization that psychotherapy, acupuncture, meditation, mindfulness practices, herbs, and supplements can actually beneficially affect not only physical health, but mental health and even brain health and functioning. Even psychotherapy has been demonstrated to result in observable changes in brain functioning.

Despite advances in brain imaging and research, psychotropic medications, while useful when indicated for serious disorders, often have side effects, are not always effective, and often cannot fully “cure” or specifically “target” certain disorders.

The integrative medicine movement attempts to “integrate” advances in Western medicine and psychiatry with Eastern medicine, and acknowledges that, in many cases, the best treatment plan may be a combination of traditional mental health and holistic health treatments.

Consequently, the Tao Institute offers a range of psychiatric, psychological, physical and holistic health services through a staff of physicians, psychiatrists, psychologists, acupuncturists and holistic health experts.

Psychotherapy Eases Chronic Fatigue

Fri, 18 Feb 2011 07:07:18 -0500

The following article is from the New York Times:

Psychotherapy Eases Chronic Fatigue, Study Finds
By David Tuller, Published: February 17, 2011

A new study suggests that psychotherapy and a gradual increase in exercise can significantly benefit patients with chronic fatigue syndrome.

While this may sound like good news, the findings — published Thursday in The Lancet — are certain to displease many patients and to intensify a fierce, long-running debate about what causes the illness and how to treat it.

Many patients, citing two recent high-profile studies, believe the syndrome may be caused by viruses related to mouse leukemia viruses, and they are clamoring for access to antiretroviral drugs used to treat the virus that causes AIDS. That treatment is very expensive and would be expected to continue indefinitely, and health insurers are not generally willing to pay for untested drug regimens.

The new study, conducted at clinics in Britain and financed by that country’s government, is expected to lend ammunition to those who think the disease is primarily psychological or related to stress.
The authors note that the goal of cognitive behavioral therapy, the type of psychotherapy tested in the study, is to change the psychological factors “assumed to be responsible for perpetuation of the participant’s symptoms and disability.”

In the long-awaited study, patients who were randomly assigned to receive cognitive behavioral therapy or exercise therapy, in combination with specialized medical care, reported reduced fatigue levels and greater improvement in physical functioning than those receiving the medical care alone — or getting the medical care along with training in how to recognize the onset of fatigue and to adjust their activities accordingly.

The cognitive and behavioral interventions outlined in the new study are a series of sessions continuing for several months. The researchers are expected to address the cost-effectiveness of the treatments in another report. (Several of the study’s authors reported financial ties to the insurance industry.)

By contrast, the idea that a viral infection is responsible for chronic fatigue syndrome, also called myalgic encephalomyelitis, has been proposed at least since early outbreaks were investigated in the mid-1980s in the United States. Although studies have shown that many patients with the disease have elevated antibody levels for several viruses, no causal role has been proved for any of them. Health officials in the United States are coordinating studies to determine why the mouse leukemia viruses were found in patients in two studies but not in several others.

A major difficulty with conducting studies on the syndrome is that there are several different ways of defining and identifying the illness. These variations have led to a wide range of estimates of its prevalence.

Patient groups and some researchers have challenged the criteria used by the British investigators as likely to include many people with depression, which often causes severe fatigue. They also note that the study excluded patients who could not get to treatment centers, most likely ruling out some of the sickest patients. And at least one survey has found that exercise therapy can significantly worsen many patients’ symptoms.

Political, Celebrity & Relationship Stalkers

Fri, 11 Feb 2011 13:33:59 -0500

Introduction To This Blog Entry On Stalking:

The information below was posted following Dr. Skoler’s February 2011 interview on stalking for the CBS “48 Hours” website.

The following reflections are derived primarily from:

• a contributed chapter by Dr. Skoler on, The Archetypes and Psychodynamics of Stalking, in the book, The Psychology of Stalking;
• a past continuing education training presentation by Dr. Skoler to CIA & NSA psychology staff on, The Differentiation of Political, Celebrity and Relationship Stalkers;
• a past research study by Dr. Skoler, funded by the U.S. Secret Service, on mentally disturbed political threateners and stalkers: Saviors of the Nation; Assassins of the Self;

Due to the concerns of many stalked women, the following discussion will focus primarily on relationship-related stalking, will only briefly mentioning celebrity stalking, and then will conclude with political stalking and the assessment of risk in such cases, particularly in the tragic wake of the shootings of U.S. Representative Gabrielle (Gabby) Giffords and others in Arizona.

Was Shakespeare A Stalker? Shakespeare’s Last Love Obsessed “Hate Sonnets” to the “Dark Lady” “Coloured Ill”

O! from what power hast thou this powerful might, With insufficiency my heart to sway? To make me give the lie to my true sight, And swear that brightness doth not grace the day? 
Whence hast thou this becoming of things ill, That in the very refuse of thy deeds There is such strength and warrantise of skill, That, in my mind, thy worst all best exceeds? 
Who taught thee how to make me love thee more, The more I hear and see just cause of hate? O! though I love what others do abhor, With others thou shouldst not abhor my state: 
If thy unworthiness raised love in me, More worthy I to be beloved of thee

One of Shakespeare’s “Dark Lady Sonnets:” #150

In my book chapter, The Archetypes and Psychodynamics of Stalking, one section deconstructed Shakespeare’s last several “Dark Lady Sonnets,” in order to explain the inner world of pathological love obsession.

It is literally impossible to find, in the history of Western civilization, a human being who is more articulate, intelligent, psychologically insightful and artistically creative than William Shakespeare. Yet, as Shakespeare finds himself becoming sexually and psychologically obsessed with the woman who rejected him, he turns his own unparalleled powers of human observation on himself, as he descends further and further into an erotomania for the “woman coloured ill” who spurned him.

The sonnet sequence also “tells a story” of a love triangle, which famous literary critics and authors, over the centuries, believe is far more like a real-life Facebook posting, or string of angry, harassing e-mails, than fictionalized poetry. The Dark Lady sonnets clearly indicate that Shakespeare’s spurning “Dark Lady” is sleeping with one of his best friends.

In sonnet #144, Shakespeare turns this double betrayal into a Renaissance metaphor of the struggle in the self between morality and immorality, between good and evil:

Two loves I have of comfort and despair,
Which like to spirits do suggest (tempt) me still?
The better angel is a man right fair,
The worser spirit a woman coloured ill.

Shakespeare’s Dark Lady sonnets can be referenced on Shakespeares-Sonnets.com. I recommend reading those numbered 127, 129, 130, 131, 133, 134, 138, 140, 141, 144, 150, 151, and the last Dark Lady sonnet, 152. (Sonnets numbered 153 and 154 are either apocryphal or out of order, and are not part of the “Dark Lady” sonnet sequence.)

Commonalities Between Types of Stalking

Despite some of the similarities between political, celebrity and relationship-related stalking, to quote the New York Yankee baseball Yoda, Yogi Berra, “the similarities are different.”

Certainly, one commonality is “the needle in the haystack problem,” the problem of the clinical prediction of dangerousness: which individual among all of the hurt, disgruntled, rejected, personality disordered, delusional or troubled stalkers is the one truly capable of inflicting physical harm or committing murder?

In fact, one motive for writing the book chapter, cited above, is that demographic “profiles” of stalkers often don’t accurately or adequately predict which stalkers will become violent. This impasse led instead to an exploration of their inner world: their psychiatric diagnoses, fantasies, obsessions and distorted thought processes.

Stalking as “Safe Sex” for the Heterosexually Impaired

Another commonality, in many cases, involves sexual preoccupation and/or inadequacy. This may seem more obvious in cases of relationship-related stalking, but was also underscored in the political assassination attempt by John Hinckley upon President Ronald Reagan.

The nation soon learned that Hinckley had become obsessed with the actress Jodie Foster. Foster had played a teenage prostitute in the Martin Scorsese film, Taxi Driver, starring Robert De Niro, as a wannabe political assassin. Many forget that the Robert De Niro character in that movie, Travis Bickle, was preoccupied by an unattainable, beautiful campaign worker, played by Cybill Shepherd.

Love Obsession as Victimizing the Victimizer

Ironically, many stalkers feel abused and tortured by the object of their own obsession. In one of his “Dark Lady” sonnets, Shakespeare describes his rejected heart feeling hung on a forged meat hook in a butcher shop; whereas OJ Simpson, making himself a literary bedfellow of Shakespeare (in psychological torment, if not iambic pentameter) claimed that he, in fact, was the one who felt like the abused spouse, not his dead wife.

Rescuing The Whore: Male Daydream, Stalking Nightmare

Of course, celebrity stalkers can also become obsessed with the unattainable, attractive, sexualized personas often possessed or postured by celebrities. Some celebrity stalkers have a kind of Mary Magdaline or “rescuing the whore” fantasy: that they will somehow rescue the highly sexual but fallen woman, such as Madonna, with a wished for “heart of gold,” into a more pure and spiritual union.

This Mary Magdaline fantasy is seen in the film Pretty Woman, in Sonja, the prostitute in Dostoevsky’s, Crime and Punishment, and in the teenage prostitute played by Jodie Foster, who is “rescued” by a wannabe assassin in the film, Taxi Driver, which obsessed John Hinckley.

The Psychology of Relationship-Related Stalkers

Many “normal” men and women, even Shakespeare, can feel lost, obsessive, preoccupied, bitter and desperate for a short while after being romantically rejected, due to the natural human processes of bonding, attaching and loss. However, many true stalkers often suffer from troubling delusional or personality disorders associated with borderline, narcissistic, paranoid and antisocial personality traits.

“Love obsession” is not really an appropriate description, because obsessive stalking, harassment and threatening obviously has very little to do with the capacity for true love, empathy and mourning.

For stalkers, as for Shakespeare’s Othello, the real or imagined loss triggers a kind of inner psychological decompensation in the self. In an irrational but paradoxical way, the stalking behavior becomes so obsessive because it is driven by psychological attempts to internally shore up a fragile but deteriorating sense of self.

Control of the “Love Object”

Analogous to the way we know that the crime of rape is not just about sex, but also about anger, power, control, domination and humiliation—so also is stalking certainly not just about protested or “unrequited love,” but rather about a fantasy of omnipotent control over the other, a kind of psychological angry joining of the self to the other that one can no longer have or control.

Whether Sting meant the lyrics in this context or not, the stalker wants to believe that the stalking behavior provides him constant monitoring and control of the “love object,” even as she tries to break away and escape him:

Every breath you take
Every move you make
Every bond you break
Every step you take
I'll be watching you….

Every move you make
Every vow you break
Every smile you fake
Every claim you stake
I'll be watching you

Lyrics by Sting

“Till Death Do Us Join”

In the traditional marriage vows, couples promise to love one another and stay together, “until death do us part.” But in the tormented world of stalkers, particularly those with paranoid, narcissistic and borderline personality disorders, the differentiation between self and other can be so troubled and fragile that the stalker feels he must link himself to the object of his own obsession forever. In the most violent cases, this involves fantasies and acts of murder, and, not surprisingly, given these psychological dynamics, murder-suicide.

Political Stalking and Threatening

The recent tragic and horrific shootings of Representative Gabrielle (Gabby) Giffords, and others in Arizona, has again highlighted the “needle in the haystack” problem of picking out the true potential assassin from all of the disgruntled, unstable and angry people who may write threatening letters, or post on the Internet threats or warnings to political figures. Fortunately, an actual assassination attempt remains a statistically extremely rare event in our society.

My own study, funded by the US Secret Service, was conducted at the forensic pavilion where John Hinckley was committed following his attempted assassination of President Ronald Reagan. The study involved the psychological testing of 30 cases of political threatening or stalking, as well as my intensive psychotherapy of a couple such cases. I titled the study, Saviors of the Nation, Assassins of the Self, to suggest the underlying narcissism and grandiosity, yet also damage, depression and suicidality, which distinguished this group of patients even from other delusional and paranoid schizophrenic patients at the very same mental hospital.

There is some thinking, particularly in this modern of age of security around political figures, that the most dangerous such stalkers may not necessarily suffer from typical schizophrenic disorders. Rather, they may have more “sealed over” delusional or paranoid disorders, with associated narcissistic grandiosity, that may not make them “look like” typical chronic mental patients when they are screened at a mental health clinic, or by the Secret Service.

Consequently, the Secret Service itself is not beyond making significant errors in “risk assessment.” Such patients are somewhat more psychologically organized to mount a more credible assassination attempt. That is, it appears the most dangerous political stalking cases may be the most complex ones to diagnose.

Another diagnostic problem is that paranoid and schizophrenic disorders can often begin or “onset” in the late teens and early 20’s. When young adults begin to psychologically fall apart or “decompensate” as they are “coming down” with a disorder such as paranoid schizophrenia, it may be difficult to diagnose the “onsetting” seriousness of the mental disorder that is about to overtake them, when they are screened at at college or county mental health counseling clinic.

And if such persons have no prior criminal history, they are often allowed to buy automatic handguns in a matter of days that can shoot 100 rounds of ammunition into a crowd in a matter of just a few minutes.

Are the Mentally Ill More Violent Than Other Groups?

It is unfortunate that our modern insanity laws have been so influenced by sensational but statistically rare cases, such as assassination attempts.

In fact, our modern insanity test, which assesses a mentally ill person’s capacity to know the difference between right and wrong, the M’Naghten Rule, dates back to an assassination attempt on the British Prime Minister in the 1800’s. The more conservative M’Naghten Rule was reaffirmed after John Hinckley obtained his insanity acquittal for his assassination attempt on President Ronald Reagan.

But what about the more typical mentally ill young adults who commit far less serious offenses? Do insanity laws, shaped by the rarity of assassination attempts, make the most sense for them?

Whether the mentally ill are more violent depends on the individual case, and the specific nature of the disorders and associated symptoms. This problem of clinical “risk assessment” will be discussed in another blog entry on this website.

The Fallacies of Diagnosing Bipolar Disorder for Real Life Trauma: Ophelia & the “Diathesis Stress Model”

Tue, 7 Sep 2010 06:12:35 -0400

Consider the case of Susan [a pseudonym], a woman in her late twenties, living in another part of the country, who is the daughter of an old acquaintance of mine.

She called me last month, after her HMO psychiatrist refused to change or lower her 5 psychiatric medications, but instead insisted on adding a sixth.

Like many, if not most people told by a psychiatrist that they have a “genetic predisposition” for a “biochemical imbalance,” the problem that brought Susan to psychiatric attention was actually caused by a “real-life” trauma or problem: the divorce of her mother from an unstable and abusive father. As she literally witnessed her mother being abused during her high school years (which led to a sudden move, new house, and marital separation) she began feeling anxious, agitated and had trouble sleeping and concentrating.

In the midst of this crisis during high school, she was told her symptoms were really evidence of a “bipolar disorder” resulting from a “biochemical imbalance.” (No one ever administered to her one of the leading psychological tests designed to confirm such a diagnosis.)

Since that time, about a decade ago, she has never been off of a staggering procession of psychiatric medication “cocktails,” a term for taking a daily combination of several different psychiatric drugs, often working at cross purposes, and sometimes prescribed to counter the side effects of one another.

Now, after being on various antipsychotic medications for six years (prescribed for her presumed bipolar condition), she is reporting an internal feeling of agitation and restlessness which can be a side effect of such medications, but which is often diagnosed as a sign of further mental illness calling for higher doses of psychiatric medication. A former swimmer and lifeguard, she had also gained at least 40 pounds––a common side effect of some of the drugs she was told specifically “targeted” bipolar symptoms.

When she contacted me, she was on lithium and an anti-convulsant medication, also supposed to treat her hypothesized bipolar disorder. In addition to these two “mood-stabilizing” medications, she was on a heavily sedating antipsychotic medication, a further sedating anti-anxiety medication and a popular prescription sleep medication known to induce possible dissociative states. Over the years, she had been on all manner of mood stabilizing medications, anti-depressants and anti-psychotic medications.

She called me terrified, after she had an apparent drug induced psychotic episode in which she was drooling, and had an experience of laughing uncontrollably as she looked down upon herself from the ceiling. At times she was so paranoid she would crawl around her home to keep below the windows.

Fortunately she had a very supportive and loving mother and husband. Susan called me, feeling distraught that her psychiatrist was now insisting on adding a sixth medication, an antidepressant medication, even though Susan told the psychiatrist that in the past antidepressants had repeatedly triggered manic psychoses requiring trips to the emergency room--a possibility specifically warned of in the DSM-IV. (See the next blog entry.)

When Susan contacted me she was so over-medicated she could barely concentrate on graduate school. When she lowered one of her mood stabilizing drugs (against medical advice) and her antipsychotic medication, she reported that soon, when she walked her dog, even colors outside seemed brighter and she could think more clearly.

When she questioned if she was really “bipolar,” her psychiatrist became upset, analyzed her “denial” as further evidence of her mental illness, and refused to refer her to a psychologist who could have administered psychological testing to confirm or disconfirm the diagnosis. Instead, the psychiatrist, who, as a psychiatrist, was not licensed to administer standardized psychological testing, used a common technique to silence patient objections. She asked Susan to take a 5 question “test” to “see” if she was “really” “bipolar.” The “test” contained ridiculously broad questions that could apply to many different real life stresses or mental disorders, such as whether there had ever been a time in her life she felt agitated or had trouble sleeping.

Today Susan is down to one medication, which her new psychiatrist has suggested she at least keep temporarily in place while she gives her body and brain a chance to stabilize after getting off all the other medications. She feels better than she has in years and has lost much of the weight she had gained from medication side effects.

The psychiatric community acknowledges that presumed “bipolar” “biochemical imbalances” only seem to come “out of the blue” in otherwise happy and unstressed people, for a very small percentage of the population.

However, a pseudoscientific rationale is often offered to explain why the presumed underlying “biochemical imbalance” is so often obviously “triggered” by real life traumas. The argument is called, “the diathesis stress model.” In plain English, the idea is, as in asthma, that there may be some underlying physiological weakness, anomaly or predisposition that is triggered, or reaches a threshold, when the body is placed under stress, in the case of asthma for example, perhaps severe emotional distress, or high levels of pollution.

Perhaps, in some psychiatric cases, this may be a reasonable hypothesis. But the problem is how many people, who are not bipolar at all, are assigned this diagnose erroneously, based on simple symptoms of real life stress that can mimic bipolar symptoms: agitation, impulsive behavior, sleeplessness, racing or obsessive thoughts, irritability, etc?

Think of Ophelia, in Shakespeare’s Hamlet. We, as the audience, know exactly what really drove her crazy. First, this tragic teenager feels betrayed, used and falsely accused by her lover, Prince Hamlet, after the adults around her try to manipulate her against him. Second, her lover, Hamlet, then mistakenly murders her own father. Third, her brother then races back from France to kill Hamlet, in revenge. We, the audience, know full well why Ophelia “snaps” under all this pressure and the resulting unbearable and competing conflicts of love and loyalty, and we know she can’t dare speak the truth. So instead, under the veil of being “crazy,” she hands out, to the main characters, flowers, which in Shakespeare’s day were loaded with psychological symbolism about her actual inner state, and she sings songs or ditties to communicate, in a hidden, tormented way, the truth of what the audience knows to be the real causes of her distress.

However, today, there is no question that the adults around Ophelia would have rushed her to a psychiatrist who would have “explained” that bipolar disorder or schizophrenia can frequently “onset” in late teenage or early college years, that her “stressors” brought out this “underlying biochemical or genetic predisposition,” and that medicating away her pain and anxiety would “correct” her “biochemical imbalance.”

Further, the leading bipolar medications (Lithium, atypical antipsychotic medications and anticonvulsants used for epilepsy) really don’t “target” a specific “bipolar mechanism.” but rather simply tamp down or limit the neuronal activity of very large areas of the brain––which might likely take the edge off anyone’s level of agitation, irritation, anxiety, restlessness and sleeplessness––no matter what the cause––thus convincing the adults around her of the validity of the “diagnosis.” (See the entry on this blog titled, “Diagnosis By Pill?”)

Recently, the New York Times noted that, in many ways, the outmoded concept of a “nervous breakdown” is perhaps a more accurate term to describe the kind of distress that brings many people to both a psychiatrist and a psychotherapist. But this has a special stigma--of not being to handle stress, versus having a presumed “genetic predisposition” for a “mood disorder” one cannot control.

In the 1950s or 1960s Ophelia might have been sent to a sanitarium to “rest” after a “nervous breakdown.” In this decade, she would have been quickly diagnosed with a “biochemical imbalance” labeled a schizophrenia or bipolar disorder and quickly over-medicated.

The popular movie, Garden State, written and directed by Scrubs actor, Zach Braff, depicts a young adult finally coming out of a fog of lithium, mood stabilizers and anti-depressants prescribed to him throughout his childhood and teenage years––after he was “diagnosed” as a child for pushing his mother, resulting in an unintended serious injury.

This is not to suggest that some people do not have true or classic “manic” tendencies or episodes, however, like Susan and Ophelia, too often, teenagers and young adults, amidst obvious real life distress, are erroneously assigned such diagnoses.

Couples: Core Conflicts & Approacher/Distancer Dynamics

Mon, 26 Apr 2010 18:46:33 -0400

The phrase “core conflicts” was termed by the marital therapist, Harville Hendrix. Couples who bicker and fight a lot may always find a different reason or excuse to start fighting, but their arguments usually take the same form, like a carefully choreographed dysfunctional dance of intimacy. He makes the same accusations against her; she makes the same accusations against him. Because this is the real underlying dynamic for bickering, couples often can’t even remember what started huge fights, out of all proportion to the original problem.

So think of your arguments as metaphors, symptoms, a symbolic power struggle in the unhappiness of a relationship. What is the real issue, the real conflict, the real unhappiness, the real hurt, the real loneliness, the real truth beneath the bickering? And what would a couple really have to face, about themselves and each other, if they let go of this miserable “dance of intimacy.” (The phrase Dance of Intimacy, comes from a book about women’s relationships by Harriet Lerner.)

Another dysfunctional couples’ dynamic is the Approacher/Distancer dynamic. Happy couples seem to take turns needing either the comfort and reassurance of each other, versus needing their space and independence from each other.

However, for unhealthy couples, one party is often complaining that he or she is is the one not getting enough time, closeness and attention, while the other partner is complaining that they feel smothered and that the other partner asking for more closeness is too needy or demanding.

Suddenly, one partner is accused of being detached, cold, unloving and rejecting; while the other partner is accused of being too needy, clingy and dependent––as each pathologizes the other in the frustration of what they think they are not getting. The more the approacher approaches, the more distancer distances––and vice versa. It is as if one partner becomes the container for all the neediness and dependency in the relationship, while the other becomes the container for all the strivings towards independence and autonomy.

Of course, healthy couples do not suffer from this false psychological dichotomy. Usually, when this dynamic occurs, it is a symptom that one, or both, partners have largely unconscious and unresolved conflicts about closeness and intimacy.

If Therapy Has Not Helped Or Worked Before

Tue, 16 Mar 2010 04:55:45 -0400

There are few feelings more discouraging than seeking out a therapist who doesn’t really “get it.” There is no question that therapy can be a very rewarding experience, or a very disappointing experience.

Part of the problem is that therapists today vary in their level of training, professionalism and sophistication––whereas physicians, for example, have a fairly defined standard of training and treat disorders with defined standards of care.

Adding to this professional inconsistency is that mental health treatment philosophies and approaches can differ widely. As one patient recently told me about her complex custody case: “Everyone has a different opinion, yet everyone is supposed to be an expert.”

Whenever people tell me that they have tried therapy but it “didn’t work,” I always ask them them how long they went to the therapist. Sometimes the individual or couple will say they only went 1-2 times. Or, they will say they went to someone for a long time but it didn’t help much, and it just seemed like they were paying someone to hear them vent. I often think: “If you had a physical problem, would you have spent 6 months going to a doctor whom you felt didn’t really help you?”

A person might end up going to a psychiatrist for a year, changing medications, adding medications, upping dosages––all based on the hope of a “quick fix”––without seeing the irony that the quick fix hasn’t been quick at all, or, without stopping to wonder how many of her or his psychiatric symptoms are now psychiatric medication side effects.

However, we live in a quick fix society. And frankly, solving many of life’s problems, especially the kind of life problems that make us feel distressed enough to seek counseling to begin with, involve commitment and work as part of the process of change.

Sometimes, people are ready to work on problems in stages. They may do one part of that work in therapy at one time in their life, and another part of that work at another time in their life with a different therapist.

When therapists rely on trends, or cliches, of the latest socially acceptable diagnosis, or “models” of therapy, they are not listening to or understanding or discovering the truth of the person sitting in front of them.

I truly believe that many, if not most, therapy failures are the therapist’s fault, at least as much as the client’s fault. If you have had an unsuccessful therapy experience in the past, consider a short term consultation, without further commitment, as to whether therapy might work for you, even if you are skeptical.

About the DSM-5 & Its Controversies

Sat, 13 Mar 2010 09:00:54 -0500

The DSM-5 is the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. Although it contains generally accepted diagnostic criteria for mental health disorders, which are accepted by courts and insurance companies, it is not without controversy. Here are a few of the debated issues:

1) The DSM-5 is criticized for relying on a “medical model” or “disease model” of mental disorder and distress. After all, it is published by the American Psychiatric Association, an organization of MDs.

2) Millions of adults, and children, can “look” like they fit various DSM-V diagnoses at different times in their lives, diagnoses such as depression or ADD.

3) The simple diagnostic and behavioral criteria of the DSM-5 often have little to do with any kind of biological or chemical definition of mental disorder and stress. Yet often these criteria are used to diagnose people in a matter of minutes, who are then immediately told that, based on meeting such diagnostic criteria, they have a life “biochemical imbalance” requiring medications affecting the brain.

4) There is the logical fallacy of: “If it isn’t in the DSM-5, it doesn’t exist.” There is no rape, incest or spouse abuse syndrome in the DSM-5. Does this “prove” a victim can’t suffer from any of these syndromes? Sounds ridiculous, but this argument is often made about whether parental alienation syndrome really exists.

5) The DSM-5 warns of the importance of “differential diagnosis,” how critical it is for a professional not to confuse one of many disorders with another. In the same way, a doctor might guess what is wrong with you, but runs tests to confirm the diagnosis, and to make sure your problems aren’t being caused by another disorder. However, these sophisticated DSM-V discussions are found in the full length version of the DSM-5, not in the quick and simple diagnostic criteria in its pocket reference companion, which are copied onto websites and into Wikipedia. The result is that a person may look at a set of criteria and say, “That is me!” But they may not know what other possible diagnoses they might “fit” such as a DSM-5 “V-Code” diagnosis for a life problem not attributable to a mental disorder, such as a divorce. However, it is more difficult to get an insurance company to reimburse you, or the mental health professional, for this “diagnosis.”

Properly Diagnosing Children Before Treating and Medicating Them

Thu, 11 Mar 2010 08:48:59 -0500

The last 20 years as seen a disturbing increase in diagnosing and labeling children and teens with mental disorders, and a corresponding troubling increase in medicating them. This time period, not coincidentally, corresponds to the FDA approval for the first popular anti-depressant, Prozac. Soon, along with diagnoses of depression, “bipolar” and “attention deficit disorder” diagnoses were applied to 100s of thousands if not millions of children.

20 years is not a long time to collect “longitudinal data” on the social and biological impact of years of childhood medication. The popular movie “Garden State,” written and directed by Scrubs actor, Zach Braff, depicts a young adult finally coming out of a fog of lithium, mood stabilizers and anti-depressants prescribed to him throughout his childhood and teenage years.

The “Diagnostic and Statistical Manual of Mental Disorders-IV,” the DSM-IV, permits several diagnoses of children and teens to avoid such premature and pathological labels. However, often insurance companies want to see pathological diagnoses if they are to reimburse for “covered” mental health services. Clinicians often feel pressure to assign diagnoses emphasizing individual child psychopathology, since insurance companies don’t like to pay for family counseling. Often, such stigmatizing labels and treatment regimens are initiated after brief diagnostic interviews, without a thorough psychosocial history, and without psychological testing that could easily confirm or disconfirm these trendy diagnoses.

While adults have a difficult enough time articulating what is really troubling them, children and teens often behaviorally “act out” their inner distress. For example, behavioral problems in school could be related to underlying depressive, anxiety, bipolar, attentional or learning disorders—or to family or abuse issues. Discovering the real etiology, or cause, would certainly be relevant to choosing the correct therapy approach, or medication, if one was really needed.

Fortunately, there are good personality and diagnostic inventories for college students, teens and pre-adolescents (ages 9-12). These tests indicate into what national percentile a child or teenager falls regarding depressive, anxious, bipolar or attentional symptoms, compared to other children of the same age and gender.

For about the cost of a single therapy session one can administer a complete psychodiagnostic personality inventory assessing many different symptoms and traits. These tests involve the youth marking a series of true false questions at a desk, and only take 25-45 minutes.

Psychoeducational testing (IQ, LD, ADD & GT testing) tends to take longer, because it is time-intensive for the therapist. To conduct these tests the psychologist must administer and asses each test item and response, and then score it.

Existential Therapy: Religion & Psychology

Wed, 10 Mar 2010 06:53:06 -0500

I believe, regardless of religious denomination, that it is impossible, and a mistake, to separate the most important problems in people’s lives from their religious beliefs, moral values and cultural identity. If you think about it, this is the first time in history when our most intimate and important problems are often not thought about in a larger spiritual or religious context. Freud, of course, was an atheist. And as he aged, more of his true feelings came out, as he tried to explain religious faith in the context of his theories.

Ironically, the roots of the modern integration of psychology and religion go back before the time of Freud. Freud himself was psychologically threatened by Dostoevsky and Shakespeare, not because of their belief in a religious world view, but because of their psychological insight. About the time that Dostoevsky, in Russia, was writing complex psychological novels, the very odd, but very important, Danish philosopher, Soren Kierkegaard, was writing about philosophy, religion and psychology in a way that would profoundly influence modern European thought and existentialism, and even modern American psychology.

Kierkegaard’s two famous psychological works are, The Sickness Unto Death, and The Concept of Dread (Anxiety). The books are about depression and anxiety. Though written from a Christian perspective, they ironically influenced both modern psychology and existentialism.

The modern American individual and group therapist, Irving Yalom, authored a book titled, Existential Psychotherapy, making the point that there are some life problems and issues that can’t be therapized away, such as emotional loss and chronic or terminal illness. In that book he discusses the work of Kierkegaard. Yalom also discusses another major figure, Viktor Frankl, a Jewish psychiatrist who wrote memoirs of his years in several Nazi concentration camps: Man’s Search for Meaning. From his experience, Frankl developed his “logotherapy” or meaning therapy. He felt that people who had something larger than themselves to live for, whether their faith, or the desire to find loved ones again, were able to find more purpose in their struggle.

Another book in this tradition won the Pulitzer Prize for non-fiction, Denial of Death, by Ernest Becker. It is a critique of the limits of traditional psychological theorists, such as Freud and Jung. This is actually the book that Woody Allen shows Annie Hall in a bookstore, to which she responds that he is always giving her books with the word “death” in the title.

Kierkegaard’s masterwork on depression and despair, The Sickness Unto Death, also made it into pop culture when the ever-pretentious Diane Chambers was quietly studying the book at the bar in Cheers. Such in-jokes are warnings to the wise that these books are very difficult to read. Fortunately, the first paragraphs of Kierkegaard’s Sickness Unto Death are purposely pretentious and convoluted, in a mocking satire of the philosophy underlying Marxism and communism. But the book doesn’t come with Cliff Notes. (Oops, thanks to Google, I see there is a SparkNotes for The Sickness Unto Death, which I would recommend if you want to tackle it.)

For a more down-to-earth discussion of the value of integrating psychology and religion try the following:

• The Road Less Travelled, & People of the Lie, by M. Scott Peck (Christian)
• Existential Psychotherapy, by Irving Yalom (non-denominational)
• Man’s Search for Meaning, by Viktor Frankl (Jewish)
• The books of Drs. Minirth and Meier, embracing psychiatry for the modern American Christian community.
• Denial of Death, by Ernest Becker (non-denominational)