How do I know if I have an addiction?
It’s usually hard for people to recognize they have a problem, which is why friends or family often step in. People with good intentions may have tried to pass on information to you about your behaviour or you may have some preconceived ideas about what behaviour actually constitutes an addiction.
This information about addiction may sometimes be inaccurate and as long as you can stop for a while you may become convinced that you don’t have a problem.
Below are some issues to contemplate that may help you come to a decision about whether your drug use/behaviour may be considered problematic.
First things first – who is an addict?
The first thing to come to terms with is that addiction is NOT defined only on how much you use/engage in a behaviour or how often you do. But rather WHAT HAPPENS WHEN YOU DO. An alcoholic is not always someone who has a drink first thing in the morning nor is it always someone who can’t make it through the day without it. A drug addict isn’t always lying in the gutters of Hillbrow with a needle in his arm and a sex addict is not someone who seeks out sex all the time.
The binge drinker, the drug user who uses only on weekends, the gambler who make s it a rule never to miss a day of work, the addict in Hillbrow, the first-thing in the morning drinker, the compulsive overeater who hides binge episodes and the compulsive sex addict may all experience similar effects of addiction, despite the fact that their using patterns differ. So while the frequency (how often) and quantity (how much) of their addictions may vary, they share a common compulsive (when I start I can’t stop) intensity in the relationship with their drug/behaviour.
So what do all addictions have in common?
What is generally shared by people who are addicted is a loss of control over their drug/behaviour resulting in a feelings of chaos, guilt, shame and general unmanageability. They also tend to continue using or engaging in the behaviour regardless of the consequences it has caused in their life.
While initial drug use or initial engagement with a behaviour may have been voluntary, the repeated use of the substance or behaviour causes chemical changes in the brain which eventually result in drug use/the behaviour becoming compulsive in nature (i.e. they cannot stop).
While the criteria for diagnosing different addictions may vary, what they all seem to share in common include:
Tolerance as defined by any of the following:
A need for markedly increased amounts of the substance to achieve intoxication or desired effect
“I need to use more, drink more, eat more/less, gamble more in order to feel the way I used to.”
Markedly diminished effect with continued use of the same amount of the substance.
“I don’t feel the same way I used to in the beginning.”
Withdrawal, as manifested by either of the following:
The characteristic withdrawal symptom of the substance “When I stop I feel anxious; sweaty; nauseous, shaky; paranoid; guilty, sick and so forth.”
The same or a closely related substance is taken to relieve or avoid withdrawal symptoms “I use more so I don’t feel anxious; sweaty; nauseous, shaky; paranoid; guilty, sick and so forth.”
The substance is often taken in larger amounts or over a longer period than was intended:
“I only meant to use a little bit, I didn’t mean for it to go on for 2 days.”
“I thought I would stop after one drink.”
“I only drew R500 for the night. I promised myself I wouldn’t spend a cent more. So how did I go through R5 000 in one night?”
There is a persistent desire or unsuccessful efforts to cut down or control substance use:
“I am never going to do this again (until next week).”
“If I can just stop for a few days, that must mean I don’t have a problem.”
“It’s the vodka that’s the problem. I am switching to wine.”
“I will leave my credit card at home tonight. That will stop me from going overboard.”
A great deal of time is spent on activities necessary to obtain the substance and or engage in the behaviour, or recover from its effects:
“I will use my credit card to pay for dinner but I will take the cash from everyone else to pay for my stuff.”
“I know I am going to have a big night so I will cancel all my plans for tomorrow and make sure I have a believable story for why I shall not answer my phone.”
Important social, occupational or recreational activities are given up or reduced because of substance use:
“I will have to leave the wedding early because there is a big poker tournament tonight.”
“I feel so sick after last night I’m sure the family will understand if I don’t make it to lunch (again).”
“I missed work again because of a bender. I better get a doctor’s note for my boss – he is starting to get fed up with me.”
The substance use is continued despite knowledge of having a persistent or recurrent physical, psychological, social or legal problem that is likely to have been caused or exacerbated by the substance use:
” feel so guilty and ashamed about what I did last night. I can’t believe I did that!”
“I just can’t seem to hold down a job, what’s wrong with people?”
“Everyone is giving me hassles, telling me I have changed. They are all mad!”
“I had a nose bleed/black out last week from using. That’s never happened before it kind of freaked me out a bit. I better try to cut back a bit.”
I haven’t done that… yet
Another thing to be bear in mind is that people often compare the things they have done as a result of their addiction in an attempt to justify why their addiction isn’t “bad”. While it is undeniable that some people have done things that you may not have in order to get drugs, alcohol, sex, money and so forth, the reality is that it’s probably because your addiction hasn’t gotten there YET and it doesn’t have to!. Addiction is a progressive disease, which means that over time IT IS GOING TO GET WORSE. We didn’t say in a day or a month or a year. The truth is the progression can be quick or it can be slow. However, of one thing we are certain: if you have an addiction eventually you will do things that you never imagined you would.
I think I may have a problem, what do I do now?
If any of the above rings true and you are compelled to do something about it, well done!
We know it can be a harsh eye-opener and it may feel like a tough reality check but it is necessary to understand your addiction for what it is, so that you can take the necessary steps to get the help you need. In order to encourage you to do this, it may be a good idea to reach out to someone you love and trust and allow them to support you through this. If you are unsure about the type of help you need, here’s an outline of scenarios and options that may help you find an approach that works for you
1. I Want to go to a treatment Center
2. I want to go to a individual Therapist
3. I want to go to a support group in my area.
Please look at www.findHelp.co.za for any of the above.
You as the family of an addict exhales after your child, husband, wife or partner is admitted into a treatment programme as it has been a lengthy and painful process to get them to this point. You might sigh and have a sense of relief, but then the questions start to pop up in your mind. At this stage the family is exhausted and needs a break from the demanding addict as all the relationships are strained. It is afterwards and closer to the addict leaving treatment that you might ask yourself “What now? “What should or shouldn’t I do or say?”. The actual question is how do I support the addict in recovery? It is important to define the term “support” vs “codependency”. These terms are confused with each other in the context of substance abuse treatment.
“Support” in this context is about the action as well as wanting the person to reach their objectives and succeeding. You have to understand that co-dependency is trying to do recovery for the recovering addict and working harder than them at it. The time that the addict is in recovery is a great opportunity for the healing process to start for the family. You have to do introspection about the role you played and how addiction has impacted on your relationship with yourself and between the members of the family. Even to take a hard look at your own negative behaviours and habits that might need to be changed.
Addiction is seen as a “family disease” and not only the problem of one person, in this case the addict, but everyone in that family. I have heard family members say “Why must I go for group sessions, I’m not the one with the problem?”. These family members don’t realize that it is their problem and that through positive family involvement, the addict feels more motivated and hopeful to succeed at their treatment and eventually recovery. It is the same concept such as supporting your favourite sport’s team and letting them know that you are on their side and believe in them. This team spirit is needed for the addict to buy into recovery whilst in treatment. They need to know that you are routing for them to win and that even if you can’t play the “game” for them, you can support them and encourage them from the side lines.
Some research has indicated that there are five things families can do to support recovery of a family member. This will mean that you would have to decide to get involved in the treatment process and open yourself up to learning and listening to new knowledge about addiction being a brain disease; addiction being a lifelong disease like diabetes; the addict’s 12 STEPS programme and even change your own myths, perceptions and negative habits or behaviours.
These are the suggested guidelines for families:
Educate yourself on the recovery process for individuals and families. Read up on addiction and even download “Pleasure Unwoven” from YouTube to understand what addiction really is about. This documentary is a good start for you as a family to understand your loved one better as an addict and that addiction is more complex than what we could have imagined.
If your recovering family member is living with you, provide a sober environment to support that recovery. Investigate your living space and make sure all drug paraphernalia and alcohol beverages have been removed from your house before the recovering addict returns home. You need to become more sensitive towards a totally abstinent lifestyle that your loved one needs to follow. This means that you have to check menus; content of medications and even change family events that involves alcohol. Discuss these scenarios with the recovering addict and determine what will work for them.
Seek professional and peer support (from a group like Al-Anon) for your own physical and emotional health. It is important to seek support groups in your area because you will need your own space to talk about the negative experiences and gain support from other families that have been there themselves. Support your family member’s involvement in treatment aftercare meetings and recovery support groups.
Assist the recovering family member with assistance in locating sober housing, employment, child care, transportation or other recovery support needs. The recovering addict will have to re-learn to live their life and need more practical support during the stage of leaving treatment.
Assertively re-intervene in the face of any relapse episode. You need to compile a relapse and aftercare contract with all the parties including the therapist before the recovering addict is discharged. This contract spells out what is expected of all parties in terms of curfews; dangerous people like friends; dangerous places; control of money, cellphones, vehicles; accountability; attending of AA/NA meetings; attending aftercare sessions, etc. Furthermore, the possibility of relapse needs to be discussed and crucial decisions need to be made regarding the consequences of a relapse. You as the family also need to be able to identify the relapse signs beforehand to make the recovering addict of them.
This is not an easy task to get involved with this process to support your loved one, but the rewards are in seeing your child, your husband, your wife or your partner change for the better. Please remember that recovery doesn’t mean that all the problems disappear overnight. There still will be challenges and disappointments that you will have to face as a family. Roles and responsibilities have changed now and this can cause conflict as change bring a sense of fear for the unknown. Make it a good habit to talk every day about recovery and practice good communication skills with each other. Honesty is one of the most important cornerstone of recovery but honesty can.
For 44 years, Phoenix House has offered services in the prevention and treatment of addiction. Our excellent track record speaks for itself as we are recognised by the medical aids as a preferred service provider. Our referral networks are extensive, and include medical practitioners, social workers, psychiatrists, psychologists, employee assistance practitioners, human resource managers, school principals, social media and the community. Click here to view their profile
CBT Can Help Older People with Insomnia
Sleep difficulties are common — 30 percent to 50 percent of adults report having trouble sleeping.
For older adults, insomnia can often be chronic and is linked to other serious health conditions. Elders who have difficulty sleeping are also at higher risk for depression, falls, stroke, and trouble with memory and thinking. They also may experience a poorer quality of life.
For these individuals, sedatives or hypnotic-type sleeping pills are a common choice as a sleep aid, however, the medications bring a risk of falls, fractures, and even death.
Cognitive-behavioral therapy for insomnia (CBT-I) is a type of talk therapy that is considered highly effective for treating older adults with insomnia. During CBT-I sessions, therapists work with patients to help them change their thinking, behavior, and emotional responses related to sleep issues, which can improve their insomnia.
Although treatment guidelines recommend CBT-I as a primary therapy for older adults with insomnia, many people do not receive it because only a limited number of therapists have CBT-I training. Primary care providers also may believe that it is challenging to motivate older adults to see a therapist for insomnia.
To address these problems, a team of researchers developed a new CBT-I treatment program. The program uses trained “sleep coaches” who are not therapists. They learn how to give CBT-I using a manual and have weekly, supervised telephone calls with a CBT-I psychologist.
The program requires brief training for the sleep coaches, who are social workers or other health educators.
In their study published in the Journal of the American Geriatrics Society, the researchers assigned 159 people to one of three treatment groups. The participants were mostly white male veterans who ranged in age from 60- to 90-years-old.
The first two groups of people received CBT-I from sleep coaches (who had a master’s degree in social work, public health, or communications) who had attended the special CBT-I training. One group of people received one-on-one CBT-I sessions with the sleep coach.
The second group also received CBT-I , but in a group format. People in the third group (the control group) received a general sleep education program, which also consisted of five one-hour sessions over six weeks. These people did not receive CBT-I from sleep coaches.
During the five one-hour sessions over a six-week period, in both the one-on-one and group sessions, the coaches counseled participants about improving sleep habits and how to avoid practices that can make it harder to sleep well.
Participants were taught techniques to enhance good sleeping. Recommendations such as using the bed only for sleeping, not for watching TV or reading, limiting the amount of time in bed so sleep becomes more consolidated, and other techniques were provided.
In both groups, the sleep coaches also had one weekly telephone call with a CBTI-trained psychologist to review how the participants were doing with the program.
Researchers collected information about the participants’ sleep habits at the beginning of the study and one week after treatments ended. They also followed up with participants six months and one year later.
Following their treatment, people with insomnia who received CBT-I from a sleep coach (either one-on-one or in a group) had lessened their sleep problems significantly, compared to people in the control group.
-Participants took about 23 minutes less to fall asleep;
-Participants’ awake time was about 18 minutes less once they fell asleep;
-Participants’ total awake time was about 68 minutes less throughout the night;
-Participants also reported that the quality of their sleep had improved.
-Six and 12 months after treatment, the participants in both CBT-I treatment groups maintained most of their sleep improvements.
The researchers said that improvements in sleep were about the same whether people worked with the sleep coach in one-on-one or group sessions.
The primary limitations of the research accompany study composition as investigators report the study was mostly limited to male veterans. As such, the results might not be the same for women or for non-veterans.
Overall, the researchers concluded that this CBT-I treatment program, delivered by sleep coaches, improved sleep quality for older adults.
Source: American Geriatrics Society
The history of psychoanalysis in South Africa is a story of tenaciousness. It began after Wulf Sachs emigrated there in 1922 with his family. Born in Lithuania in1893, he had trained at the Psycho-Neurological Institute in St. Petersburg (under Pavlova and Bechterev), at the University of Cologne, and at London University, where he took a degree in medicine. He began as a General Practitioner in Johannesburg but his interest in psychology was intensified by the experience of working with black schizophrenic patients at the Pretoria Mental Hospital from 1928.
In 1929-30 Sachs underwent a six month analysis in Berlin (possibly with Brill) and he came into contact with Freud, whose diaries indicate that Freud, Anna Freud and Ernest Jones were all well disposed towards him, and ‘intrigued’ by the idea of a South African Study Group under his leadership. (Dubow, 1993; see also Molnar, 1992, pp. 173, 215-216, 294). Sadie (Mervis) Gillespie added that at this time Sachs spent some time in New York getting supervision from Helene Deutsch and Grete Bibring.
After returning to South Africa, Sachs gave a series of lectures on psychoanalysis which were organized by Professor Hoernle of the Wits University philosophy department. These lectures formed the basis of his introductory book on psychoanalysis ‘Psycho-Analysis: Its Meaning and Practical Applications’ to which Freud himself contributed a commendatory foreword (see Dubow, 1993).
In 1935, Freud proudly announced the establishment of a South African Psychoanalytic Society (in a postscript to his 1924 ‘Autobiographical Study’). Wulf Sachs was appointed as a Training Analyst by the British Psychoanalytical Society, and in Johannesburg he gathered a group of interested young people around him and took on cases, including the analysand who became the hero of his book Black Hamlet. The original group was composed of Anne Hayman, Max Joffee, Eric Levine, Esmond Gaynor Lewis, Sadie Mervis, Louis Miller, Joan Phillips, Ismond Rosen, Bill Saffrey, and Saul Udwin. Clarissa Bernstein served as honorary secretary.
The advent of Apartheid and sudden death of Sachs in 1949 aged 56 put a premature end to the Society’s fledgling training programme, when most of his group emigrated to England. Thereafter, South Africans wishing to undertake accredited psychoanalytic training of any kind had to do so abroad. Few returned. Wally Joffe did come back, and set up a practice in Johannesburg after completing his training in London, and soon became the focus of a small discussion group, hoping that this would develop into an official Psychoanalytic Study Group. But feeling professionally isolated he returned to London after three years and sadly, that group disintegrated.
The South African Institute for the Study of Psychoanalysis was the next development. The remarkable happened. A wealthy South African by the name of Sydney Press approached Professor Lynn Gillis offering to establish a fund for analysts to train abroad. A non-profit foundation called the South Africa Institute for the Study of Psychoanalysis was formed and registered as such in 1962. It was supported by several prominent South African academics and members of the Medical Council and was approved by the British Society. William Gillespie, the then President was brought out to help with advice and arrangements and a committee was formed to interview applicants. Amongst those supported were Anton Obholzer (who felt compelled to return the loan), E Smit, Fakhry Davids, Ronnie Doctor, Mark Solms. [Gillis, personal communication].
Since such training typically extended over several years, practical considerations and the unfavourable political situation at home meant that few indeed returned when qualified. But quite a few visited to give workshops and lectures to the flourishing body of home grown psycho-analytical psychotherapists both in Johannesburg (see Hamburger, 1992) and Cape Town. From 1979 onwards contributers included Isca Salzberger Wittenberg; Henry Rey; Michael Feldman; Iain Dresser; Martin and Sheila Miller; Judith Jackson; Steven Dreyer; Edna O’Shaughnessy; Eric Brenman; Anne Hayman; Sadie Gillespie; George Pollock and myself.
In the wake of the momentous political developments of the early 1990s a group of expatriates in London formed the South African Psychoanalysis Trust (SAPT) with the singular aim of bringing South African psychoanalysis into line with international standards through the establishment of an accredited training institute. As Mark Solms wrote, ‘We fully realised from the outset that psychoanalysis as a mode of treatment (perhaps especially in a developing country) cannot flourish in the absence of the wider practice of psycho-analytic psychotherapy. However, since the latter already existed in South Africa, and since the reverse is also true (i.e., psychoanalytic psychotherapy cannot flourish in the absence of psychoanalysis), we decided to focus our efforts solely on the formation of an IPA-accredited institute. The further alignment of psychoanalytic psychotherapy training programmes in South Africa with international norms and standards would – we thought – naturally flow from this, as would many other potential benefits related to the broader application of psychoanalytic knowledge’ (2010).
The SAPT did significant groundwork by organising two international conferences in South Africa. Mark Solms recalls that at the first of these, held in 1997, David Sachs (Philadelphia-based grandson of Wulf Sachs and then Chair of the New Groups Committee of the IPA) made an important announcement informing local delegates that the IPA had recently established procedures for psychotherapists working in countries (such as in the former Soviet bloc) in which the normal development of psychoanalysis had not been possible, but whose standards of training were nevertheless roughly equivalent to those laid down by the IPA, to become ‘Direct Members’ of the IPA. This initiated a dialogue between Dr Sachs and several local psychoanalytic psychotherapists who met the IPA’s minimum criteria – in terms of personal training analysis, supervised control analyses and theoretical instruction. Following the second conference, and shortly after Karen Kaplan-Solms and Mark returned to South Africa, the SAPT, having fulfilled its mandate, was dissolved. The baton was now passed to the two of them to take the training effort forward.
Mark Solms again: ‘The immediate task was to attain the magical number of four IPA members living and working in South Africa. This makes it possible for a local group to apply to the IPA for official ‘Study Group’ status, which is the first step toward the establishment of an accredited training institute’ (Solms, 2010).
Following meetings with representatives of local psychoanalytic organisations in both Cape Town and Johannesburg a series of didactic seminars began in 2003 focusing on basic psychoanalytic concepts, led jointly by Katherine Aubertin (a Paris-trained member of the IPA who had returned home in 1986) and Mark. This was followed by a second series of theoretical seminars in which the basic concepts were applied to a study of published clinical case reports. Later the seminar were transformed into several clinical seminar groups in both Johannesburg and Cape Town to accommodate the demand for membership and the inevitable boundary problems that arise in psychoanalytic organisations, where therapists and patients are sometimes also colleagues.
In 2006 all the Johannesburg and Cape Town groups were consolidated to form a single national organization, called the South African Psychoanalysis Initiative (SAPI) currently consisting of about 160 members which also offers clinical seminars for newly qualified psychologists and mental health practitioners working in community settings. It offers clinical seminars for newly qualified psychologists and mental health practitioners working in community settings since each student in South Africa is required to complete one year of community service to register as a psychologist. In addition, intensified collaboration between psychoanalysts and neuroscientists has occurred as a result of Karen Kaplan Solms, psychoanalyst and a speech and language pathologist and neuropsychologist, and Mark Solms relocating to South Africa. As Head of the Psychology Department at the University of Cape Town, Mark has created a Masters Programme in Neuro-psychology and the 14th Annual Congress of the International Neuro-psychoanalysis Society was held in Cape Town in August 2013, with the ‘integration of brain and mind’ hailed as a new frontier. SAPI also runs a research group in Cape Town that focuses on the implications for clinical work of recent neuroscientific revisions of instinct theory and the comparison with Freudian drive theory. The University of Cape Town offers a PhD programme in psychoanalysis and two of the students form the core of the Cape Town and Johannesburg SAPI Research Groups.
The 14th Annual Congress of the International Neuro-psychoanalysis Society was held in Cape Town in August 2013
Meanwhile the South African Psychoanalytic Association (SAPA) achieved IPA Study Group status at the IPA’s 46th Congress in Chicago in July 2009. This has been expensive, involving bi-annual visits by three members of the IPA to oversee its progression from Study Group (with a minimum of four local IPA members), to Provisional Society (once a minimum of 10 members has been reached), to Component Society (when fully independent status is achieved) – at which point the Sponsoring Committee will be dissolved.
So, formal psychoanalytic training is now being offered in South Africa. To date there are seven training analysts/supervisors (Barnaby B. Barratt, Gyuri Fodor, Karen Kaplan Solms, Sue Levy, Mary-Anne Smith, Mark Solms and Elda Storck. Alan Levy, who joined the Study Group in 2011, left for London at the end of 2015). All qualified overseas – four in London, and one each in Vienna, Zurich and the USA. They also share administrative and teaching tasks across the two cities, Johannesburg and Cape Town with three recently qualified home-grown psychoanalysts, and two other IPA Direct Members form part of the SAPA Study Group with 22 candidates. New intakes occur every three years and there is ongoing interest in the admissions procedures.
In 2010 South African Psychoanalytic Confederation (SAPC) composed of around 40-odd member groups representing more than 500 individuals, a consolidation of the years of steady work in a complex political climate. Dozens of groups joined and worked at creating the constitution and ethical code – from small rural reading groups to large institutes of psychoanalytic learning. It was also a vote of confidence in the future of psychoanalysis in this country and a reflection of the wish to normalize the local situation in an international context.
Finally, SAPI has an annual weekend congress in February, previously held on the Solms-Delta wine farm in Franschhoek, and now in Johannesburg at Ububele (the brainchild of Tony and Hillary Hamburger, who have created a centre for community outreach services, education, training projects and psychotherapy on the threshold of Alexandra, a local township). This two-day colloquium was originally convened by Sharon Raeburn with 12 people and headed over many years by Jonathan Sklar (both from London). It has grown exponentially to over 120 participants in recent meetings, and usually attended by some international colleagues, including Alexandra Billinghurst, Vice President of the IPA in 2016. Over the previous 10 years these conferences have focused on complex and exciting topics such as The Embodied Mind, led by Marilia Aisenstein in 2014. The 2015 keynote address by Irma Brenman Pick was on Creativity and Authenticity, and previous conferences debated issues of race, trauma, reconciliation, and forgiveness and most recently, ‘splits and divides in societies’. The atmosphere that pervades the organization is one of people courageously engaged in a radical pioneering project. Attending these meetings as I have done from the start is a heady mixture of new discovery and extraordinarily honest yet troubled self-examination in the context of a slowly recovering traumatised society.
As Mark Solms remarked in 2013 ‘seeing psychoanalysis taking root in South Africa is not for the faint-hearted, but taking root it is!’
joan-professor-joan-raphael-leff-1Joan Raphael-Leff, PhD, psychoanalyst (Fellow, British Psychoanalytical Society) and social psychologist, leads the Anna Freud Centre academic faculty for psychoanalytic research. Previously, she was head of University College London’s MSc in Psychoanalytic Developmental Psychology, and professor of psychoanalysis at the Centre for Psychoanalytic Studies, University of Essex and professor extraordinary at Stellenbosch University. For 35 years she has specialized in emotional issues of reproduction and early parenting, with more than 150 single-author peer-reviewed publications, and twelve books. Founder and first international chair of COWAP (IPA’s Committee on Women and Psychoanalysis) in 1998, she provides training for practitioners working with teenage parents, and is consultant to perinatal and women’s projects in many high and low income countries.
Dubow, S (1993) Wulf Sachs’s Black Hamlet: A Case of ‘Psychic Vivisection’? African Affairs, 92:519-556
Sachs, W. (1934) Psycho-Analysis: Its Meaning and Practical Applications, London: Cassell
Gillespie, S. (1992) Historical notes on the first South African psychoanalytic society, Psycho-analytic Psychotherapy in South Africa, 1:1-6
Hamburger, T. (1992) The Johannesburg psycho-analytic psychotherapy study group: a short history, Psycho-analytic Psychotherapy in South Africa 1:62-71
Molnar, M. (Ed) (1992) The Diary of Sigmund Freud 1929-39: A record of the final decade, London: Hogarth Press, 1992.
Raphael-Leff, J. (2015) Trauma, reconciliation, embodiment: An account of the 9th and 10th SAPI conferences, Psycho-analytic Psychotherapy in South Africa, 24:118-125
Solms, M. (2010). The Establishment of an Accredited Psychoanalytic Training Institute in South Africa. Psycho-Analytic Psychotherapy in South Africa, 18: 13–19.
Storck, E. (2010). The Launch of the South African Psychoanalytic Confederation: A Witness Report. Psycho-Analytic Psychotherapy in South Africa, 18:1–12.
Storck-van Reenen, E., & Smith, M-A., (2015) Psychoanalysis in Post-Apartheid South Africa Journal für Psychoanalyse, 56: 152–164
In addition to existing sources, I drew on several personal interviews I conducted with three nonagenarians: British psychoanalysts Anne Hayman and Sadie Mervis Gillespie, and the previous Professor Psychiatry at the University of Cape Town, Lynn Gillis. I want to thank Oliver Rathbone of Karnac books for donating some foundational volumes for the two psychoanalytic libraries at Ububele and in Cape Town, respectively.
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This entry was posted in Psychoanalysis and tagged Black Hamlet, Joan Raphael-Leff, Mark Solms, Psychoanalysis in South Africa, South African Psychoanalysis Initiative (SAPI), South African Psychoanalysis Trust (SAPT), South African Psychoanalytic Confederation (SAPC), Wulf Sachs. Bookmark the permalink.
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There are certain skills that, once you learn them, you can reasonably expect to remember forever. Counting, reciting the alphabet, signing your own name — all things that stick with you, unless illness or injury takes them away.
Which makes it all the more jarring when one of those basic skills suddenly disappears. In Scientific American yesterday, Yale University psychiatry resident Daniel Barron described the case of “Mike Brennan” (a pseudonym), a 63-year-old man who went to work one morning in 2010, sat down at his desk with the morning newspaper, and discovered he no longer had the ability to read. He hadn’t suffered any trauma, wasn’t battling any neurological disease — it was like his reading ability had been lifted cleanly out of his head, leaving him otherwise healthy and intact.
The problem: Brennan, a cardiology technician, was a former smoker who had struggled with high blood pressure, both of which he knew to be risk factors for stroke. Fearing that might be what was happening, he went to the ER for testing, which revealed no other symptoms — his vision and hearing were normal, he still knew the names of objects and colors, and he had no trouble thinking clearly. The only issue was reading: He could recognize letters, but he couldn’t string them together; he could write, but he couldn’t make sense of what he’d put on the page.
The diagnosis: Brennan was diagnosed with “pure alexia,” defined as “a selective impairment of reading in the absence of other language deficits [that] occurs as a consequence of brain injury in previously literate individuals.” In his case, as he had suspected, the injury turned out to be a stroke – a tiny one, in a part of the brain called the left inferior occipitotemporal cortex, which helps process visual information.
Mystery solved. Except, Barron wrote, two things were particularly unusual about Brennan’s diagnosis: One, it was the first time that such a small stroke had caused the disorder, which usually results from much more significant injuries. And two, it pointed to the existence of a part of the brain that scientists had been hotly debating for years.
The “visual word form area” — a brain structure specifically devoted to processing letters — was first proposed in the 1990s by researchers who noticed that reading caused an uptick in activity in the left inferior occipitotemporal cortex, where Brennan’s stroke occurred. The theory immediately led to controversy, Barron wrote — “the kind that, at a conference, provokes shouts and screams from otherwise calm and collected scientists”:
For one thing, the very search for a “visual word form area” was misguided because it personified the brain’s real work, which is to process and decode visual information. Brain regions act as an assembly line of neural groups that each contribute some cognitive rivet or weld to a larger percept. A visual word form area confused an assembly line for a one-man-band.
Finally there was the problem of evolution. Because reading was a relatively new cultural invention, humans couldn’t have evolved to read text in the same way that mammals evolved to recognize faces—there simply hadn’t been enough time. This made it hard to believe in a brain structure expressly devoted to reading.
Over the next several years, though, a series of studies incrementally pushed scientists closer to accepting the possibility. One experiment — conducted on a group of illiterate Colombian guerilla fighters trying to reintegrate into society — found that as adults learned to read, gray matter builds up in specific parts of the brain. Another, comparing literate and illiterate adults, zeroed in on changes in the left inferior occipitotemporal cortex: “When one learns to read,” Barron explained, the area “is recycled from a general visual recognition center to a specialized word recognition center, at the expense of other tasks.”
And then came Brennan’s case — “the final piece of the puzzle,” as Barron put it, proving the existence of the visual word form area by showing what happened when it was damaged. It’s also a powerful example of the brain’s flexibility: “The way in which the area is repurposed from general visual recognition to word specialist,” he wrote, “is a reminder of how powerfully the brain can retool and adapt—essential processes both in learning and healing.” There’s plenty scientists still don’t know about this part of the brain, but in the meantime, as they work to figure it out, Brennan — with the help of a speech-language therapist and repeated grade-school style vocabulary drills — has relearned how to read.
Are we fooling ourselves?
I had a nice conversation on a plane the other day with a woman who told me that she learned about the importance of positive thinking from reading self-help books.
When I asked if she found this advice useful, she said, "not really." We both laughed, but I think this is true for a lot of people. And yet, we keep hearing about the power of positive thinking. Why?
Perhaps it has something to do with the fact that negative beliefs about the self, the world, and the future can lead to anger, anxiety, and depression. And to feel better, it seems reasonable to turn to "optimistic" or "positive" thinking.
But this strategy can backfire if our new ideas aren't believable, realistic, or confirmed by our experiences.
When positive thinking goes wrong
Have you ever tried to convince yourself that you'd ace the job interview and get hired immediately?
That you'd stand up in front of an audience and deliver a perfect presentation?
That you'd start up a conversation with a stranger who would see your greatness and be thrilled to chat with you?
That you'd be able to stick to your diet because this time you're truly motivated?
Sometimes beliefs like these are supported by the data—pleasant reactions from other people, consistently healthy behavior, and other successful outcomes.
But sometimes we experience disappointing outcomes that don't match our predictions. If we try to guide ourselves through life with positive thoughts, what happens when things don't work out so well?
When beliefs and experiences don't match, we become confused, frustrated, and disappointed. This is why positive thinking is so limited. It often seems forced or inauthentic and it only works when we have the experiences we desire.
What's the alternative?
A better bet is to practice replacing negative beliefs with ideas that are more accurate and useful.
For example, when you catch yourself thinking in unreasonable ways, begin to assess accuracy. Some questions to ask yourself:
What's the evidence to support this belief?
Is there any evidence to reject it?
Is there a more accurate way to think about this situation?
Next, consider the usefulness of the belief and whether it would benefit you to change it. Some questions to ask yourself:
What's the likely effect of thinking this way?
How does it affect my emotions? My behavior?
What would happen if I changed my belief?
Using exercises like these to move toward more accurate and useful beliefs can have a huge impact on the intensity of unpleasant emotions.
Leading anti-depressant drugs like Prozac boost serotonin, but it also appears to be involved in signalling anxiety within the brain
It is known as one of the “happy hormones” and its discovery ultimately led to the development of what were hailed as depression ‘wonder drugs’ like Prozac.
But, despite being prescribed as a treatment for anxiety, these ‘SSRI’ drugs designed to boost levels of serotonin in the brain had a strange and mysterious side-effect. In some cases, they initially made people feel more anxious or even suicidal.
Now a new study, published in the journal Nature, has found that, contrary to the popular view serotonin only promotes good feelings, it also has a darker side.
Researchers in the US delivered a mild shock to the paws of mice and found this activated neurons that produce serotonin in an area of the brain known to be involved in mood and depression.
Artificially increasing these neurons’ activity also appeared to make the mice anxious.
Using sophisticate equipment to monitor the mice’s brains, the scientists, from North Carolina University’s medical school, then mapped what they described as an “essential” serotonin-driven circuit “governing fear and anxiety”.
Professor Thomas Kash, one of the researchers, said: “The hope is that we'll be able to identify a drug that inhibits this circuit and that people could take for just the first few weeks of SSRI use to get over that hump.
“More generally, this finding gives us a deeper understanding of the brain networks that drive anxiety and fear behaviour in mammals.”
According to the NHS website, SSRIs are "usually the first choice medication for depression" because they "generally have fewer side effects".
"These can be troublesome at first, but they'll generally improve with time," it says.
It says the "common side effects" of the drugs can include: "Feeling agitated, shaky or anxious; feeling or being sick; dizziness; blurred vision; low sex drive; difficulty achieving orgasm during sex or masturbation; in men, difficulty obtaining or maintaining an erection."
The US researchers said the next step was to find out whether the same serotonin brain circuitry exists in humans.
“It’s logical that it would since we know SSRIs can induce anxiety in people, and the pathways in these brain regions tend to be very similar in mice and humans,” Professor Kash said.
They suggested that existing drugs might be capable of blocking the anxiety-inducing effects of serotonin.
“We're hoping to identify a receptor [in the brain] that is already targeted by established drugs,” Professor Kash said. “One of them might be useful for people as they start taking SSRIs.”
The most important parenting you’ll ever do happens before your child turns one — and may affect her for the rest of her life. One mother’s journey through the science of attachment.
The stage is set: a room with two chairs and some toys on the floor. A mother and her 1-year-old baby enter and begin the Strange Situation, a 20-minute, eight-episode laboratory experiment to measure “attachment” between infants and their caregivers.
Through a one-way mirror, researchers observe the pair, cataloging every action and reaction. It doesn’t take long to determine the baby’s baseline temperament: physical, running to every corner of the room; inquisitive, intently exploring and mouthing every block; or reserved, wistfully holding a wind-up toy. The mother is told to sit down and read a magazine so the baby can do whatever she is naturally drawn to do. Then a stranger comes in, and the baby’s reaction is observed — is she afraid of the stranger, nonchalant, or drawn to her? This indicates the style of relating to people in general, and to the mother by comparison.
The mother is instructed to leave the room, leaving her purse on the chair, a sign that she will return. Here we see how the baby responds to the experience of being left — does she howl and run to the door? Or does she stay put, on the floor, in a mountain of toys? The stranger tries to soothe the baby if she is upset. Otherwise, she leaves her to keep exploring.
After a few minutes, cut short if the baby is truly under duress (but that happens rarely), the mother returns for Reunion No. 1. The theory of attachment holds that a behavioral system has evolved to keep infants close to their caregivers and safe from harm. The presumption is that all babies will be under stress when left alone (and in fact, heart rate and cortisol levels indicate that even babies who don’t appear distressed still are). So when the mother returns to the room, researchers are watching to see whether the relationship works as it should. Does the reunion do its job of bringing the baby from a state of relative anxiety into a state of relative ease? In other words, is the child soothed by the presence of the mother?
If the baby was upset during separation but sits still as a stone when her mother returns, it’s likely a sign of an insecure attachment. If the baby was relaxed when left alone and is nonplussed by reunion, that’s less significant. If the baby hightails it to her mother, then screeches mid-approach, indicating a change of heart, that’s a worrisome sign too.
But the most important moment is Reunion No. 2, after the mother leaves again and returns again. If a baby who was upset during separation still does nothing to acknowledge her mother’s return, it’s a sign that the baby, at only a year old, has already come to expect her advances to be rebuffed. If the baby reaches out for love but isn’t able to settle down enough to receive it (or it’s not offered), that may reflect a relationship filled with mixed messages. And if the baby is wild with sadness then jumps like a monkey into the mother’s arms and immediately stops crying, the baby is categorized as secure, coming from a relationship in which she expects her needs to be met. The same goes for a mellow baby whose cues are more subtle, who simply looks sad during separation, then moves closer to Mother upon reunion. In both cases, the relationship works. (And just to be clear, a “working” relationship has nothing to do with the baby-wearing and co-sleeping and round-the-clock care popularized by Dr. William Sears’s attachment-parenting movement; plenty of secure attachments are formed without following any particular parenting philosophy.)
Separate, connect. Separate, connect. It’s the primal dance of finding ourselves in another, and another in ourselves. Researchers believe this pattern of attachment, assessed as early as one year, is more important than temperament, IQ, social class, and parenting style to a person’s development. A boom in attachment research now links adult attachment insecurity with a host of problems, from sleep disturbances, depression, and anxiety to a decreased concern with moral injustice and less likelihood of being seen as a “natural leader.” But the biggest subfield of attachment research is concerned, not surprisingly, with adult attachment in romantic relationships (yes, there’s a quiz). Can we express our needs? Will they be met? If our needs are met, can we be soothed? Adults with high attachment security are more likely to be satisfied in marriage, experience less conflict, and be more resistant to divorce.
The trouble is that only around 60 percent of people are considered “secure.” Which, of course, means that a good lot of us have some issues with attachment, which gets passed from generation to generation. Because if you had an insecure attachment with your parents, it is likely that you will have a more difficult time creating secure attachments for your own children.
The poet Philip Larkin was not the first or the last to notice that parents, “they fuck you up.”
When my daughter Azalea was born, I was flooded with feelings of love. But it wasn’t long before I returned to a more familiar sense of myself, and that love was mixed with ambivalence, internal conflict, impatience, and sometimes anger. Yes, I adored my baby, the way she nose-breathed on me as she nursed, her milky smell, her beautiful face, her charming smiles, her bright energy. Her. I loved her. But I was exhausted and overwhelmed, and what might be expressed as irritability in some parents felt more like rage to me. I knew better than to express anger at a baby, but my control dials felt out of reach. I never hit or shook my daughter, but I did yell at her, in real and frightening fury. One time, when she was 6 months old, she was supposed to be taking a nap, but instead she was pulling herself up in her crib, over and over again, nonstop crying. I was over it, done, nothing left. I sat on the floor in her darkened room, and made my ugliest, angriest, face at her, seething, yelling at her to just…go…to…SLEEP.
If this had been a one-off, I could have rationalized that every parent loses it at some point. But this kind of heat was all too available to me. I would occasionally confess my behavior to my husband, a psychotherapist, but he rarely saw it up close. So as much as he, my own therapist, and my friends tried to support us both, I was largely alone in my shame. And my daughter was alone with a warm and loving and sometimes scary mom.
I had read Dr. Sears and his attachment-parenting ideas before Azalea was born, but I was deeply suspicious that a checklist of behaviors could teach anyone how to raise a human being. I would read things like “Respond to your baby’s cues,” and think, Right. As if. Her cues were often inscrutable and always exhausting. Sears’s cavalier oversimplification annoyed me to no end and added to the weight of expectations and disappointment.
As Azalea grew, some things got easier. Language helped. Her ever-increasing cuteness and sweetness helped. Our connection developed, and I loved doing things together — reading books, going to Target, cooking, cuddling, walking, hanging out with friends. Things were good. Except when they weren’t. Like the time in the grocery store as I was checking out with Thanksgiving groceries while struggling to manage Azalea’s unwieldy 10-month-old body in front of a line of blankly staring, silently huffing adults. I remember the jaw-setting, skin-tingling, adrenaline-pumping feeling of anger overtake me. While I don’t remember exactly what I said to my squirming baby, I will never forget the disgusted look on the checkout lady’s face, confirming that whatever outburst I settled on was definitely not okay.
In my dark moments, I felt like something inside me was missing, that thing that functions deep down that keeps us from hurting the people we love. But I also tried to remind myself that the cult of perfect parenthood is a myth, that there is no way to avoid making a mess of our kids one way or another. That gave me some peace. Then, when Azalea was 4, I interviewed Jon Kabat-Zinn, the mindfulness and meditation expert who has written many books, including Everyday Blessings: The Inner Work of the Mindful Parent. I think I was hoping he might encourage me to set down my burden of guilt and shame, maybe even offer a God-like let it go. But that wasn’t what happened.
Kabat-Zinn: The meaning of being a parent is that you take responsibility for your child’s life until they can take responsibility for their own life. That’s it!
Me: That’s a lot.
Kabat-Zinn: True, and it doesn’t mean you can’t get help. Turns out how you are as a parent makes a huge difference in the neural development of your child for the first four or five years.
Me: That is so frightening.
Kabat-Zinn: All that’s required, though, is connection. That’s all.
Me: But I want to be separate from my child; I don’t want to be connected all the time.
Kabat-Zinn: I see. Well, everything has consequences. How old is your child?
Me: Four and a half.
Kabat-Zinn: Well, I gotta say, I have very strong feelings about that kind of thing. She didn’t ask to be born.
I knew then that I needed to figure out why I am the kind of mother I am, and what effect it was having on my daughter.
What began as a quiet inkling that studying attachment might help me understand my vast and varied shortcomings as a mother unfolded into a bona-fide obsession with the entire field of attachment research, inspiring me to write a book and to sign up for training in the Strange Situation. So last August I traveled to Minneapolis where, for the past 30 years, professor Alan Sroufe, co-creator of what has become known as the Minnesota Study, a seminal, 30-year longitudinal study of attachment, has trained researchers, grad students, clinicians, and intrigued writers to become reliable coders of the Strange Situation. I knew that only through training could I learn to discern the bedrock of an infant’s most important relationship. I wanted to become that trained eye.
From our seats in a big classroom, students from around the world — Italy, Peru, New Zealand, Mexico, Israel, Japan, and Zambia — watched several videotaped Strange Situations a day, spanning the history and breadth of the field itself, from early, grainy footage with American moms wearing Gloria Vanderbilts and wedge sandals to HD-quality contemporary Swedish pairs. The action is so simple — alone, together, alone, together — it’s almost lyrical. Though the Strange Situation has been done with fathers and other primary caregivers (and monkeys!), the structure is always the same and always points to one thing: the crazy, difficult, beautiful, mysterious nature of trying to love someone.
At the beginning, I was lost. I couldn’t track the action, let alone what mattered, and I got distracted by the wrong details, or hung up on my own reactions. Is it the whiny babies who are insecure and the robust, easygoing ones who are secure? Not necessarily. Attachment is not about temperament. If a big crier is soothed by his mother’s return, he is securely attached. If an anxious kid knows how to scramble for safety and feel felt, it’s another good sign. This is why the Strange Situation works so well — it highlights the relationship while controlling for almost everything else.
Eventually, I learned how to read the cues, and I began to notice the quickest glance and connect it with the rest of the baby’s behavior. I began to notice the difference between a full-on wrap-around-the-legs greeting and a limp request for contact, and the significance of each. I started to wonder about the baby who reached up to be held and kicked at the same time. And I began to worry about all those “good” babies who just sat there, moving shapes around the floor, unaffected by their lifeline’s comings and goings.
While attachment behaviors look different across cultures, the attachment system itself is universal. All babies fall into one of the patterns: Secure (B), Insecure/Avoidant (A), and Insecure/Resistant (C). (There are also eight subgroups and a whole other strain within these categories called disorganization.) In the case of Avoidant babies, there is often little or no acknowledgment of the mother’s return. The chill in the air is unnerving. The marker of the avoidant baby, as opposed to the secure one who simply doesn’t need as much contact, is either a subtle averting of their gaze, or an overt change of direction en route to connection. You can see babies literally change their mind as they make a beeline for comfort. Resistant babies, meanwhile, are pissed — kicking, arching, hitting. They make a big show of wanting contact, but they are unable to settle even after the one they desire has returned.
B-4 is a subgroup of secure babies who express a lot, need a lot, can be a bit feisty, but who know where their bread is buttered. My favorite Strange Situation starred a little B-4 girl in a lavender dress who reminded me of Azalea. Sitting in the darkened classroom, I watched the baby toddle around in her little sneakers, bawling her head off when her mother, a thin, sad-seeming young woman with ’80s hair and Reeboks, left. But when the mother returned, the baby ran to her and was immediately picked up. The crying stopped. This was not one of those moms with tons of affect and big expressions of there, there. She just picked her up, and the baby molded right to her, put her head on her shoulder, and then (and this is the best thing ever) the mother and daughter patted each other’s shoulders simultaneously. Co-regulation, a mirror. Then the baby got back on the floor to play.
I thought back to when my daughter Azalea was that age, wearing dresses with giant bows, walking on stiff legs, flyaway curls in pig tails — an adorable, willful, comfort-seeking missile. Then there was me, self-concerned, kind of unavailable, moody, angry. I looked around at all the mothers and daughters and fathers and sons in the classroom, staring up at the big screen, as this sad-looking mother and her big-feeling daughter showed us all how it’s supposed to be done, each of us probably wondering the same thing: What about me? What about her? What about us?
Before attachment theory came into view in the 1950s, the field of developmental psychology was very much focused on the interior drives of each individual, not their relationships. Then a British psychoanalyst named John Bowlby came along and made the case that relationships mattered more than anyone had previously suspected. His theory, influenced by the study of animal behavior, was that primates require a primary caregiver for survival, not as a means to receive food (as the behaviorists believed), but in order to be and feel close to a protective adult. According to Bowlby, it was in service to this goal of real and felt security that certain so-called “attachment behaviors” had evolved to elicit a caregiver’s response — crying, following, smiling, sucking, clinging. In other words, babies had evolved to send signals to their caregivers when vulnerable (afraid, sick, hurt, etcetera) that required a response (picking up, cuddling, tending to, etcetera) that kept them safe from danger. At the heart of the attachment system is a primitive kind of call and response that keeps the species alive.
While Bowlby is known as the father of attachment, a prodigiously smart psychologist who worked briefly as his researcher, Mary Salter Ainsworth, is the one who brought his theory to life. In 1954, Ainsworth’s husband got a job in Uganda and she accompanied him, determined to set up a research project testing her and Bowlby’s budding theory with real people. After a year of observing Ganda mothers and babies, she noticed that the babies who cried the least had the most attentive mothers. And she saw how “maternal attunement” to babies’ cues seemed to determine these patterns.
While previous studies had noted of a mother’s “warmth,” or a child’s smiles or cries, what made Ainsworth’s observations original was that she noticed relational sensitivity, the actual relationship between two beings. The sensitive caregiver, she writes, “picks [the baby] up when he seems to wish it, and puts him down when he wants to explore … On the other hand, the [caregiver] who responds inappropriately tries to socialize with the infant when he is hungry, play with him when he is tired, or feed him when he is trying to initiate social interaction.” She also noticed that the babies who were most comfortable exploring were the ones whose mothers made it clear they weren’t going anywhere.
Ainsworth followed up her work in Uganda with her famous “Baltimore Study,” the first to methodically observe mothers and babies in relationship, in the home, and then with the laboratory procedure designed to replicate what she saw in the home, the Strange Situation.
Bowlby’s theory was that babies can’t handle their own fear, sadness, wet-diaper-ness, hunger, etcetera and need someone to handle it for them. This process begins with “co-regulation” with the caregiver and ends, ideally, with “the establishment of the self as the main executive agency of security-based strategies.” In other words, children who are effectively soothed by their caregivers eventually learn how to do it for themselves. And what of those for whom this doesn’t happen?
It was with no small amount of trepidation that I began to wonder what happened to Azalea’s tears when I wasn’t able to absorb them. Where does a baby’s unshared heartbreak go? I thought back to so many times when I turned away from her anguish, and how simple it would have been for me to turn toward her instead. I began to see her toddling along in the world, following the hot, human trail of seeking connection — checking back, exploring, moving away, returning. And I saw how difficult it was for me to tolerate that much needy attention.
Was that because I had an insecure attachment myself? Pictures of myself as infant — actual 1969 Polaroids, as well as mental images — began coming into my mind. I know my mother nursed me, which was unusual at the time (I also know she smoked while nursing, as in at the same time). I know she was thrilled that I turned out to be a girl after two boys, that she always knew she would name her daughter Bethany. I started to wonder how my mother and I would have done in the Strange Situation. When Azalea was born and I struggled with keeping her little body occupied, my mom recalled, Gosh, I used to just put you kids on the blanket with some toys.
As a writer who has been in and out of therapy pretty much my whole life, it’s not like I had never thought about my childhood, or worked with difficult feelings before. But learning about Bowlby’s and Ainsworth’s work made me wonder if at least some of my troubles — all manner of adolescent acting out, complicated personal relationships, low self-esteem — were an expression of an insecure attachment. I was a poster child, really, for insecurity. As Sroufe and his colleagues write, “Attachment history itself, while related to a range of teenage outcomes, was most strongly related to outcomes tapping intimacy and trust issues.”
And if I had an insecure attachment, was it affecting me even now, as an adult? One of the most profound modern advances in attachment theory came from a longitudinal study by Ainsworth’s former student Mary Main. Main was trying to unravel the relationship between a child’s attachment security and their caregiver’s internal working model of attachment. So, in what became known as the “Berkeley Study,” children were assessed in the Strange Situation as usual, but in addition their parents were asked a series of questions about their early attachment relationships, questions designed to “surprise the unconscious” and reveal the person’s true state of mind. The first big news was just how closely correlated a child’s attachment classification was to their parents’ adult attachment representation. The correlation was so striking that Main decided to check back in with the children at age 19, to ask them the same series of questions about their early-childhood relationships. What she discovered was that most had the same attachment classification as when they were in the Strange Situation at a year old. Later, other researchers found that what came to be known as the Adult Attachment Interview actually predicted how someone’s baby might do in the Strange Situation. Attachment, it seems, is remarkably consistent throughout a life (though can also be changed by positive and negative forces) and even from one generation to the next.
While generally a research tool, the AAI is sometimes used in clinical settings, with therapists administering the interview to patients. It’s a highly specialized procedure, expensive and time-consuming, but so full of potential insight I couldn’t get it out of my head. I knew that taking the AAI wouldn’t change history — mine or Azalea’s — but I might be able to get some answers.
I had met Dr. Howard Steele, the expert in attachment who agreed to administer my AAI, two summers before, when, after I told him about the research I was doing, he invited me to observe a Strange Situation in his lab. Still, taking the train to the New School’s Center for Attachment Research, I was incredibly nervous.
The AAI contains 20 open-ended, slightly startling questions about one’s relationships in early childhood, along with prompts to reflect about it all, designed to elicit and reveal the speaker’s internal working model of attachment. The questions “require a rapid succession of speech acts, giving speakers little time to prepare a response.” They begin with general inquiries about the nature of one’s relationship with parents, then drill down a bit, asking for five adjectives that describe that relationship, with supporting memories and details. Then come questions about how your parents responded to you in times of early separation, times of illness or loss, feelings of rejection, “setbacks” — all with requests like “You mentioned that you felt your mother was tender when you were ill. Can you think of a time when this was so?”
Next, the AAI is transcribed verbatim, then carefully coded for adult attachment security. This is done through a two-pronged approach — assessing both the “probable experience,” as in what the primary relationships were probably like, and the “state of mind,” which investigates things like idealization, preoccupied anger, and disorganized responses as well as vague speech and insistence on lack of memory.
Secure adults tend to value attachment relationships and are able to describe experiences coherently, whether negative (e.g., parental rejection or overinvolvement) or positive, says Main. Dismissing adults tend either to devalue the importance of attachment relationships or to idealize their parents without being able to illustrate their positive evaluations with concrete events demonstrating secure interaction. Preoccupied adults are still very much involved and preoccupied with their past attachment experiences and are therefore not able to describe them coherently. Dismissing and preoccupied adults are both considered insecure.
The AAI has been found to be reliable independent of intelligence, or verbal fluency, or interviewer. The most articulate, detail-oriented trial lawyer, ordinarily linguistically unflappable, may report that her mother was kind, loving, warm, and fun but have an inability to recall any details to support that. In fact, she might repeat herself, or give irrelevant details. This would indicate a possibly insecure/dismissive state of mind, indicating the lawyer may well raise an avoidant baby. It’s not a good relationship per se but the subject’s state of mind in relation to their relationships that determines their children’s attachment security, which provides a foundation for those children’s socio-emotional health and happiness, which develops into their adult state of mind, which affects their own children’s security. And so on.
Suddenly, there I was sitting in a little room with a professional listener, trying to come up with five adjectives to describe my mother and scrambling to find relevant memories to support my choices. I remembered my mother taking me into the bathroom at the end of the hall to talk about some drama that had happened at school. I described the sofa bed she used to make when I was sick, and the story of my dad blowing me off when I got a giant splinter in the backyard. I tried to explain my feelings of disconnection even in the presence of a mother who really did seem to try, and how that disconnection turned into anger and more distance. When Steele asked me about why I thought my parents raised me the way they did, it was easy to look at their parents and understand why my dad was shut down and my mom a little hard to access. And I didn’t feel the least bit angry, not even for the thing that had plagued me my entire life — a pervasive feeling of shame for having been neglected, not cared for, not protected from danger.
I feared that if my results came back “preoccupied” (I knew I wasn’t dismissive), I would feel humiliated, as if my entire interest in attachment was merely a manifestation of my neuroses. But when I returned to the office later that afternoon to receive my score, what I felt was relief. My score, Steele said, was secure/autonomous. I asked him if he would be so bold as to predict, were I pregnant today, what kind of baby I would have. A B4, he said — secure, with an edge. Like the girl in the lavender dress. I was the mom with the mullet and Azalea was the girl with the big, fat, soothable tears.
I didn’t need a test to tell me that Azalea, who is now 10, does seem happy, well-regulated, and comfortable in the world. The other day, as I drove her and her 5-year-old friend Leroi to violin, I watched them talk about their respective field trips in the rearview mirror. I was so proud of the way Azalea cut short her story of climbing the fire tower so that Leroi could tell his kindergarten tale. I could feel her softening her voice when she talked to him and watched her face turn gentle as she offered to help him with the seat belt.
Beyond all the research linking secure attachments to everything good, attachment is connected to something so profound it’s hard to describe. The literature calls it “mentalization”; UCLA psychiatrist Dan Siegel refers to it as “mindsight.” Basically, it’s the experience of knowing you have a mind and that everyone else has one, too. Then it’s one small step to see that others have feelings, too.
Was Azalea’s behavior with Leroi a result of her capacity to mentalize and therefore take care of her friends? I hope so. Did she learn that from me? Maybe. If so, does this mean our work is done? Hardly. But it’s comforting to see that, despite all my very real, very unsettling shortcomings, something so important is functioning well. After all, it’s the attachment-inspired capacity to feel that makes us care for and attune to others. And apparently the process is much more forgiving than I imagined.
My AAI subgroup was F3B, a category for a small percentage of the population who have, Steele told me, “suffered adversity” but are still able to have some coherence of mind in relation to attachment. In my confidential feedback, Steele wrote: “Overall, there is a sense that this speaker knows her own mind and the mind of others she cares about. Probable past experiences are mixed … She learned to turn to herself and to her inner world, which became richly developed (as appears to be the case for her daughter too in the next generation) … an adaptive strategy!”
This was a revolutionary way for me to think about my childhood. Yes, I wish some things had been different, but what if my self-reliance and sense of reflection — two things I value greatly — developed not in spite of my upbringing but because of it? What if I was taught from a young age how to see myself, from parents who — research suggests — had a knack for the same thing.
I had spent a lifetime worrying that there was something wrong with me. Then with my kid. Then with my family. But, as Sroufe pointed out in Minneapolis while we watched some ultimately secure but hardly perfect mother-baby duos in the Strange Situation, something was working.
Attachment is a simple, elegant articulation of the fact that, yes, we really do need each other, and, yes, what we do in relation to each other matters. And yet we don’t have to get it right all the time, or even most of the time. As Steele and his wife Miriam write in an essay in the book What Is Parenthood?, “Even sensitive caregivers get it right only about 50 percent of the time. There are times when parents feel tired or distracted. The telephone rings or there is breakfast to prepare. In other words, attuned interactions rupture quite frequently. But the hallmark of a sensitive caregiver is that the ruptures are managed and repaired.”
Maybe all this room for error means we’re wired for forgiveness.
Or maybe, as Steele gently suggested at the end of our interview, even though I experienced my early life as very painful, maybe, in fact, it wasn’t that bad. Technically speaking.
Caregivers need to protect space between reassurance and diagnosis
When parents bring their young child to see me in my behavioral pediatrics practice, they seem to be at war with themselves. They simultaneously seek reassurance that there is “nothing wrong” and validation of their often deep and longstanding struggles.
Our current health care and education systems are constructed in a way that puts the question “what” front and center. The focus, both for parent and clinician, is on making a diagnosis.
This drive to name the problem leaves us with an inaccurate and potentially harmful choice between “normal” and “disorder.” In contrast, when we can protect a kind of virtual space between these two extremes, we can learn how a child’s behavior, from his perspective, might make sense.
Behavior is a form of communication. Understanding that communication leads us to know what to do to help a child and family. When we are able to listen for the “why” without pressure to name the problem, the solution often presents itself. Consider the following example.
Four-year-old Michael came to my office at the recommendation of his pediatrician and preschool teacher for an “ADHD evaluation.” Usually I meet first with both parents, but his mother Angela came alone. I opened up the visit with an invitation to tell me her story.
Michael had been a challenging child from birth, intense and difficult to soothe. Angela had struggled with postpartum depression. When Michael turned two and began in a developmentally appropriate way to say no, Angela found herself full of rage. She told me how such typical behaviors as resisting a bath would precipitate an extreme reaction from her, sometimes even harshly grabbing Michael by the shoulders and shaking him. She felt terrible shame about her behavior. Her voice began to tremble. She wept in the safety of my office as she let herself experience the grief around her troubled relationship with her son.
When I saw Michael and his mother together the next week, Angela joyfully reported at the start of the visit that, while mealtime had been a primary battleground, Michael had eaten an entire spaghetti dinner by himself. The whole tone in the household had shifted dramatically, as Angela, feeling some relief from her debilitating feelings of guilt and shame by sharing them with me, began to enjoy her son for the first time in years.
In turn, once Michael connected with his mother in more positive ways, he reconnected with his own natural appetite. As we worked together in the coming months his behaviors Angela and the teachers had been attributing to ADHD began to subside. The relationship between mother and son took a different direction.
Here we have a situation that was not “normal.” Clearly both mother and child were struggling. Yet Michael’s behavior represented not a disorder, but rather an effort to communicate his distress. He was attempting to find a way to connect with his mother.
As I describe in my new book The Silenced Child, even the notion of an “ADHD evaluation” conveys a level of certainty that is not consistent with contemporary developmental science. While the constellation of behaviors we call “ADHD” has some known genetic components, there is not a gene for ADHD.
The rapidly growing field of epigenetics show us that when we can change the environment to decrease the level of stress, as occurred in this vignette by “simply” listening, we have the opportunity to change not only behavior, but gene expression and so structure and function of the brain.
Michael’s history of “difficult” behavior in infancy suggests that his challenges might have a genetic component. But when we can support and listen to parent and child together in the early years when the brain making hundreds of connections per second, we have the opportunity to set development on a healthy path.
An abundance of contemporary research in neuroscience, psychoanalysis, and developmental psychology tells us that being curious about the meaning of behavior, rather than simply naming and eliminating it, offers the path to growth and healing.
Multiple forces in our culture, as I also describe in my new book, can get in the way of listening for meaning. For young children and families, both reassurance and diagnosis of a psychiatric disorder represent variations on not listening. In contrast, when we protect time for listening with curiosity, free from pressure to either reassure or diagnose, we allow parents to connect with their natural expertise and help get development back on track.
Claudia M Gold M.D. Claudia M Gold M.D.
Child in Mind
A good mental health professional is crucial, offering more than just medication
The biggest regret of those who with depression or bipolar is that they didn’t obtain a rigorous diagnosis and treatment plan early enough.
Lora Inman is one such person, interviewed in my book Back From The Brink. A long-time depression sufferer and passionate mental health advocate, she went for decades without a proper diagnosis or treatment, which prolonged her suffering.
Lora’s story illustrates three very good reasons why you need a trusted mental health professional to help you.
Not all doctors are trained in mental health issues
In the 1960s, little information was available on depression and bipolar disorder. Lora visited experts in several states who couldn’t diagnose or help her; they simply didn’t know enough about mental health.
Today, mental health issues are better understood and information is more accessible. Despite this, levels of training in mental health among medical professionals can be alarmingly low even now.
Finding the right mental health professional is the most important step towards preparing an effective treatment plan. Your primary care physician may be, but not always, your first point of call.
The right expert can help unlock and navigate the mental health network with you
Lora’s psychiatrist put her on four or five different medications, sometimes in combination, as part of her treatment plan. Before that, she had even tried electroconvulsive therapy in her quest to battle postpartum depression.
A good mental health professional is the gatekeeper to the mental health network. They can help you understand your illness, how it may affect you and discuss and refer you to treatment options.
Crucially, the mental health professional can monitor how you are responding to treatment and modify, stop or change it as needed.
The right expert can give you hope
Lora says her psychiatrist saved her life thanks to the support she offered. My own research shows that emotional support from a mental health professional is often more important than the treatment itself!
Why was Lora’s psychiatrist so important for her? Because the psychiatrist offered hope, reassurance and compassion. Most importantly, she listened.
An expert’s opinion can be highly influential and a powerful motivator. Both Lora and her psychiatrist believed she could get better.
If your mental health professional doesn’t offer you hope, you’re unlikely to commit yourself wholeheartedly to a treatment plan. After all, if even the experts aren’t optimistic, why should you be?
But the right mental health professional for you, rather than any mental health professional, can make the difference between an endless cycle of medications or treatments and a trusted ally with the training, reach and support needed to help you.
A healthy mind helps us move in life-enabling ways
I am lying on the floor, knees held gently against my chest. My heart hurts. Thoughts flail and screech in ear-splitting rings around my head. Why did she say that? Doesn’t she understand? Who does she think I am? Why can’t she see me?
The pain sticks under my ribs, sucking vital energy in and down. I don’t want to move. I can’t. My stomach is locked shut. I just want to curl up in the palm of this gripping pain and dissolve into nothingness.
I breathe again (I can’t help it) and exhale sharply. I cling to my knees, drawing them in tight. I don’t want to let go. I don’t want to open my body, my self. I don’t want to be this vulnerable. I want to be safe, protected, enclosed like a small hard ball.
What is mental health?
I take my cue from the philosopher, Friedrich Nietzsche. “Great health” is an ability to digest our experiences. To digest or metabolize experiences is to take whatever is given in any moment—any thought, feeling, or sensation, any cruel word, kind act, or humiliating fall—and transform it—by chewing, mashing, churning, breaking it down—into a sweet stream of energy capable of nourishing our ongoing bodily becoming.
We humans are essentially creative at a sensory level. Our bodily selves are always sensing, always moving, always creating the patterns of sensation and response that make us who we are. Some of that bodily movement—firing and wiring—gives rise to a thinking mind as an inward extension of our bodily self. Our minds are tools that our bodily selves create in order to help us live well. Minds look forward and back. They predict what will happen on the basis of what has been. They calculate options and risks, and all in the service of keeping our bodily selves moving, creating, thriving, becoming who we are.
A healthy mind, then, is one that helps us embrace our experiences as occasions to discover the range and reach of what our bodies know. A healthy mind is one that finds in whatever fear, anger, sadness, despair, irritation, confusion, or frustration we feel, a potential for pleasure that has yet to unfold—an energy and guidance impelling us to move in relation to ourselves and others in ways that align our well-being with the challenge at hand. A healthy mind helps us move in life-enabling, experience-metabolizing ways.
Sometimes, however, our minds get sick: they can’t help us move. Nearly half of all adults, at some point in our lives, will endure times of acute mental, physical, and emotional suffering, and find ourselves unable to work, play, eat, sleep, or open deeply to others—times when we are arrested by anxiety or depression, anger or fear, compulsions or addictions, and unable to digest our experiences.
Why sick? Why stuck? We live in a culture that teaches us to ignore the movement of our bodily selves. From the earliest age, we learn to think and feel and act as if we were minds living in bodies. We learn to identify our “self” with our mental power; we learn to perceive our “body” as material thing for which “we” are responsible. Then, when faced with the stress of a life-altering change, a critical decision, or draining fatigue, we tend to mobilize the resource we think is best: mind over body. We try to control our bodies: we impose diets, schedules, and plans, or rely on drugs and surgery to exact a will we lack. We distract and numb, starve and indulge our sensory selves. We rehearse a separation from our bodily selves that prevents us from feeling what we are feeling. Our emotions remain lodged in our throats and bellies and hearts and limbs, undigested, causing so much depression and despair.
As I breathe again, unable to help it, I feel it. In spite of myself, I feel something new—a sensation of the earth pushing up from below me. I am not falling into a black hole. I am resting on a presence that is larger than me that is pressing up through me and holding me up.
Instinctively, I let go. I can’t help it. I breathe again and drop into the earth, holding on to nothing. Emptying my mind. The plug in my heart releases and sensations of disappointment and despair run through me, along me, out of me, into the earth.
In spite of myself, impulses to move arise within me—I feel them—expressions of the irrepressible, undeniable flow of life that will not stop beating and breathing, growing and healing, searching for new ways to move through me. My mind resists, holding on to fear, but my bodily self knows more.
Our hungers are prophetic. The scope and kinds of mental illnesses that we as individuals and as a culture are suffering are calling us to reconnect the activity of our minds with the movement of our bodily selves. We need to cultivate a sensory awareness of the movements that are making us.
The truth is that at the heart of any and every pain is a desire—a desire to move, to love, to heal, to give, to receive. We would not even feel the pain of not caring if we did not care. And within every desire is in turn an impulse to connect—an impulse to create the relationships with whatever and whomever we need to support us in becoming who we are, and giving what we have to give.
When we move, we breathe. When we breathe, we feel. When we feel we open the floodgates to all of our searing sensations, past, present and future. But we also open ourselves to the possibility of sensing what is always true: that our bodily selves, in every moment of our lives, are providing us with vital information about how to move in ways that will not recreate the pain.
When we breathe to move and move to breathe we open to the possibility of sensing the wisdom in our desires. Whether we are wrestling with issues of food, intimacy, and purpose (see What a Body Knows) or with our parents, partners, and progeny (see Family Planting), how we move matters.
I breathe down again, along the stream of my spine, feeling the bed of earth cupping its flow. My experience shifts and I am suddenly aware of the desire at the heart of my pain.
I hurt. I hurt because I want. I want because I am alive. This desire, this life, is a power in me that is stronger than the fear. Stronger than the hurt. It is the point of the pain—to wake me up to the power of this desire. To my need to move.
A resolve appears. I take a small step. I can act out of my love and not my fear or anger. I can meet her where she too is hurt and coming toward me—in the heart of her desire for more. The knot of pain softens and unfolds in affirmation. I am OK. Healing happens.
The latest study intensifies concern that SSRIs are both ineffective and harmful
“For young people with major depression,” the Washington Post reported earlier this month, “antidepressants may help little if at all.” From ABC News in Australia, the focus extended to more than the drugs’ limited efficacy; it included their risk of harm, including from side effects and heightened suicidality: “Antidepressants for kids and teens ineffective, may even be harmful, study finds.”
The study in question, published earlier this month in The Lancet and led by Dr. Andrea Cipriani at Oxford University, examined the effectiveness and potential harm associated with 14 SSRI and Tricyclic antidepressants, prescribed in large numbers to adolescents and children worldwide: amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine. The Lancet meta-analysis examined data from 34 earlier studies involving more than five thousand youths, most of them aged 9 to 18, who had moderate to severe symptoms and had received a diagnosis of major depression. As Linda Searing at the Washington Post reported, “In an average year, an estimated 2.8 million Americans age 12 to 17, or roughly 11 percent of that age group, have at least one depressive episode.”
The Lancet study is significant not just in scale but also in explicitly correcting for bias, as it incorporated the results of unpublished clinical trials while offsetting for the fact that drug companies had funded 65 percent of them. Even taking into account that figure, 88 percent of the trials indicated additional risk of bias (29 percent of them were at high risk, while the remaining 59 percent indicated a moderate risk of bias).
But it was the study’s conclusion that drove health headlines around the world, though the finding itself wasn't exactly news: only one of the drugs, fluoxetine (Prozac), was found to be marginally more effective than placebo at relieving depression, an advantage offset by the drug's substantial number of side effects, including an increased risk of suicidal thoughts.
Weighing risks relative to benefits, the researchers concluded that antidepressants “do not seem to offer a clear advantage for children and adolescents” with major depression. Additionally, Dr. Cipriani explained, “the selective reporting of findings in the published trials and clinical study reports” made claims on behalf of such research dubious and of low value scientifically.
Jon Jureidini, a professor at the University of Adelaide, wrote in commentary about the research that the findings had “disturbing implications for clinical practice ... as the risk-benefit profile of antidepressants in the acute treatment of depression does not seem to offer a clear advantage for children and adolescents.”
That conclusion—disturbing though well-publicised elsewhere and thus far from surprising—acquired greater urgency as ABC News highlighted prescribing patterns for Australian children and adolescents between 2009 and 2012, noting that the number of children aged 10 to 14 who had been given antidepressants in those years had jumped by more than a third.
Iain McGregor, a professor at the University of Sydney and co-author of the study that generated that finding, asked pointedly at the time, “Why are we so reliant on meds for our mental wellbeing?”
It's a question doctors and parents of the many thousands of children and adolescents given antidepressants studied doubtless need to be asking, especially with the latest meta-analysis one of many signaling that the drugs are neither effective nor without a substantial risk of harm.
From quirky to serious, trends in psychology and psychiatry
Christopher Lane, Ph.D.
Christopher Lane, Ph.D., has won a Prescrire Prize for Medical Writing and teaches at Northwestern University. He is the author of Shyness: How Normal Behavior Became a Sickness.
The common physical and psychological signs of an anxiety disorder
Anxiety comes in many forms, but all the different types often have certain core features.
Like many mental health problems, almost everyone experiences anxiety from time-to-time.
Whether it is a problem all depends on the amount and nature of the anxiety.
Everyday anxiety in response to stressful events is normal, but severe anxiety in response to relatively minor events can be seriously disabling.
Bear that in mind when reading the signs of a ‘disorder’.
For example, a lot of people have problems sleeping and muscle tension every now and then.
This might happen before a job interview, when going into hospital or before a stressful event.
But experiencing anxiety frequently and intensely over smaller matters can be a sign of something more serious.
Here are four typical psychological symptoms:
Feelings of panic, fear and uneasiness.
Feeling constantly ‘on edge’ or restless.
Having a frequent sense of dread.
And here are six typical physical symptoms:
Shortness of breath.
These ten do not cover the full extent of what people experience.
People often report a very wide range of different physical and psychological symptoms.
I have seen lists with at least 50 items.
Some people have many symptoms, others have fewer.
The real key to diagnosing an anxiety disorder is in the extent of the symptoms and how they affect everyday life.
People experiencing severe or disabling anxiety most days should consider seeking some kind of help.
Psychological therapies (including self-help) are particularly good at treating anxiety disorders.
Apart from ‘generalised anxiety’, anxiety can also be triggered by all sorts of different things.
Many of these are familiar terms nowadays: phobias, PTSD and social anxiety.
Your personality influences everything from the friends you choose to the candidates you vote for, yet many people never spend much time thinking about their personality traits. Understanding your personality can give you insight into your strengths and weaknesses. It can also help you gain insight into how others see you.
Most modern-day psychologists agree there are five major personality types, referred to as the "five-factor model," and everyone possesses some degree of each.
People who rank highest in conscientiousness are efficient, well-organized, dependable, and self-sufficient. They prefer to plan things in advance and aim for high achievement. People who rank lower in conscientiousness may view those with this personality trait as stubborn and obsessive.
Fun fact: Studies show that marrying someone high in conscientiousness increases your own chance of workplace success, as a conscientious spouse can boost your productivity and help you achieve the most.
People who rank high in extroversion gain energy from social activity. They're talkative, outgoing, and comfortable in the spotlight—but others may view them as domineering or attention-seeking.
Fun fact: Be on the lookout for a strong handshake. Studies show that men with the strongest handgrips are most likely to rank high in extroversion and least likely to be neurotic (see below). However, the same doesn't hold true for women.
Those who rank high in agreeableness are trustworthy, kind, and affectionate toward others. They're known for pro-social behavior and are often committed to volunteer work and altruistic activities. Other people, however, may view them as naïve and overly passive.
Fun fact: Seek a financial investor who is high in agreeableness. Studies show that agreeable investors are least likely to lose money from risky trading. But you may want to avoid an investor who's high in openness—that personality trait is associated with overconfidence, which can lead an investor to take excessive risks.
4. Openness to Experience
People who rate high in openness are known for having a broad range of interests and vivid imaginations. They're curious and creative, and tend to prefer variety to rigid routines. They're known for their pursuits of self-actualization through intense, euphoric experiences, like meditative retreats or living abroad. Others may view them as unpredictable and unfocused.
Fun fact: Openness is the only personality trait that consistently predicts political orientation. Studies show that people high in openness are more likely to endorse liberalism and more likely to express their political beliefs in general.
Neurotic people experience a high degree of emotional instability. They're more likely to be reactive and excitable, and they report higher degrees of unpleasant emotions like anxiety and irritability. Other people may view them as unstable and insecure.
Fun fact: Neurotic people seek acceptance by publishing a lot of pictures on Facebook. Studies find they're less likely to post comments or updates that could be seen as controversial, and much more likely to post lots of pictures. (They also have the most photos per album.)
Understanding the Basics of Personality
An individual's personality remains relatively stable over time. The traits you exhibited at age seven are likely to predict much of your behavior as an adult. You can, of course, change some of your traits—it takes hard work and effort to make big changes, but most researchers agree that it is possible.
There is a growing body of research into the effectiveness of psychoanalytic psychotherapy.
Researchers have demonstrated good evidence for the positive effects of psychodynamic therapies for various psychological disorders, including depression, anxiety, post-traumatic stress disorder (PTSD) and eating disorders. The studies referred to here have evaluated either the general effectiveness of long- and short-term psychodynamic psychotherapy, or the impact of psychodynamic psychotherapy on specific illnesses. These studies are among an ever-increasing number being published and cited in eminent psychological, psychiatric and medical journals.
Examining the effectiveness of long-term psychodynamic psychotherapy (here meaning at least a year or 50 sessions) in complex mental disorders, a paper from 2011 found that long-term psychodynamic psychotherapy (LTPP) appears to be more effective than less intensive forms of psychotherapy in treating complex mental disorders.  Another paper reviewing LTPP on a larger scale compared 23 studies, involving a total of 1053 patients. It concluded that LTPP had a significantly higher rate of effectiveness in targeting problems and general personality functioning than shorter forms of psychotherapy.
A widely cited paper from 2010 summarized the evidence for the general effectiveness of psychodynamic psychotherapy. It concluded that psychodynamic therapy has as positive an impact on patients as other therapies, such as cognitive-behavioural therapy (CBT), that have been more readily promoted in modern healthcare What is more, patients who had psychodynamic therapy not only saw an improvement in their psychological difficulties during treatment, but this improvement continued after treatment had ended.
In a 2008 paper focusing on depression, researchers produced an overview of the effectiveness of psychoanalytic and psychodynamic therapies. The paper examined available evidence, and concluded that the benefits for patients of short-term psychodynamic therapies are equivalent to those produced by antidepressants and CBT.
Research has also been conducted into the impact of psychodynamic psychotherapy in specific psychological disorders. A 2007 study investigated the effects of psychodynamic psychotherapy in panic disorder. The researchers compared the effect on patients of panic-focused psychodynamic therapy versus relaxation training. There were 49 adults in the study, and they were all diagnosed with panic disorder. Many were also suffering from agoraphobia and/or depression. The participants who received psychodynamic treatment showed a significantly greater reduction of panic symptoms than those receiving relaxation training, as well as greater improvement in psychosocial functioning (the term ‘psychosocial’ refers to an individual’s psychological state in relation to social factors).
In 2011 researchers conducted a review of trials into the effect of short-term psychodynamic psychotherapy in patients with personality disorder. Looking at the results of eight studies, the researchers concluded that psychodynamic psychotherapy may be considered an effective treatment option for a range of personality disorders, producing significant and medium- to long-term improvements for a large percentage of patients.
Research has also been done into the cost-effectiveness of psychodynamic psychotherapy, which has often been regarded as too expensive to be funded in the public sector. In fact, a study of more than 100 patients who had received at least six months’ worth of NHS psychiatric treatment without improvement, found that psychodynamic psychotherapy resulted in both significant improvements in the patients’ symptoms and value for money. Not only did the patients’ mental health improve with psychodynamic psychotherapy, but they also spent fewer days as in-patients, had fewer GP consultations, required less contact with practice nurses, needed less medication and sought less informal care from relatives. Consequently the extra cost incurred through using psychodynamic treatment was recouped within only six months.
(Based on a research summary by Jessica Yakeley and Peter Hobson)
 Leichsenring, F., Rabung, S. (2011). Long-term psychodynamic psychotherapy in complex mental disorders: Update of a meta-analysis. The British Journal of Psychiatry, 199(1): 15-22.
 Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy. Journal of the American Medical Association, 300, 1151-1565.
 Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist 65(2): 98-109.
 Taylor, D. (2008). Psychoanalytic and psychodynamic therapies for depression: the evidence base. Advances in Psychiatric Treatment, 14, 401-413.
 Milrod, B., et al (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164, 265-272.
 Town, J.M., Abbass, A., Hardy, G. (2011). Short-term psychodynamic psychotherapy for personality disorder: A critical review of randomized controlled trials. Journal of Personality Disorders, 25(6): 723-740.
 Guthrie, Moorey, Margison et al (1999). Cost-effectiveness of brief psychodynamic-interpersonal therapy in high utilizers of psychiatric services. Archives of General Psychiatry, 56, 519-526.
Read Peter Fonagy's talk: "Grasping the Nettle – or why Psychoanalytic Research is Such an Irritant"
Read Ron Britton's response to "Grasping the Nettle"
Read Phil Richardson's response to "Grasping the Nettle"
Create a Calm and Positive Mindset With These 7 Simple Cues
Happiness, gratitude, kindness—here's how to add these feelings to your day.
The other day I was bounding up the stairs to get something I’d forgotten when I had this realization: Although getting older, I am still healthy enough to climb stairs with ease—in fact, I enjoy it! Suddenly I felt deep gratitude for my good health.
“Gratitude” is a mental attitude I want to cultivate. So it occurred to me…Why not use every instance of stair-climbing as a cue to evoke and savor that wonderful inner feeling of gratitude?
It worked. As I continued to link “gratitude” with “stair-climbing,” I found that the “gratitude attitude” would pop up automatically in other situations, especially those involving physical activity like walking or gardening.
Deliberating setting up a cue—like stair-climbing—to trigger a desired emotional state—like gratitude—l was a new idea for me. True, I had often used cues to trigger a behavioral habit or action, like blocking the stairs with the laundry basket so I couldn't possibly forget to carry it down to the laundry room. This time, though, I began to think about how I could use cues as signals to a more positive mental outlook. I came up with seven great ideas that work for me. Adopt them for yourself or use them to imagine how you could create your own cues for positive mental states.
But first…what IS a cue?
Clues to Cues: First Steps
A cue is a signal that reminds your brain to activate a particular emotion, action, or thought.
Without thinking about it, you probably use cues all the time to activate the mental states you need. For example, if you know you are going to meet up with a manipulative person, you will probably activate a mental state of wariness. Or, if you are about to visit a sick friend, you might naturally feel a caring concern as you enter his home.
But you can also deliberately choose cues to create helpful and happier mental attitudes. To do this, you could identify one positive mental state you would like to cultivate or strengthen. Some possibilities:
Got it? Then you’ve done two important things:
You’ve made the decision to change, and…
You’ve defined your goal.
Now you just need to do this:
Choose your cue.
Cues to Use
Almost anything can serve as a cue, as long as it triggers the thoughts or emotions you are trying to evoke. My 7 ideas are below. Notice that even unpleasant mental states or sensations can sometimes be used to activate pleasant ones.
Use a pleasant sound as a cue for a positive mental state. We live next to a church. I find that I can link the sound of the church bells to one of my goals—a calmer mind. So when I hear those bells, I take a few deep breaths, relax my body, and clear my mind. Ah, much better!
Use an unpleasant sound as a cue for a positive mental state. BLLLT! That’s the unpleasant sound announcing that my partner has a message on his phone. At first I felt startled and then annoyed when I heard this grating noise. But my partner is hard of hearing and needs a loud sound that will get his attention. So I decided to make lemonade out of lemons and use the harsh jangle as another cue for a calmer mind. Deep breath, calming self-talk…Ah, much better!
Use an object as a reminder. Fellow PT blogger Toni Bernhard shares an unlikely cue to the mental habit of “kindness” in her wonderful book, How to Wake Up. When she leaves the house, she uses the cue of her hand on the doorknob to remind her to approach other people in a friendly and open-hearted way. What a beautiful way to cultivate a positive mental attitude and a worthwhile value!
A piece of art, a gift from a loved one, a photo of loved ones—any or all of these could become cues to the positive mental state of loving. I cherish a mug with hearts on it that my partner gave me 20 years ago for Valentine’s Day. While others might see it as just a cheesy mug, I feel the love every time I use it!
Use a time of day as a reminder. To build feelings of happiness, take one minute in the evening for the classic “Three Good Things” exercise. Just think or write about three things that went reasonably well that day. In one research study, participants who wrote down three good things each night for just one week boosted their happiness levels and reduced feelings of depression for 6 months!
I adapted this exercise to promote self-confidence and a spirit of learning, re-labeling it “The 3 Growth Things.” For each “good thing” that occurred during my day, I figure out if I just got lucky or if I did something that helped create that positive experience. Recognizing my own role in my happiness is empowering. If there was a significant event that I did not handle well, I thought about what I might do differently next time, thereby changing a mistake into a learning experience.
Use a negative state of mind as a reminder to activate the positive state of mind that you seek. This sounds impossible and, yes, it can be a challenge! But with a little practice, you can do it. For example, you are probably all-too-familiar with your critical inner voice. When you hear it making harsh judgments about you (again!), deliberately counter that voice with self-compassion. Possible self-talk: “It was a difficult situation. Maybe I didn’t handle it the way I wanted to. But anyone can make a mistake. And now I know what to do.”
Use your body as a cue. Sitting up straight is not only good for your spine; it could be a wonderful cue for the mental states of “assertiveness,” “motivation,” or “determination.” In fact, one study showed that practicing good posture could increase your willpower. Likewise, standing up could be a cue to become more alert. Deliberately smiling could be a cue to put your troubles in perspective; the act of smiling in itself will trigger a happier mood.
Use an activity to create a positive mental state. I mentioned stair-climbing. Two more popular activities, both well-researched, are singing and—wait for it!—dish-washing. And of course many people use meditation or prayer to evoke a more hopeful or calmer mental state. (For more stress-reducing activities, click here.)
The practice of setting up cues and using them regularly may seem like a small contribution to your mental health. Yet you will discover that these small actions lead to many benefits. Paying attention to your personal cues may help you "wake up" to the present moment. Positive mental states can lift your mood, give you energy, and provide you with much-needed infusions of happiness or calm on a daily basis. Used enough, you may even be able to create a new mental habit. Eventually you may find that you've built up reserves of positive emotions in your mind and brain, reserves on which you could draw during tough times.
After a while, you may habituate to your chosen cues. If your cues lose their power to trigger positive emotions, try new cues or focus on different mental attitudes. Cues have their limits, but they are good ways to add gratitude, contentment, and calm to your daily routine.
Anxiety symptoms are common in children and adolescents, with 10-20% of school-aged children experiencing anxiety symptoms. An even larger number of children experience stress that does not qualify as an anxiety disorder. So how can you help to reduce your child's anxiety and stress?
1) Encourage your child to face his/her fears, not run away from them.
When we are afraid of situations we avoid them. However, avoidance of anxiety-provoking situations maintains the anxiety. Instead, if a child faces his or her fears, the child will learn that the anxiety reduces naturally on its own over time. The body cannot remain anxious for a very long period of time so there is a system in the body that calms the body down. Usually your anxiety will reduce within 20-45 minutes if you stay in the anxiety-provoking situation.
2) Tell your child that it is okay to be imperfect.
Often we feel that it is necessary for our children to succeed in sports, school, and performance situations. But sometimes we forget that kids need to be kids. School becomes driven by grades, not by enjoyment of learning if an 85 is good, but not good enough.This is not to say that striving is not important.It is important to encourage your child to work hard but equally important to accept and embrace your child's mistakes and imperfections. (Click here to read more about this in another blog post, The Eyes of the Tornado).
3) Focus on the positives.
Many times anxious and stressed children can get lost in negative thoughts and self-criticism. They may focus on how the glass is half empty instead of half-full and worry about future events. The more that you are able to focus on your child's positive attributes and the good aspects of a situation, the more that it will remind your child to focus on the positives. (Click here to read more about focusing on the positives in Embracing the Worst).
4) Schedule relaxing activities.
Children need time to relax and be kids. Unfortunately, sometimes even fun activities, like sports, can become more about success than they are about fun. Instead, it is important to ensure that your child engages in play purely for the sake of fun. This may include scheduling time each day for your child to play with toys, play a game, play a sport (without it being competitive), doing yoga, paint, have a tea party, put on a play, or just be silly.
5) Model approach behaviour, self-care, and positive thinking.
Your child will do what you do. So if you avoid anxiety-provoking situations, so will your child. If you face your fears, so will your child. If you take care of yourself and schedule time for your own needs, your child will learn that self-care is an important part of life. If you look for the positive in situations, so will your child. Children learn behaviours from watching their parents. So when you think about your child's psychological well-being think about your own as well.
6) Reward your child's brave behaviours.
If your child faces his or her fears, reward this with praise, a hug, or even something tangible like a sticker or a small treat. This is not bribery if you establish this as a motivator prior to your child being in the situation. If you reward behaviours your child will engage in them more often.
7) Encourage good sleep hygiene.
Set a bed time for your child and stick to that bed time even on weekends. Also have a 30-45 minute bed time routine that is done every night. This helps your child to transition from the activities of the day to the relaxed state necessary to fall asleep.
8) Encourage your child to express his/her anxiety.
If your child says that he or she is worried or scared, don't say "No you're not!" or "You're fine." That doesn't help your child. Instead, it is likely to make your child believe that you do not listen or do not understand him/her. Instead, validate your child's experience by saying things like "Yes, you seem scared. What are you worried about?" Then have a discussion about your child's emotions and fears.
9) Help your child to problem solve.
Once you have validated your child's emotions and demonstrated that you understand your child's experience and are listening to what your child has to say, help your child to problem solve. This does not mean solving the problem for your child. It means helping your child to identify possible solutions. If your child can generate solutions, that is great. If not, generate some potential solutions for your child and ask your child to pick the solution that he or she thinks would work best.
10) Stay calm.
Children look to their parents to determine how to react in situations. We've all seen a young child trip and fall and then look to their parent to see how to react. If the parent seems concerned, the child cries. This is because the child is looking to their parent for a signal of how to react to the situation. Children of all ages pick up on their parent's emotions and resonate with them. If you are anxious, your child will pick up on that anxiety and experience an increase in his/her own anxiety. So when you want to reduce your child's anxiety, you must manage your own anxiety. This may mean deliberately slowing down your own speech, taking a few deep breaths to relax, and working to ensure that your facial expression conveys that you are calm.
11) Practice relaxation exercises with your child.
Sometimes really basic relaxation exercises are necessary to help your child to reduce their stress and anxiety. This might mean telling your child to take a few slow, deep breaths (and you taking a few slow breaths with your child so your child can match your pace). Or it might mean asking your child to image him or herself somewhere relaxing, like the beach or relaxing in a backyard hammock. Ask your child to close his/her eyes and imagine the sounds, smells, and sensations associated with the image. For example, close your eyes and picture yourself on a beach. Listen to the sound of the surf as the waves come in and go out. In and out. Listen to the sound of the seagulls flying off in the distance. Now focus on the feel of the warm sand beneath your fingers and the sun warming your skin.Your child can do these techniques on his or her own during anxiety-provoking times.
12) Never give up!
Anxiety and stress can be a chronic struggle and often the source of a child's anxiety changes over time so it can feel as though you are always putting out fires. With repetition of the anxiety and stress management techniques, your child will learn how to lower his/her anxiety level and how to cope with anxiety-provoking situations.The key is repetition so keep it up!
If you think that your child is suffering from an anxiety disorder or experiencing a high level of stress or you need the help of a therapist please see the following resources:
My website: http://psychology.case.edu/research/fear_lab/index.html
Child Anxiety Network: http://www.childanxiety.net/
Anxiety Social Net: http://www.anxietysocialnet.com/
A reader wrote to me: "I am currently in therapy. What do you think is the best way to get the most out of it? Perhaps, you could write an article about it?"
Getting counseling, coaching, or psychotherapy are major commitments of money and time, not just the sessions but the work you must do between sessions to get the most from them.
We tend to think that the coach/therapist/counselor is the key to making all that worthwhile but what the client does may be at least as important. Here are things you might want to do:
Which treatment modality works best (e.g., cognitive-behavioral vs childhood-rooted therapy) depends heavily on the individual client. It's been said, only half joking, that the most successful modality is the one you believe in. So trust your gut feeling---but that feeling should be based on a careful selection process:
Speak with two or three practitioners recommended highly on Yelp or by your friends. Google them and visit their site to see if they specialize in your kind of problem. Just as you wouldn't use a general practitioner for a serious physical problem, you shouldn't use a generalist counselor for your serious psychological or career problem. So, see an appropriate specialist: depression, helping unhappy lawyers, whatever.
Try a session with one or more good prospects. Don't be too swayed by the practitioner's niceness. Sometimes, a practitioner is nice but ineffectual. The key question is, "Do you sense the practitioner is quite competent in the art and science of helping someone with your problem and whose personality and intellectual style is compatible with yours. A spiritual, intuitively oriented client might not do so well with a practitioner who stresses logical reasoning.
Before sessions. Except perhaps for the first session, email a suggested agenda to the practitioner. Writing it concretizes your thinking and helps the practitioner prepare for your session. Of course, if s/he suggests an alternative, consider it, although you generally should have the final say.
Be appreciative. It's easy to forget that practitioners are people too, and while we try to be our best with all our clients, we're more likely to go the extra mile for clients we like. So, express your appreciation for their efforts on your behalf.
Be honest and ask for honesty.
Practitioners aren't mind readers. If you withhold what's really going on, it could take even a skilled, intuitive practitioner a long time to get to the foundational issue(s.) Be as honest as you can.
Conversely, ask the practitioner to be honest with you: If s/he perceives an important negative about you, even if it might be tough for you to hear, say that you'd rather hear it. Of course, the practitioner isn't always right, so if s/he says something that feels wrong, tactfully, say so.
If the practitioner is doing something you feel isn't helpful--for example, being too tough or not tough enough, too intellectual or too touchy-feely, too practical or not practical enough, tactfully give the feedback. Most practitioners are eager to flex to meet client needs or at least be given an opportunity to explain why s/he's doing what s/he's doing.
Take notes and/or record the session. People forget so much of what goes on in sessions. I record all sessions and urge my clients to, within a day, listen to the mp3 and take notes. That way they derive the session's full benefit right away. Procrastinating clients who wait to listen until the day before our next session miss out on a lot.
Ask questions. There really are no dumb questions. If a question pops into your mind, getting the answer usually should take precedence over what's going on the in the session.
Ask for homework. If the practitioner doesn't assign homework, ask for it or propose an assignment. You're only in sessions a tiny fraction of your week. You must try out ideas generated in the session, do research on possible directions, keep a log, etc.
Love yourself enough to fully commit to doing that homework, not perfunctorily but with zest. This may be the key to getting the most of your counseling, coaching, or therapy.
Have you ever wondered if couples therapy could help you and your partner resolve an ongoing conflict, learn to communicate better, or reach new levels of intimacy? Couples therapy can do each of these things, but only if you avoid common traps and pitfalls. Here are six ways to make couples therapy work for you.
1. Don't wait too long.
When I worked as a couples therapist, it was not uncommon for one member of a couple to let slip that they'd already consulted an attorney about a divorce. Sometimes both members of the couple had "lawyered up." It seemed they wanted to be able to say they had tried everything, but really they had already made up their minds and wanted out. Couples therapy in such a situation is likely doomed to fail. Couples have a much better chance at repairing the relationship if they catch the problems early on.
2. Find the right therapist.
Make sure you do your homework and go to a therapist trained in some type of evidence-based couples therapy. Couples therapy requires many specific skills; a therapist trained in John Gottman's approach would be my first choice.
3. Be honest with the therapist.
It's frustrating working with couples when one or both parties don't tell the truth. As I mentioned above, sometimes people have already consulted an attorney about a divorce and are not upfront about this. Other times ongoing affairs are involved and kept a secret. Another area frequently kept hidden from me is that of substance abuse. A good therapist will not judge you, but needs to know everything in order to help you.
4. Show up for the session.
I mean this literally and figuratively. First of all, be there on time and ready to participate. Turn off your phone and put it away. This may seem obvious, but I've actually had to tell people to put away their phones during the middle of a session. Actively engage in the session. Do your best to listen, share, and have an open mind.
5. Do your homework.
Some couples therapy will require work between sessions. You may be asked to fill out relationship questionnaires. You may be asked to practice communication skills. There may be materials to read. If it sounds like school, it is: you're learning new relationship skills. It sounds cliché, but you'll get out of couples therapy what you put into it.
6. Give it time.
Couples often want quick fixes to problems that have built up over years, perhaps even decades. Gottman notes that, on average, couples spend six years being unhappy before getting help. That results in a lot of resentment! Don't expect couples therapy to work magic overnight. Similarly, don't expect the therapist to "fix" your problems—a good therapist will act more as a relationship coach. In time, if you do your part, there's hope that you and your partner can remember the good things that brought you together in the first place.
Depression: 7 Powerful Tips to Help You Overcome Bad Moods
Source: Jared Erondu/unsplash.com
There is no health without mental health.
In the past decade, depression rates have escalated, and one in four Americans will suffer from major depression at one time in their lives.
While there is no quick fix or one-size-fits-all for overcoming depression, the following tips can help you manage depression so it does not manage you.
1. Beware of rumination. The word "ruminate" derives from the Latin meaning for chewing cud, a less than appetizing process in which cattle grind up, swallow, then regurgitate and rechew their feed. In the human realm, ruminators analyze an issue at length (think “emotional vomiting.”). Studies show that depressive rumination most often occurs in women as a reaction to sadness, while men tend to focus on their emotions when they're angry, rather than sad. Many ruminators remain in a depressive rut because their negative outlook hinders their problem-solving ability.
Remind yourself that rumination does not increase psychological insight.
Take small actions toward problem-solving.
Reframe negative perceptions of events and high expectations of others.
Let go of unhealthy or unattainable goals and develop multiple sources of social supports.
2. Focus on what you’re doing right. As rough as your life is right now, you haven’t fallen off the edge, and this is not just by chance. Key is to remember that humans are remarkably resilient and capable. Because depression can cloud your judgement, it can be tempting to overemphasize the negative aspects of situations, while discounting the positives.
Action-plan: At the end of the day, write down three things you did well. No need to overthink this, and no act of taking the high road is too small. For example, “When my coworker emailed the budget proposal, he forgot to cite a source. Rather than get upset, I spent two minutes researching the answer and added the information myself.”
3. Resist the urge to live in the past. Time spent reliving, rewriting and recreating the past is like purchasing a one-way ticket to the dark depths of despair. This insidious mental habit is as much a threat to emotional wellbeing as any. Self-loathing or blaming others will not get you on the right side of feeling better, any more than believing the answer is found at the bottom of a bottle of Jack Daniels. You cannot do life differently if you don’t change your thought process.
Action-plan: Commit to a new way of thinking and you will commit to a new way of being. If living in the past takes up a lot of your mental real estate, this article will help you rewire your thought process. Past regrets serve one purpose and that is to rob you of your resolve to do things differently in the present.
4. Leave the future where it belongs. Just as the living in the past leads to depression, fearing or worrying about the future contributes to anxiety. Daily stress and frustration are primarily caused by persistent feelings of overwhelm caused by uncertainty. Chronic worriers tend to catastrophize and before you know it, every headache is a brain tumor, and every romantic rejection is proof that you’re fated for a life of solitude.
Action-plan: Have faith in uncertainty, and in life. A good way to practice is by cultivating a state of mindfulness each and every day. When you learn to intentionally redirect your mind to what is happening in the here and now, you’ll increase your mental energy reserves so you can spend more time on enjoyable tasks. Click here for a beginner’s video about mindfulness basics.
5. Incorporate structure into every day. A lack of scheduled activities and inconsistent routines can increase feelings of helplessness and a loss of control over the direction of your life. Adding a plan to your day can help you regain that sense of control and decrease the feeling that you’re just a passive participant in life.
Action-plan: The following guide may help you develop structure and assess whether your time is well-spent based upon your productivity and moods. On a paper or word document, make five columns:
1. Time of day:
- Early morning (waking time until 10am)
- Late morning (10am—12pm)
- Early afternoon (12pm—3pm)
- Late afternoon (3pm—5pm)
- Evening (5pm—8 pm)
- Night (8pm until bedtime)
What you plan to do (complete the night before)
What you actually did (if different from your plans)
How you felt about what you did (rate your mood on a scale of 1-10)
Situations and thoughts which may have negatively affected your mood. Fill out at end of day. Adjust and revise accordingly.
Remember there are very few victims in this world. Despite your childhood and life experiences, you are responsible for your choices as an adult. While trauma and tragedy may have informed your world view and your ability to trust others, nothing good comes out of seeing yourself as a victim (even if you were).
Action-plan: Take responsibility for your life. Switch the dial from victim to survivor and revel in feelings of strength and empowerment. Rather than seek retribution over those who have wronged you, seek redemption. Refuse to wallow in self-pity and focus on comforting others. After all, there is always someone out there fighting a battle greater than yours. The victim gives up at the first sign of struggle, while the survivor puts one foot in front of the other and keeps moving.
7. Find your social support network. Humans are wired to connect. Chicago psychologist John Cacioppo, author of the book, Loneliness, writes about how "the need for social connection is so fundamental that without it we fall apart, down to the cellular level. Over time blood pressure climbs and gene expression falters. Cognition dulls; immune systems deteriorate. Aging accelerates under the constant, corrosive presence of stress hormones. Loneliness, Cacioppo argued, isn’t some personality defect or sign of weakness—it’s a survival impulse like hunger or thirst, a trigger pushing us toward the nourishment of human companionship."
Action-plan: In short, reach out: Call a friend or family member and get together for coffee, or go for a hike, or meet up at a park. Even small steps like volunteering and smiling at strangers makes a difference. In long, open up your life.
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Copyright 2016 Linda Esposito, LCSW
Do you ever attribute your child’s wild or wound-up behavior to the presence of a full moon? If so, you’re far from the only parent to feel as though your child might open his mouth and howl at the dark sky. Our connection to the moon and to lunar cycles has been the subject of legend, speculation, and mythology for much of human history as we know it.
The relationship of human behavior—and sleep—to the shifting phases of the moon has also been the subject of scientific inquiry. While still scientifically underexplored relative to the influence of solar, seasonal, and circadian rhythms and clocks, the effects of lunar rhythms are being investigated by scientists across disciplines. There is mounting evidence that the lunar cycle influences physiological function and behavior in animals, including birds, fish, and other marine life.
With regard to its effect on human physiology, behavior, and sleep, the scientific findings of the impact of lunar rhythms has been mixed, with some findings pointing to associations between phases of the moon and changes to sleep patterns and activity levels, while other studies failing to show a link.
Full moon, less sleep
A new, large-scale international study examines the effects of lunar phases on the sleep and waking activity levels of children. Researchers from around the globe collaborated on this investigation, which included more than 5,000 children from 12 different countries. They discovered a change in children’s sleep patterns associated with the changing phases of the moon.
Researchers used data from the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE), an ongoing research project with study sites in Australia, Brazil, Canada, China, Columbia, Finland, India, Kenya, Portugal, South Africa, United Kingdom, and the United States. The countries that participate in ISCOLE reflect a diversity of geographic location as well as a range of economic development and other sociocultural factors. (These participating nations represent five major geographic regions of the world: Europe, Africa, the Americas, Southeast Asia, and the Western Pacific.)
The children in the study were between the ages 9-11. A total of 5,812 children participated in the study, spread roughly evenly among the 12 participating nations. Sleep and waking activity levels were measured using waist-worn accelerometers. Researchers collected data on nighttime sleep duration, and sleep efficiency—the amount of time spent sleeping compared to the total amount of time spent in bed. They also assessed waking activity levels from light to moderate and vigorous, and overall sedentary time. The data collected was analyzed in relation to three different lunar phases:
Full moon (plus or minus 4 days)
Half moon (plus or minus 5-9 days from the nearest full moon)
New moon (plus or minus 10-14 days from the nearest full moon)
The scientists’ analysis revealed a small, but statistically significant, change to children’s sleep duration in connection with the full moon. The children slept an average of 4.9 minutes less during the time of the full moon, compared to the time of a new moon, for an average 1 percent reduction in total sleep time.
This was the only sleep and activity measurement that was associated with changing moon phases. Researchers found no links between the different lunar phases and children’s waking activity levels, sedentary time, or sleep efficiency.
Other evidence of the moon-sleep connection
While scientists didn’t find broad or dramatic shifts in children’s sleep patterns linked to the moon, their study—the first to examine the lunar influence of sleep in children across five major regions of the world—did establish a modest but meaningful link between sleep duration and lunar phases. This research aligns with other, previous studies that have demonstrated an association between human sleep patterns and the lunar cycle.
Swiss researchers in 2013 shared results of an in-laboratory study of sleep and lunar cycles. They found several significant changes to sleep patterns associated with the full moon:
Decreased sleep duration: participants slept 20 minutes less, on average, during the full moon phase
Delayed sleep: participants took an average of 5 minutes longer to fall asleep at or around the full moon
Reduced melatonin: participants showed lower levels of the “sleep hormone” at the full moon
Diminished sleep quality: Participants reported sleeping less soundly during the full moon phase
Changes to sleep architecture: Participants spent less time in slow wave sleep, and took longer to reach REM sleep, near to the full moon
This study garnered a lot of attention, as it strongly suggested links between human physiology and sleep and the phases of the moon. Additional studies subsequently reported similar changes to sleep patterns linked to the lunar cycle. One investigation—also conducted by scientists in Sweden—found reduction in sleep time of an average of 25 minutes near the full moon. Researchers also found changes to sleep architecture, particularly a change in the time it took participants to enter REM sleep around the time of a new moon. Participants, who slept in laboratory during the study, also demonstrated greater reactivity to environmental stimuli while asleep, during periods of a full moon.
A team of scientists from Europe, Canada, and the U.S. also found links between the lunar cycle and sleep duration, sleep efficiency and quality, and changes to slow-wave sleep and REM sleep.
Moon-sleep findings mixed
But not all evidence points clearly to an association between sleep and the lunar cycle, or demonstrates uniformly what that association may be. A recent study of more than 2,000 men and women in Switzerland found no link between the phases of the moon and sleep duration or sleep quality.
Another recent investigation—one of the few other studies to look specifically at children’s sleep in relation to lunar phases—found changes to sleep and activity levels that were distinctly different from the current study. In this study, Danish researchers studying 795 children ages 8-11 found that children slept slightly more—an average of 3 minutes—around the time of the full moon, not less. In addition, they found that children’s activity levels also changed in relation to the moon, and that children were slightly less active during the full moon phase, by an average of about 4 minutes of moderate or vigorous activity.
The folkloric link between sleep and waking behavior and the moon has been with us for a very long time. We’re only at the beginning of a scientific exploration of this possible connection, and how it may affect our sleep patterns—and our children’s. We know that other forms of animal life possess physiological and behavioral connections to the moon. More research—sure to come—may eventually show us whether we do as well.
Michael J. Breus, PhD
The Sleep Doctor™
In a fast paced, technology driven, highly pressured work and family enviroment, one of the most important aspects of one's wellbeing is your Mental Health.
Read about some important Lifestyle changes that can assist in promoting and boosting better mental health.
When we seek help for a mental health condition, we can expect to hear about various medications and treatment options, but what’s often missing from the conversation is any talk of lifestyle changes. In a recent University of Illinois study, about half of those with symptoms of mental illness reported that they receive no wellness advice from their health care provider.
That’s a lamentable oversight because lifestyle changes—things as simple as nutrition and exercise—can have a significant impact on quality of life, for any of us, but especially for those dealing with issues such as depression, anxiety, bipolar disorder and schizophrenia. They can also help minimize the development of risk factors that can lead to conditions like diabetes, cardiovascular disease, and hypertension, all of which are seen at higher rates in those with mental illness, the study noted.
If you are dealing with a mental health challenge, take the initiative when speaking to your clinician. Ask for specifics on what changes you can safely make in your daily life to improve your mental health; there’s no single answer. But research has shown that lifestyle changes in several key categories can pay healthy dividends for most. Among the most powerful:
1. Enhance Your Diet
Research shows that our diet can influence our mental health, for both good and bad. Fruits and vegetable are associated with better mental well-being, according to recent research from the University of Warwick. That’s important because mental well-being—feelings of optimism, happiness, self-esteem and resilience—can help protect not only against mental health problems but physical ones as well.
Fatty foods, on the other hand, may increase the risk for psychiatric symptoms by changing the bacteria that live in our gut, according to new research. A study done with mice showed increased anxiety, impaired memory, repetitive behavior, and brain inflammation as a result of a high-fat diet. Some fats, however, fall into the “good” category. Omega-3 fatty acids such as are found in salmon, for example, may help with some forms of depression.
Sugar, of course, should have only a minimal place in your diet. Not only can it spark rapid weight gain and an addictive response in some, it has been linked to higher rates of depression and can make mental health symptoms worse, according to the National Alliance on Mental Illness (NAMI).
2. Make Exercise a Priority
You’ll want to check with your doctor before you start any exercise regime, but physical activity has been shown to have significant benefits for those dealing with mental health issues. A Southern Methodist University study labeled exercise a magic drug for those with anxiety and depression disorders and called on doctors to more widely prescribe it. Research shows even low levels of activity—things such as walking or gardening for half an hour a day—can help ward off depression now and even later in life. Exercise has also been shown to improve the mental and physical health of those with schizophrenia. (One note: If you have bipolar disorder, be aware that exercise can trigger mania in some. Get your doctor’s OK before adding new forms of physical activity to your life.)
As a bonus, exercise helps not only with mental health and fitness but also with weight control. This is especially important because weight gain is a side effect of many medications for mental illness. Extra pounds may not only make you less healthy and more prone to developing illnesses such as diabetes, they can also add to your mental distress.
3. Practice Techniques to Reduce Stress
Stress feeds mental illness, and mental illness feeds stress. Taking steps to minimize the stress in your life can help slow this vicious cycle. Consider adopting techniques such as mindfulness meditation; a Carnegie Mellon University study found that even 25 minutes a day for three days in a row can reduce stress and build resilience. And a Johns Hopkins research analysis determined that meditation can improve symptoms of anxiety and depression.
Yoga is another powerful choice for stress reduction, as well as being good exercise. A Queen’s University study found it can even help us view the world in a less negative, less threatening way, which can be a huge benefit for those with mental health disorders. (Again, a note for those with bipolar disorder: A recent study found risks as well as benefits in yoga. According to a recent study, some with bipolar disorder found it a “life-changing” positive, while a minority reported it can intensify both high and low moods.)
4. Get Enough Sleep
We all crave a refreshing night’s sleep, but don’t always get it. We can boost our odds by committing ourselves to good sleep hygiene. That means going to bed and getting up at a consistent time, getting sufficient exercise (earlier in the day rather than late at night), avoiding heavy evening meals and caffeine, practicing relaxation techniques, and forgoing activities that get in the way of our shuteye, such as those Netflix marathons. If you’re still having trouble, don’t turn automatically to sleep aids, which research shows may actually shorten your lifespan. See your doctor or a sleep specialist for help.
Making lifestyle changes in support of your sleep is well worth the effort. Poor sleep has multiple negatives: Studies show fatigue makes it harder to choose healthy foods, it’s been linked to obesity and cell damage, and it can make mental illness symptoms worse. Sleep deprivation has been shown, for example, to trigger schizophrenia symptoms. Consistently good sleep, on the other hand, can help keep stress at bay, as well as boost mood, protect the brain and give us the energy we need to deal with all that life throws at us.
A great article talking about relationships and modern marriage. It's well worth a read.
When I stopped shooting coke and heroin, I was 23. I had no life outside of my addiction. I was facing serious drug charges and I weighed 85 pounds, after months of injecting, often dozens of times a day.
But although I got treatment, I quit at around the age when, according to large epidemiological studies, most people who have diagnosable addiction problems do so—without treatment. The early to mid-20s is also the period when the prefrontal cortex—the part of the brain responsible for good judgment and self-restraint—finally reaches maturity.
According to the American Society of Addiction Medicine, addiction is “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” However, that’s not what the epidemiology of the disorder suggests. By age 35, half of all people who qualified for active alcoholism or addiction diagnoses during their teens and 20s no longer do, according to a study of over 42,000 Americans in a sample designed to represent the adult population.
The average cocaine addiction lasts four years, the average marijuana addiction lasts six years, and the average alcohol addiction is resolved within 15 years. Heroin addictions tend to last as long as alcoholism, but prescription opioid problems, on average, last five years. In these large samples, which are drawn from the general population, only a quarter of people who recover have ever sought assistance in doing so (including via 12-step programs). This actually makes addictions the psychiatric disorder with the highest odds of recovery.
While some addictions clearly do take a chronic course, this data, which replicates earlier research, suggests that many do not. And this remains true even for people like me, who have used drugs in such high, frequent doses and in such a compulsive fashion that it is hard to argue that we “weren’t really addicted.” I don’t know many non-addicts who shoot up 40 times a day, get suspended from college for dealing and spend several months in a methadone program.
Only a quarter of people who recover have ever sought assistance in doing so (including via 12-step programs). This actually makes addictions the psychiatric disorder with the highest odds of recovery.
Moreover, if addiction were truly a progressive disease, the data should show that the odds of quitting get worse over time. In fact, they remain the same on an annual basis, which means that as people get older, a higher and higher percentage wind up in recovery. If your addiction really is “doing push-ups” while you sit in AA meetings, it should get harder, not easier, to quit over time. (This is not an argument in favor of relapsing; it simply means that your odds of recovery actually get better with age!)
So why do so many people still see addiction as hopeless? One reason is a phenomenon known as “the clinician’s error,” which could also be known as the “journalist’s error” because it is so frequently replicated in reporting on drugs. That is, journalists and rehabs tend to see the extremes: Given the expensive and often harsh nature of treatment, if you can quit on your own you probably will. And it will be hard for journalists or treatment providers to find you.
Similarly, if your only knowledge of alcohol came from working in an ER on Saturday nights, you might start thinking that prohibition is a good idea. All you would see are overdoses, DTs, or car crash, rape or assault victims. You wouldn’t be aware of the patients whose alcohol use wasn’t causing problems. And so, although the overwhelming majority of alcohol users drink responsibly, your “clinical” picture of what the drug does would be distorted by the source of your sample of drinkers.
Treatment providers get a similarly skewed view of addicts: The people who keep coming back aren’t typical—they’re simply the ones who need the most help. Basing your concept of addiction only on people who chronically relapse creates an overly pessimistic picture.
This is one of many reasons why I prefer to see addiction as a learning or developmental disorder, rather than taking the classical disease view. If addiction really were a primary, chronic, progressive disease, natural recovery rates would not be so high and addiction wouldn’t have such a pronounced peak prevalence in young people.
But if addiction is seen as a disorder of development, its association with age makes a great deal more sense. The most common years for full onset of addiction are 19 and 20, which coincides with late adolescence, before cortical development is complete. In early adolescence, when the drug taking that leads to addiction by the 20s typically begins, the emotional systems involved in love and sex are coming online, before the cognitive systems that rein in risk-taking are fully active.
Taking drugs excessively at this time probably interferes with both biological and psychological development. The biological part is due to the impact of the drugs on the developing circuitry itself—but the psychological part is probably at least as important. If as a teen you don’t learn non-drug ways of soothing yourself through the inevitable ups and downs of relationships, you miss out on a critical period for doing so. Alternatively, if you do hone these skills in adolescence, even heavy use later may not be as hard to kick because you already know how to use other options for coping.
The data supports this idea: If you start drinking or taking drugs with peers before age 18, you have a 25% chance of becoming addicted, but if your use starts later, the odds drop to 4%. Very few people without a prior history of addiction get hooked later in life, even if they are exposed to drugs like opioid painkillers.
So why do so many people see addiction as hopeless? One reason is “the clinician’s error,” which could also be known as the “journalist’s error” because it is so frequently replicated in reporting on drugs.
If we see addiction as a developmental disorder, all of this makes much more sense. Many kids “age out” of classical developmental disorders like attention deficit/hyperactivity disorder (ADHD) as their brains catch up to those of their peers or they develop workarounds for coping with their different wiring. One study, for example, which followed 367 children with ADHD into adulthood found that 70% no longer had significant symptoms.
That didn’t mean, however, that a significant minority didn’t still need help, of course, or that ADHD isn’t “real.” Like addiction (and actually strongly linked with risk for it), ADHD is a wiring difference and a key period for brain-circuit-building is adolescence. In both cases, maturity can help correct the problem, but doesn’t always do so automatically.
To better understand recovery and how to teach it, then, we need to look to the strengths and tactics of people who quit without treatment—and not merely focus on clinical samples. Common threads in stories of recovery without treatment include finding a new passion (whether in work, hobbies, religion or a person), moving from a less structured environment like college into a more constraining one like 9 to 5 employment, and realizing that heavy use stands in the way of achieving important life goals. People who recover without treatment also tend not to see themselves as addicts, according to the research in this area.
While treatment can often support the principles of natural recovery, too often it does the opposite. For example, many programs interfere with healthy family and romantic relationships by isolating patients. Some threaten employment and education, suggesting or even requiring that people quit jobs or school to “focus on recovery,” when doing so might do more harm than good. Others pay too much attention to getting people to take on an addict identity—rather than on harm related to drug use—when, in fact, looking at other facets of the self may be more helpful.
There are many paths to recovery—and if we want to help people get there, we need to explore all of them. That means recognizing that natural recovery exists—and not dismissing data we don’t like.
Maia Szalavitz is one of the nation’s leading neuroscience and addiction journalists, and a columnist at Substance.com. She has contributed to Time, the New York Times, Scientific American Mind, the Washington Post and many other publications. She has also published five books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006), and is currently finishing her sixth, Unbroken Brain, which examines why seeing addiction as a developmental or learning disorder can help us better understand, prevent and treat it. Her last column for Substance.com was about which parts of the 12 Steps she would keep, which she would throw away and why.
Considering the expansion of state sponsored psychotherapy services in the UK, a recent article explores the political role of psychotherapy in society and examines some of the philosophical roots of the "talking cure."
As a liberal, I support the state’s provision of CBT for two reasons: first, it leaves open the question of the meaning of life, and second, it’s effective and people ask for it. (As an aside, I do think there should be a more diverse range of evidence-based therapy available.) It’s quite another matter for the state to impose a comprehensive theory of the good life on their citizens without their consent. I am wary of governments using pseudoscience to smuggle moral paternalism in through the back door. A society in which we are all quantified according to our adherence to Positive Psychology would be a regression into the Middle Ages.
(Image credit: Fox Valley Institute)
NO Simon Wessely, member of the Royal College of Psychiatrists
Next week the American Psychiatric Association is publishing its fifth take on the classification of psychiatric disorders, the DSM-5. Judging by the sound and fury, you might be forgiven for thinking that this is something radical – a great breakthrough in our struggle to better understand mental disorders, or alternatively a dastardly plot to extend the boundaries of psychiatry into everyday life and emotions at the behest of greedy drug companies. Or, if the position statement from the Division of Clinical Psychology (DCP) is to be believed, an attempt to emphasise the biological causes of mental disorders over the social and psychological.
In fact, it is none of the above. A classification system is like a map. And just as any map is provisional, ready to be changed as the landscape changes, so is classification. Our knowledge of the changing landscape can come from many sources. This week's Lancet, for example, highlights new research showing the genetic overlaps between several serious psychiatric disorders, which call into question the current boundaries between schizophrenia and bipolar disorders (genes matter, even if we don't yet fully understand how). I expect that the map of severe mental illness in DSM-6, when it appears, will have been redrawn and that it will be on the basis of a better biological understanding of those disorders.
But does that mean that, as the DCP is saying, psychiatry is gradually being taken over by the biologists, attempting to reduce human experience to the level of molecules and cells? The answer is an unequivocal no. Psychiatry is the study of the brain and the mind. Psychiatrists look at the whole person, and indeed beyond the person to their family, and to society. That is why even as a medical student I knew that psychiatry was for me – it was about biology, but it was also about psychology, and sociology, ethics, politics and much else. Psychiatrists react to the tired arguments about biology versus psychology in the same way as geneticists react to sterile debates about nature versus nurture – it's both. Mindless psychiatry is as unhelpful as brainless psychiatry, and the psychiatrist who ignores the social environment is, well, not a psychiatrist. Political decisions about the economy in, for example, Greece or Russia have had serious consequences on some, but not all, mental disorders.
So why the fuss about DSM-5? After all, it's hardly a good read – not the kind of book anyone will take on holiday – and it isn't the system of classification that we use over here in any case. In practice, most UK mental health professionals will barely notice much difference. Some diagnostic criteria will have improved, others less so, and no doubt there will be some "only in America" stories about the inevitable daft new category. But most of those in the business of helping those with mental disorders will be less concerned with what is in and what is out than with the reality of underfunded and overstretched services. The idea that we are part of a conspiracy to medicalise normality will seem frankly laughable as we struggle to protect services for those whose disorders are all too evident under any classification system.
Simon Wessely is a member of the Royal College of Psychiatrists and chair of psychological medicine at King's College London
YES Oliver James, author and clinical psychologist
A student friend of mine once started claiming that she was being controlled by electrical impulses beamed across the city by "authoritarian capitalists". She spent hours in the bath, cleaning herself.
Following her removal to an asylum, her parents arrived to collect her possessions. Nearly all of her (mostly clean) clothes were deemed so "soiled" they would need to be burnt. The room was obsessively cleaned. Her father was a health inspector.
Within the medical model of mental illness, she had inherited genes predisposing her to obsessive rituals and to psychosis. The model does not entertain the possibility that the health inspector's intrusiveness distressed her or, as it turned out, that he had sexually abused her.
Yet 13 studies find that more than half of schizophrenics suffered childhood abuse. Another review of 23 studies shows that schizophrenics are at least three times more likely to have been abused than non-schizophrenics. It is becoming apparent that abuse is the major cause of psychoses. It is also all too clear that the medical model is bust.
In the press release accompanying publication of DSM-5, David Kupfer, who oversaw its creation, states: "We've been telling patients for several decades that we are waiting for biomarkers. We're still waiting." This is an astonishing admission that there are no reliable genetic or neurological measurements that distinguish a person with mental illness.
While there is some evidence that the electro-chemistry of distressed people can be different from the undistressed, the Human Genome Project seems to be proving that genes play almost no part in causing this. Eleven years of careful study of our DNA shows that differences in it do not explain mental illness, hardly at all. If one sibling is anxious or depressed and another is not, at most, differences in DNA can only explain 1-5% of why it is one and not the other.
Of course, some researchers maintain that, given more time (and money), they will still come up with significant results. But off the record, nearly all molecular geneticists admit that it now really does look as if differences in DNA will explain very little.
By contrast, there is a huge body of evidence that our early childhood experiences combined with subsequent exposure to adversity explain a very great deal. This is dose dependent: the more maltreatment, the earlier you suffer it and the worse it is, the greater your risk of adult emotional distress. These experiences set our electro-chemical thermostats.
So does subsequent adult adversity. For instance, a person with six or more personal debts is six times more likely to be mentally ill than someone with none, regardless of their social class: the more debts, the greater the risk.
We need fundamental changes in how our society is organised to give parents the best chance of meeting the needs of children and to prevent the amount of adult adversity.
Oliver James trained and practised as a clinical psychologist. He is the author of Love Bombing – Reset your Child's Emotional Thermostat
The International Neuropsychoanalysis Society is hosting its 14th conference in Cape Town from the 22nd to the 25th of August. The conference is entitled The Clinical Applications of Neuropsychoanalysis and will feature internationally renowned experts such as Jaak Panksepp, Mark Solms, Oliver Turnbull and Katerina Fotopoulou.
The congress is aimed at professionals working with all aspects of mind/brain disorders and development. Neuropsychoanalysis contributes to understanding the mind/brain interface. But what are the practical implications of this understanding for our clinical work, as psychoanalysts and therapists or as neuropsychologists and psychiatrists? Set in the beautiful grounds of the University of Cape Town, this congress will address that question. Come learn about the implications of neuropsychoanalytic research for such diverse clinical topics as conversion disorders, depression, addiction, epilepsy, dementia and focal neuropsychological syndromes (e.g., confabulation). Find out also about the clinical implications of neuropsychoanalysis for conventional psychoanalytic therapy.
CPD points will be provided for both the conference and the education day. Please click on the link below to go to the conference webpage.
Using a new treatment that has shown promising results in alleviating major depression, researchers at Stanford now claimed some success using transcranial magnetic stimulation (rTMS) to treat sufferers of chronic pain.
Until now, pain seemed out of reach for rTMS because the regions involved in pain perception lie very deep within the brain. The other disorders helped by rTMS all involve brain areas close to the skull. To treat depression, for example, a single magnetic coil directs a magnetic field at the dorsolateral prefrontal cortex, a region of the brain's outer folds. When aimed at different areas of these outer folds, rTMS improves the motor symptoms of Parkinson's disease, staves off the damage of stroke, lessens the discomfort that follows nerve injury and treats obsessive-compulsive disorder. The magnetic field affects the electrical signaling used by neurons to communicate, but how exactly it improves symptoms is unclear—scientists suspect rTMS may redirect the activity of select cells or even entire brain circuits.
Using examples from vacations to colonoscopies, Nobel laureate and founder of behavioral economics Daniel Kahneman reveals how our "experiencing selves" and our "remembering selves" perceive happiness differently. This new insight has profound implications for economics, public policy -- and our own self-awareness.
Widely regarded as the world's most influential living psychologist, Daniel Kahneman won the Nobel in Economics for his pioneering work in behavioral economics -- exploring the irrational ways we make decisions about risk.