Rowman & Littlefield Publishing Group

Relapse Prevention: It’s The “How” That Counts

By Deborah Serani

A recent study from the University of Toronto suggests how you process information determines if you’re at risk for a depressive relapse. More specifically, researchers learned via the use of fMRI technology that how the brain responded to a sad event was a predicting factor.

In this study, depressed participants were shown a series of sad clips of movies. Individuals who ruminated about the sadness they experienced fell into another depressive state as opposed to those who were able to feel and accept their emotional experience. It’s been long-known that patterns of negative thinking put a person’s mental health at risk. Like treading water, negative thinking gets you nowhere fast, leaves you fatigued and overwhelmed. Before you know it, you’re unable to problem-solve, and depression sets in. In this study, individuals who experienced the depth of their sadness and accepted the limits &/or hardships continued with their recovery intact. So, when it comes to keeping your depression from relapsing, it’s all about “how” you move through your experiences.

Taking the “how” to a scientific level, fMRI data showed that frontal brain activity resulted in ruminating behavior whereas brain activity in the rear part of the brain signaled acceptance. This is of great interest not only to researchers, but also to therapists who specialize in depression treatment. This study supports the aims of psychotherapy and medication, where interrupting a negative rumination style is the targeted goal of treatment. For those who live with depression, learning how to problem-solve, visualize and work toward acceptance of what one can change and what one cannot, can help inoculate against relapse.

“Part of what makes depression such a devastating disease is the high rate of relapse,” says Norman Farb, a PhD psychology student and lead researcher. “This study suggests that there are important differences in how formerly depressed people respond to emotional challenges that predict future well-being.”

Reference:

Farb, N.A.; Anderson, A.K.; Bloch, R.T. & Segal, Z.V. (2011). Mood-linked responses in medial prefrontal cortex predict relapse in patients with recurrent unipolar depression. Biological Psychiatry, DOI: 10.1016/j.biopsych.2011.03.009

Deborah Serani is a psychologist in private practice in New York and the author of Living with Depression: Why Biology and Biography Matter along the Path to Hope and Healing.

Mental Illness Does Not Erase Your Dreams: The Little Metal Box

By Randye Kaye (parts first published on Ben Behind His Voices blog)

Mental illness makes news. Usually sensational news. CNN reports that Jared Lee Loughner is unfit to stand trial. Last month, Catherine Zeta-Jones spoke openly about her bipolar diagnosis. Charlie Sheen? Anybody’s guess. (But I say: get that man into treatment, stat!)

But what about the people who don’t make the news? What about the large proportion of consumers who are managing their lives somehow, or trying to, without shooting anyone or landing on the cover of People? Those who have been diagnosed with mental illness deserve respect - and help. Their courage is enormous, the obstacles often beyond comprehension for those who don't understand.

My son, Ben, earned another six college credits this semester, and is still on the Dean's list. Plus - in the past two months - a new job, and a move to his own small apartment. All this after seven hospitalizations, seven years in a group home, eight years unemployed. Amazing! He's getting his life back in small steps. But there’s no news coverage for people like Ben.

Why did it take so long? Ben has paranoid schizophrenia. That kind of messes up your path to maturity. Never, never compare his progress to someone else his age whose brain functions without illness. There are other yardsticks to use.

Ben spent lots of time dealing with an illness whose onset confused us all, and then lots of time learning to recover. He’s still learning to recover. But years ago, when all was in confusion and chaos, he’d still had dreams, which he wrote down and kept in a little metal box. I discovered these seven years after his fifth trip to the Emergency Room for psychiatric admission.

When I cleaned out Ben’s last apartment seven years ago, I’d found a little metal box. At that time, I peeked at its contents: more scraps of paper, obviously precious enough to be stored in this place of honor. I couldn’t bring myself to open these papers then. What crazy ideas would I find written on them? He was so desperately ill, his schizophrenia so in charge of his mind at that time. I’d seen enough; I’d heard enough. I threw the box in with the rest of his “desk supplies” and stored it away with more evidence of his disastrous attempt to live on his own that year.

Recently, I rediscovered that old metal box in a storage bin in Ben’s childhood bedroom. It had originally held mints: “Organic Cinnamon Snaps! Over 100 snaps per box,” reads the cover. The hinges are covered in duct tape now; the picture of forests and volcanoes under the words has faded. Ben’s little treasure box, now seven years old.

I open it. Inside are pages ripped from a small spiral notebook, carefully folded to fit. I hesitate. I do – and I don’t - want to open these.

What will I find? What secrets has he kept in here? I hold the box in my hand, a key to the things my son considered sacred when he was 20 years old.

I take out the first paper and unfold it. I expect to see what I have found before in his writings from that period: grandiose ideas, poetic phrases, delusions that guide my son when his symptoms flare up.

But I’m wrong. It’s only a list of phone numbers, readable, organized. His friends, our family, his most recent employers. At the bottom of the list, the names of some old friends – from high school days – with no numbers listed.

People he hoped to get in touch with again, I think. I’d almost forgotten how many friends he used to have. So many friends. Would they even talk to him now?

I open the next paper. It’s another list, with “Stuff” written across the top, then: candles, lawn chair, blank tapes, phone card, origami paper. The list goes on; it’s a “want” list, or a shopping list. Things he’d like to have for his birthday, perhaps. The simplicity of these small desires touches me.

The next sheet is a to-do list. Again, the handwriting is legible and the columns organized. There are about seventy-five items on this list. Most are written in blue ink, a few in green, black or red. I stare at this for a long time.

Among the plans he’d made:

• Write letters (with a list of over twenty people, including me, Ali, other family, old friends, our rabbi, his old therapist – what had he wanted to say?)
• Write play
• Write animal language dictionary
• Make gifts: Mom pillow, Dream Catchers, Ali cookbook (for his sister)
• Compose college essay
• Build a drum
• Make chess set

More lists: movies he wanted to see, videos he wanted to rent, books he wanted to read, CDs he wanted to buy.

I’d almost forgotten that he used to have dreams. So many dreams, such simple ones. Any dreams at all. It’s not fair! He had all of these plans. Will he ever get to do them?

At the bottom of the pile is a last piece of folded paper. This one is messier, but I can still read what it says. It is full of quotes, ideas, and plans that are more internal. Written here are ideals Ben wants to live by, almost like New Year’s Resolutions:

• Listen a lot.
• Blow nothing up out of proportion.
• Simplify, don’t be hypersensitive.
• Don’t judge people.
• Don’t use your muscles, use your mind.
• Don’t use big words.
• Think before I speak or act.
• Don’t try to control others, let them be.
• Reach out to people, lovingly.
• Hear and consider others’ points of view.
• …and the list continues.

I’d had no idea Ben was trying to change himself all the time I was desperately trying to change him.

Plans for his life - a life at a standstill for so many years. A life worth living; a life worth saving; a life stolen from him. Will he – will we -ever get it back? My boy, my precious boy. I know you’re still in there. Come back to us. Come back to you.

I wipe my eyes, carefully refold the papers and put them back in the little metal box. I wish I could sleep with it under my pillow, like a lost baby tooth, and have my wishes – and Ben’s – come true.

Randye Kaye is an actress, broadcaster, voice talent, and speaker. She is the author of Ben Behind His Voices: One Family's Journey from the Chaos of Schizophrenia to Hope.

School Bullying and Teen Suicide

By Stuart W. Twemlow

Suicide in victims of bullying at school is a rare event, and a startling one. In general, teenaged boys are much more likely to die by suicide than girls. This is true in all age groups by a factor or three to four. The recent case of Phoebe Prince, aged 15, who hanged herself in South Hadley, Massachusetts, after chronic bullying by a group of girls and boys in the school (who have been charged criminally), is an exception. The school has been the center of a cyclone about bullying in Massachusetts that will no doubt lead to many law suits, much acrimony, and defensiveness by the school, the parents of the children who bullied, and the parents of Phoebe Prince.

Interestingly, research conducted by the Menninger Foundation and Baylor College of Medicine has shown that bullying has had much more of a negative affect on boys than girls in terms of chronic victimization. In a study we performed over a three-year period in elementary-school-aged children, severely bullied boys ended up with internalizing symptoms including depression, anxiety, and suicidal thoughts and actions significantly more than girls. Chronic, severe victimization by others of a peer group, especially in teenagers who are susceptible to peer-group opinion, is extremely damaging, traumatizing, and humiliating. In some ways, the experience is like multiple rape in front of an audience, especially for these peer-sensitive adolescents.

The United States of America, which has for many years lagged behind the rest of the world including the United Kingdom and Scandinavia, in research into bullying, is finally beginning to wake up. In the last five years especially, there has been a massive increase in serious research about bullying. However, we are no nearer to the solution. We have not found a way of reducing bullying in a stable way in schools. One of the points that we do know is that the school must be committed to it with the same intensity as it is committed to teaching intellectual skills. It is not simply an add-on to make children more comfortable. We also know that punishing bullies does not work at all. Most zero-tolerance programs have been dropped.

So what does work? We have found that teaching children to be aware of each other and how relationships are developed (mentalizing) is extremely important. Children must become conscious of how they use their personal power as victimizers, victims, or even bystanders. Adults are very important models for this conduct. But the last word has not been said.

Phoebe Prince’s tragedy has caused an uproar, fueling suggesting that bullying be made a mandated reporting offense. This would focus a great deal of attention on bullies and may lead to punishment or treatment for them, but it would leave the massive audience of bystanders and victims unattended. Easy as a legal solution sounds, until the community as a whole adopts anti-bullying as a high-priority public-health issue, no meaningful change will occur.

Stuart W. Twemlow, MD, is professor of psychiatry and behavioral sciences at Baylor College of Medicine and the co-author of Why School Anti-Bullying Programs Don’t Work.

Fix the System to Heal the Kids

By Pat Pernicano

I spent March 18-20 in Chicago at the Ben Franklin Summit for Clinical Excellence, entitled Freud Meets Buddha: Mindfulness as a Therapeutic Tool for Healing Trauma. The conference focused on the impact of child abuse, neglect, and evidence-based treatment. It was clear that a wide range of professionals researching and treating trauma, from MDs to PhDs, are on the same page.

The conference presented abundant data about what goes wrong when children are abused and/or neglected: their brains change (memory areas shrink and thinking areas can’t shut off strong emotion); they don’t trust anyone (“attachment deficits”); they think they are the cause of the maltreatment (“insignificant” or “not-good-enough” children); and they end up in relationships and situations that “prove” their skewed beliefs are true.

So what does it take for these kids to heal and become resilient adults? If they are going to stay in their families, the whole family needs to change. The parents (many who were abused or neglected as kids) have their own work to do. And if kids aren’t going to stay in their families, they need to be somewhere they can have long-lasting, safe, trusting, “secure base” relationships: new attachments that undo the old beliefs and experiences. The relationships need to be close and personal, with as much autonomy and control as possible given to the child who formerly had so little control over his or her life.

Believe it or not, nurturing, loving, consistent, dependable relationships have the capacity to heal the damaged brain, the poorly regulated hormone system, and the person’s sense of self. Throw in some good therapy and self-care (relaxation, yoga, meditation) and you may see lasting change.

So what actually happens to kids in “the system” (CPS, courts and treatment)? The parents get classes in parenting and “offender” groups but don’t change their relationships with their kids. It’s pretty sad. The parents who never got cared for don’t have a clue how to put their children’s needs (emotional and physical) before their own. The kids get removed, “protected,” and put in group or foster homes, many too large for close attachments to develop. And when the children show their rage, sadness or defiance, they are once again “not good enough” and get bounced to the next home.

The system doesn’t work. Kids “bounce” from home to home; and the biological parents remain without a clue. How can you give what you did not get? Clearly we need a bigger type of change— systemic, attachment-focused change that is more than “skin-deep” and gives kids a permanent, loving home much earlier in life.

Pat Pernicano, PsyD, is director of clinical services at Providence Self Sufficiency Ministries, and the author of Family-Focused Trauma Intervention: Using Metaphor and Play with Victims of Abuse and Neglect (Jason Aronson) and Metaphorical Stories for Child Therapy: Of Magic and Miracles (Jason Aronson).

The Hidden Key to Stopping Teenage Drug Abuse

By Michael Hammond

The National Office of Drug Control Policy has recently published their annual findings from a compilation of national surveys that indicates that drug and alcohol use among adolescents is down in some areas—such as marijuana use—and up for some other substances—such as alcohol. Unfortunately, the reality of drug use among kids will not change any time soon.

Drug experimentation among teenagers is a function of curiosity coupled with naivety, coupled with thrill-seeking and peer pressure, and the sense that it won’t hurt to try it at least once. It is also influenced by advertising. Alcohol advertising says that people who drink are mature, sophisticated, popular, and are having a heck of time while doing it. They’re cool. You want to be cool, don’t you? Then sit down with your friends and have a Bud while watching the football game.

Likewise, many of the same factors exist with the upswing in prescription drug abuse among kids: it’s medication; it’s prescribed by doctors; it’s in the medicine cabinet, so it’s not going to kill you. C’mon, take this; it will only give you a little buzz. You can wash it down with your beer.

There have been billions of dollars spent and countless numbers of lectures given to kids to try and prevent drug abuse. These efforts are laudable and should continue. However, there is one area that is more effective than education, media campaigns, and police patrols, and that doesn’t cost the government a dime: teaching parents how to decisively and consistently parent their teenagers to stop and prevent adolescent drug use. Teenagers consistently rate their parents as the most influential and trusted people in their lives. Parents can take advantage of this fact.

When parents know precisely how to monitor and supervise their kids—which involves knowing where they are, who they are with, and what they are doing—know who their friends are and information about them, and have strong emotional ties to their parents, kids are considerably less likely to use drugs or be involved in antisocial activities.

Children need two things from their parents: strong behavioral controls and strong emotional attachments. When kids have the one and not the other, or too much of one and not the other, they are likely to fall into a deep well of trouble. When the parenting skills of the two approaches are in balance, kids tend to avoid trouble and experience success.

If this idea resonates with you and you want to learn decisive parenting skills for parents of teenagers to avoid drug use, and many other kinds of problem behaviors, then you may want to get a copy of my book, Decisive Parenting. I have taught thousands of parents how to use the skills in this book, based upon sound scientific principals, and you can learn them as well.

Michael Hammond, PhD, is a clinical psychologist, a licensed marriage and family therapist, and the author of Decisive Parenting: Strategies That Work with Teenagers.

A Psychoanalytic Call for Peace Between Believers and Non-believers

by Robert Langs, M.D.

          Four highly visible and prominent authors (S. Harris, D. Dennett, R. Dawkins, and C. Hitchens) have recently penned books that attack religion as a sham and the belief in the existence of a transcendental God as more or less delusional. Believers have tended to respond by pointing out first, that God has a divine plan and acts in mysterious ways, and second, that these writers show considerable ignorance regarding, and misrepresentations of, religious beliefs. As suggested by Harold Bloom, the outcome of this rancorous debate is that only the already convinced are convinced.

          As a psychoanalyst who has developed a new, adaptation-centered paradigm of psychoanalysis and thus a new view of human life, I want to offer an olive branch to both sides of this conflict. It is based on the insight that coping with death and the three forms of death anxiety it evokes—predatory (the fear of being attacked or killed), predator (the guilt-ridden need for punishment by death for harming others), and existential (the fear of one’s personal mortality)—are the fundamental challenges for all of humankind. Uniquely, we meet these threats using two distinctive adaptive systems of the emotion-processing mind, one that is attached to conscious awareness and the other without such a link. The activities of this deep unconscious system are encoded in narratives such as dreams and daydreams. Comparing the reactions of these two systems to the same death-related events we find that conscious responses tend to be muted, infused with denial, and poorly thought out, while deep unconscious reactions tend to be brutally candid, exceedingly wise, and based on grim images of destruction, devastation, and horror.

          Relevant to the effort to make peace between believing and non-believing combatants, clinical observations of patients’ unconscious efforts to cope with traumatic incidents indicate that there are two basic types of individuals. The first group will consistently encode a series of grim themes that validly reflect the most forbidding meanings of a given trauma and its frightful impact on them. In contrast, the second group will either fail to remember a dream or will report a dream that is bland and without the terrifying imagery that one would expect in light of the trauma with which they are dealing. Both responses are ways of shutting off access to their always terrifying deep unconscious perceptions of the trauma at hand. Furthermore, the narrators will always generate strong themes in response to the least trauma and the non-narrators will always react with mild or absent imagery. There are, then, two very different, rather fixed, archetypal ways of coping unconsciously with the death anxieties aroused by a death-related trauma.

          We can apply these findings to believers and non-believers when it comes to the existence of a supernatural God. Both the belief and disbelief in a transcendental God are, at bottom, psychological ways of dealing with death and its attendant anxieties. Depending on how it is utilized, each approach may be either adaptive or dysfunctional. Each has been successful in bringing peace to many individuals and is responsible for peaceful respites for societies and nations. But each also has spawned madness, violence, and war. Given that a person's adaptive preferences, which are consciously and unconsciously motivated and sustained, tend to be almost set in stone, trying to change this preference is a pointless and generally unfeasible task. Extremely difficult and seldom feasible. This means that there are strong reasons to find ways to enhance the efforts of both secularists and those of faith to cope with their death anxieties, which in turn means that it is unwise and unnatural to try to disassemble belief systems related to the existence of God.

           There is, I think, a moral to this story. Both believers and non-believers ultimately are trying to cope with life and its relentless nemesis, death. Each group has, on the basis of many forces unknown to them, come up with an adaptive solution that is reflected in part in their thoughts about the existence of God. But surely, no one can or should tell another person how to go about resolving their death anxieties nor should they decide for them the role that religious beliefs should play in these efforts. One answer does not and cannot fit all. An individual's chosen mode of trying to cope with death anxiety should be respected and every effort made to improve its chances of success through insights into the needs that are satisfied by these convictions.

          Only a joining of forces based on a deep understanding of the positions of those on both sides of this debate and a combining of resources and understanding can help us to ameliorate the power, often evil and destructive, that death holds over our lives. A familiar phrase captures my message: United we conquer, divided we fall.

Robert Langs, M.D. is the author of 45 books on issues pertaining to human emotional life, including the recently published Beyond Yahweh and Jesus: Bringing Death’s Wisdom to Faith, Spirituality, and Psychoanalysis.