Dialectical behavior therapy (DBT) is a comprehensive, evidence-based treatment approach used to treat individuals with a wide variety of issues, including relationship conflict, anxiety, depression, bipolar, self-injury, eating issues, and substance abuse. Developed in the 1980s by psychologist Marsha M. Linehan for the treatment of borderline personality disorder and chronic suicidality, this method has since been adapted and utilized to help clients with much less severe issues. The therapy can help clients who exhibit extreme emotional reactions, helping them develop self-acceptance while also learning coping skills to better regulate their emotions and handle distress. DBT uses both individual therapy sessions and group skills training, as well as telephone coaching between sessions.

The DBT model combines a behavioral therapy approach with eastern mindfulness practices. In one sense, the term dialectical refers to the goal of synthesizing the extreme opposites inherent in the rigid “black and white” thinking of many clients who have trouble regulating their emotions. “Dialectical” also applies to the core DBT principle of practicing acceptance strategies while implementing change strategies, in the process of reducing and modifying self-destructive behaviors.

This type of therapy is very support-oriented; it helps clients identify their strengths, build new skills, and increase their self-esteem. DBT focuses on cognitive issues by indentifying destructive thought patterns and replacing them with more neutral and accepting internal dialogues. It is designed to be a nonjudgmental collaboration, with the therapist and client working together to increase emotional awareness and understanding, minimize negative thought patterns and behaviors, and develop new coping and problem-solving skills.

The four modules of dialectical behavior therapy:

• Core mindfulness: The first of the four primary modules of DBT, this concept involves learning to observe one’s emotions, describe those emotions, and fully participate in present experiences. This skill forms the foundation for the other three modules, and is derived largely from eastern practices of living in the moment.
• Interpersonal effectiveness: The second core component of DBT teaches clients assertiveness skills and strategies to ask for what they need, set boundaries and say no when appropriate, and deal more effectively with interpersonal conflict.
• Distress tolerance: The third module entails clients developing nonjudgmental acceptance of themselves as well as their current situation. The focus is on learning to accept the present reality and to tolerate crises, and making use of strategies such as distraction, self-soothing, and improving the moment. Practicing these skills will increase the client’s ability to tolerate challenging events and environments.
• Emotion regulation: The final module of DBT consists of three main goals: to understand one’s emotions, reduce emotional vulnerability, and decrease emotional suffering. With this in mind, some of the specific skills taught in DBT include identifying and labeling emotions as well as evaluating: events that prompt the emotion, interpretations that trigger the emotion, how the emotion is experienced, how the emotion is expressed behaviorally, and the aftereffects of the emotion.

In the case of adolescent treatment, Dr. Alec Miller has adapted Dr. Linehan’s model to incorporate parents attending skills training groups with their teens. There is an additional module, “walking the middle path,” which focuses on helping parents and their children understand each other’s viewpoints and reduce conflict and invalidation.

The five functions:

Dialectical behavioral therapy was designed to fulfill five primary functions:

• Enhance behavioral capabilities: DBT helps clients develop important life skills that help them regulate emotions, experience the present moment, improve interpersonal interactions, and better tolerate distressing situations.
• Improve motivation to changes: DBT supports clients’ motivation to change by tracking and reducing detrimental behaviors, thereby increasing quality of life.
• Generalize capabilities to other environments: In order for the client to make progress, the skills learned in therapy must transfer to a wide variety of situations. This is accomplished through homework assignments and practicing skills. Telephone consultations also can be valuable in helping clients utilize these skills in their daily lives.
• Support client and therapist capabilities: DBT aims to maintain and build the capabilities of therapists through continued training and consultation-team meetings.
• Enhance therapist motivation: The DBT model encourages the use of support, validation, feedback, and encouragement between therapists to avoid burnout and improve their effectiveness.

Stages of treatment:

The course of DBT generally flows through three stages:

• Stage 1: This stage is primarily focused on eliminating or reducing serious behaviors, including self-injury, suicidal thinking, and aggression. Behaviors that interfere with therapy also are addressed, such as missing appointments and not returning phone calls.
• Stage 2: The client strives to increase quality of life and experience emotions in a less intense manner. The client continues to eliminate or decrease destructive behaviors, and address other issues or situations that are interfering with daily life, such as past trauma.
• Stage 3: The client is experiencing increased feelings of completeness, self-respect, and love.

Who can benefit:

Though DBT originally was developed to treat more severe issues, such as borderline personality disorder, suicidal behaviors, and self-harm, the treatment has become a widely respected method for treating clients who exhibit the following, much milder traits and issues:

• Difficulty with emotional regulation
• A high level of reactivity, with a slow return to baseline
• Impulsiveness with a tendency toward self-destructive behaviors
• An inclination toward extreme thinking, unable to perceive a middle ground
• A lack of sense of self, tending to feel incomplete or empty
• A history of instability in relationships, and difficulty with interpersonal interactions
• Extreme sensitivity, accompanied by rapid mood swings, anxiety, and depression
• Fears of abandonment and trouble with intimate relationships

Dialectical behavior therapy has proven to be a very effective tool to help people manage intense emotions, change negative thought patterns, and decrease self-destructive behaviors. Individual therapy sessions focus on current detrimental behaviors in the client’s life, while group sessions involve learning skills from the four modules: mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation.

Well, maybe not real fireworks. But according to MeiMei Fox—a speaker, depth psychotherapy life coach, and author of a recent article—feeling as if fireworks are exploding is one of the 10 sure signs that you’ve found your true love. Fox, who has had her share of failed relationships, worked with her new husband to come up with 10 signs that partner is Mr. or Mrs. Right:

1. Sexual attraction: Even though fireworks may eventually smolder, sexual attraction to your partner is a must and serves as a foundation for love, honesty, and intimacy.
2. Authenticity: Partners should be comfortable with each other exactly as they are, with no pressure to act like someone they’re not.
3. Commitment: If one partner is not able to commit wholeheartedly to the relationship, it could mean they have doubts. Commitment is at the core of a true loving union.
4. Honesty: There is no place for secrets in the most important relationship of your life. “When it’s true love, you should find yourself wanting to share everything,” Fox says. “Your love is made simple and true by being honest.”
5. Unity: Each partner must put his or her needs behind those of the relationship. As the old saying goes: “There is no ‘I’ in team.” True love is about teamwork.
6. Priority No. 1: The relationship should come before anything else. The love you share with your soulmate should be the most valuable thing in both of your lives, and you should stay committed to letting nothing get in the way of working toward and sharing in its success.
7. It’s romantic: Relationships should not be all work. They should be fun, and each partner should be living in the fun of the relationship rather than talking about the relationship and its problems.
8. Your friends are happy: People sometimes worry too much about what their friends will think of a new love interest. Fox agrees that outsiders may be able to see things in your partner that you can’t. When family and friends like the person who makes you happy, it’s a good sign.
9. You want to be home: Looking forward to returning home to the arms of your partner reinforces that you’re with someone you love, value, and enjoy being with.
10. Having that lucky feeling: Fox says that she feels as if she’s won the lottery every morning she wakes up next to her husband. Although that might not happen all the time for most people, you can be pretty sure you’ve found a keeper if you feel darned lucky that he or she found you too.

Reference:
Fox, MeiMei. 10 Signs You’ve Found “The One” (n.d.): n. pag. The Huffington Post. 12 Sept. 2012. Web. 12 Sept. 2012. http://www.huffingtonpost.com/meimei-fox/10-signs-youve-found-the-_b_1870841.html

Major depressive disorder (MDD) is a mental health problem with both psychological and physical effects. Someone diagnosed with depression may have strong feelings of sadness or a loss of interest in normal activities; physical symptoms may include lethargy, body pains, insomnia, and headaches. Despite decades of research and study, fast and effective treatment for depression remains an unfulfilled goal. Currently, the preferred approach for depression treatment begins with cognitive behavioral therapy and may include one or more psychotropic medications. 

Suicide risk is a serious complicating factor in the treatment of major depressive disorder, and choosing the appropriate drug intervention remains a haphazard procedure. Because many antidepressants are potentially linked with a heightened risk of suicidal behavior, doctors must exercise caution. Response to psychotropic drugs, particularly antidepressants, is highly individual. A period of trial and error is often necessary before doctors can identify the optimum drug or drug combination. In cases of possible suicidal thoughts and behavior, the best course of action is often observation, possibly in an inpatient facility.

A recently completed study at the New York State Psychiatric Institute promises to offer some guidance in the selection of treatment for severely depressed individuals with suicidal tendencies. The study consisted of two groups, one receiving Paxil (paroxetine) and the other receiving Wellbutrin (bupropion). The choice of these specific drugs was deliberate: Paxil belongs to the selective serotonin reuptake inhibitors (SSRI) category and is among the most frequently prescribed antidepressants; Wellbutrin is a non-SSRI medication with a different mechanism of action. However, both medications still carry the “black box” warning to notify doctors and pharmacists of potentially dangerous side effects, namely the increased suicide risk. A second aspect of the study included functional MRI scanning of each participant’s brain—once at the beginning of the 8-week trial and once more at the conclusion. Participants were given a cognitive task during the scan to assess how each of them processed sensations of reward.

The initial phase of the study is complete. Data on the 125 participants is currently being compiled and analyzed. Researchers hope that one of the drugs will reveal itself as a more effective remedy for major depression, although they may find that one of the drugs leads to a higher rate of side effects. In any event, the data from this study will help attending physicians and therapists make better choices when treating their most severely depressed patients.

References:

1. Bupropion, t. c. (n.d.). WELLBUTRIN XL® (bupropionhydrochloride extended-release tablets). DailyMed. Retrieved July 18, 2012, from http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=14812
2. Depression (major depression). (n.d.). Mayo Clinic. Retrieved July 18, 2012, from http://www.mayoclinic.com/health/depression/DS00175
3. Paroxetine/Bupropion in Suicide Attempters/Ideators With Major Depression. (n.d.). ClinicalTrials.gov. Retrieved July 18, 2012, from http://clinicaltrials.gov/ct2/show/NCT00429169?recr=Open&intr=%22Bupropion%22&rank=16

My last piece on focusing ended with a definition of felt sensing as a “temporary wave, from the sea of being” (Madison, G.). What is meant by a temporary wave from the sea of being?

It is time to introduce Gendlin’s conception of human being. Note that I said “human being,” not “a human being.” For Gendlin, human being is “interbeing”—what we think of as an individual being is a “livings in the world, and living with” (Gendlin, 1978-79). He calls this principle Interaction First.

Gendlin conceives of human beings experientially not as separate “things” in interaction with each other. More radically, he sees our environments and us as a continuous co-creative process. We are not “inside our skins, but are our living-in the world, and living-with others” (Gendlin, 1978-79). Even our physical being is a continuous process with its inner and outer environments. Hence, in his view, it is impossible to conceive of human being as a separate entity. We are interbeing.

What is a living body such that it has the intricacy of our situations? … With the old concepts, people might say that Focusing is “subjective.” But clearly, if the situation is carried in the body, then a felt sense is not subjective. Objective then? No, also not, since “objective” means the units and patterns to which science limits anything it studies. We could fashion a new sentence that is neither subjective, nor objective, nor both: The body IS an interaction process with the environment, and therefore the body IS its situations. The body isn’t just a sealed thing here, with an external situation over there, which it merely interprets. Rather, even before we think and speak, the living body is already one interaction process with its situation. The situation is not out there, nor inside. The external “things” and the subjective “entities” are derived from one single life-interaction process (which they always bring along with them). (Gendlin 2004)

This is a radical view and paradigm shift that is difficult to absorb. We are used to thinking about ourselves and the environment “around us” through the lens and language of a Cartesian world. We are imbued with philosophical assumptions idealizing objectivity and neutrality and a mechanistic relationship of mind over body. For example, we may have heard of such concepts as the “observer effect,” yet we go about living in a way that leaves context out of the equation.

For Gendlin, the making of meaning is a pluralistic, contextual, constructed process; it is changing and dynamic, not static and eternal (Mitchell, 1993). Our lived bodily sense of things is a function of our interbeing, and our capacity for felt sensing extends us beyond the confines of our delimited physical body.

Recall that I started my first piece by saying that you have within you—“beneath” your everyday practical use of language—another dimension, an inner language that is an imagistic dialogue between you and your immediate experiencing. It is you speaking to yourself (and listening to yourself) in your own code. Gendlin calls it the zigzag between the everyday use of language and the way we may actually hold our experiencing in a bodily felt way.

Gendlin says that this kind of processing exists preconceptually, beneath our everyday use of language and concepts and the assumptions we have about how the world works. In focusing, we find our own language and meaning that is in fact much more specific and precise than our usual use of language. We find language from the sea of our being.

A client with a traumatic history sits quietly, with eyes lowered, pausing to find a way to articulate why his time in boarding school (60 years ago!) is still so meaningful to him. His life before boarding school was consumed by his father’s collapse into psychosis. He is sensing into the situation regarding boarding school—without any explicit reference to his catastrophic childhood history. After a full few minutes of silence, he finds one word that fits: Life at boarding school was “manageable.” At the point that he says “manageable,” tears come to his eyes. He doesn’t know why, but his felt sense tells him, preconceptually, that “manageable” feels right.

The therapist, attuning to her client, takes in “manageable” and acknowledges it. As it resonates within her, she realizes how much is contained in this word “manageable” for her client. Then she drifts into her own felt sense of his childhood and finds ‘unmanageable’ experientially embedded in the world of her client’s meaning making, the therapist quietly offers the newly emerging word “unmanageable” without any reference to his history, and the client considers it.

A few moments later, the client’s full catastrophe of life with his father’s illness impacts him, but in a different way. His therapist has offered a word that touches into his world precisely and with great specificity. What is captured here in two words—manageable and unmanageable—is much more than the common meaning of these words. The client is referring to the experiential world of living-with and living-in his father’s psychosis, as well as to the emergent significance of what boarding school provided for him. The unmanageable and the manageable.

 Notice that the felt sensing came first. With “manageable,” he has begun to capture the world of his experiencing—the profound relief of finding himself for the first time in a world that he could handle (boarding school). Then “unmanageable” is intoned, and he resonates with the years of struggling with the catastrophe of his father’s psychosis. “Manageable” arose as a temporary wave from the sea of being. “Unmanageable” emerged from their shared sea of being.

And this shared moment deepens their therapeutic journey.

References

1. Gendlin. E. T. (1978-79). Befindlichkeit: Heidegger and the philosophy of psychology. Review of Existential Psychology & Psychiatry 16, 43-71.
2. Gendlin, E.T. (2004). Five philosophical talking points to communicate with colleagues who don’t yet know focusing. Staying in Focus. The Focusing Institute Newsletter, 4 (1), 5-8. From http://www.focusing.org/gendlin/docs/gol_2187.html
3. Madison, G., www.gregmadison.net.focusing_way_being.
4. Mitchell, Stephen A. (1993). Hope and dread in psychoanalysis. New York: Basic Books, pp. 285.

Fear can be a strong motivator. People who are afraid of living in poverty may be motivated to pursue any career option in order to avoid financial destitution. In a similar way, individuals who are afraid that they may develop specific health-related problems may work tirelessly to maintain optimal physical condition. Fear often has been linked to motivation, both positively and negatively. Until recently, however, few studies examined how fear of failure affects activity-related performance.

Jocelyn J. Bélanger of the University of Maryland sought to determine how negative feedback on specific tasks affected motivation in individuals fearful of failure (obsessive) and those who were passionate about their activity but less worried about setbacks (harmonious). In a series of experiments, Bélanger found that individuals who are passionate about achieving their goal perform differently based on their style of commitment. In particular, those with obsessive passion responded with positive motivation to negative/failure cues while those with harmonious passion saw no change in performance. In fact, the harmonious passion participants maintained the same level of performance throughout the experiments, regardless of whether they received success or failure feedback.

“Obsessive passion, associated with defensiveness, predicts performance aimed at avoiding failure, whereas harmonious passion, associated with a secure self-concept, predicts stable performance,” Bélanger said. These findings suggest that fear works as a motivator for individuals with obsessive passion. Bélanger believes that people who feel their sense of self is threatened by failure of goal attainment may unconsciously respond to that threat by increasing their performance. However, those who have harmonious passion traits are less threatened and view the feedback, positive or negative, merely as information needed to continue the process of attaining their goals. The results of this study offer valuable information that could be used for the development of goal-attainment strategies in the professional, academic, and sports arenas, and could help clinicians better understand an individual’s reaction to goal-achievement outcomes.

Reference:
Bélanger, J. J., Lafrenière, M.-A. K., Vallerand, R. J., Kruglanski, A. W. (2012). Driven by fear: The effect of success and failure information on passionate individuals’ performance. Journal of Personality and Social Psychology. Advance online publication. doi: 10.1037/a0029585

Psychologists are exposed to many stressors that could cause them to have a negative outlook on their careers. Dealing with long hours, extensive paperwork, and insurance companies can lead to burnout in the mental health field. Working with difficult clients and being privy to distressing information can also place psychologists at a high risk for work-related stress and job dissatisfaction. Although most of the existing research suggests that psychologists are relatively happy with their careers, Patricia A. Rupert, associate professor of psychology at Loyola University in Chicago, wanted to explore the nuances of job satisfaction among them.

Rupert assessed surveys from two groups of psychologists that were part of a larger survey. The first group of 129 psychologists reported high job satisfaction levels, while the second group, consisting of 102 psychologists, reported moderate satisfaction levels. Rupert’s goal was to analyze the factors that contributed to high satisfaction versus moderate satisfaction. She looked first at whether job satisfaction correlated with growth and income opportunities as well as working environments. Secondly, Rupert identified working hours, case load, therapeutic mode, administrative responsibilities, professional improvement strategies, and negative client interactions.

The review provided evidence that several variables contribute to career satisfaction for psychologists. Specifically, Rupert found that the majority of moderately satisfied psychologists had poor professional and personal life balances and felt little sense of control in their work environments. The most satisfied participants were those with a harmonious personal/professional structure and positive work experiences. In contrast to research that suggests high rates of burnout among mental health professionals as a result of the work stressors, this research demonstrates that there are multiple nuances that influence the overall job satisfaction of therapists and psychologists. “Our results provide encouraging evidence that, despite the many challenges providers face in this evolving health care environment, practicing psychologists, as a whole, remain very satisfied with their careers,” Rupert added.

Reference:
Rupert, P. A., Miller, A. O., Hartman, E. R. T., Bryant, F. B. (2012). Predictors of career satisfaction among practicing psychologists. Professional Psychology: Research and Practice. Advance online publication. doi: 10.1037/a0029420

Next Friday, August 31, 2012, GoodTherapy.org is thrilled to welcome Dr. Laurie Moore, who will present Healing Betrayal Caused by Infidelity, a FREE CE teleconference for GoodTherapy.org members available with 1.5 CE Credits. We encourage you to join us for this exciting event, so if you have not already, register today!

Working with clients who are suffering from betrayal caused by infidelity is complex, including grieving stages, posttraumatic stress (PTSD), and additional factors. This article refers to infidelity as a breach in agreed emotional and sexual monogamy. Some couples agree to open relationships or polyamory, which is a different situation. Infidelity as defined in Wikipedia is “a breach of an expectation of sexual and or emotional exclusivity.” This involves a lie and broken promise, causing feelings of intense betrayal for many people.

Infidelity has become a common problem. Some infidelity statistics state that over 50% of both men and women engage in infidelity (Journal of Marital and Family Therapy, 2012) and others say 30% to 60% (Wikipedia, 2012).

Those suffering from infidelity betrayal commonly go through Kubler Ross’s well-known stages of grief:

1. Denial: This didn’t really happen or it’s not really as upsetting as I feel it is.
2. Anger: How could you?
3. Bargaining : If only I had communicated differently, this would not have happened.
4. Depression : I feel helpless. Nothing I can do changes this discomfort.
5. Acceptance : I have been hurt and disillusioned but I am at peace with myself.

The experience of grief due to infidelity includes additional factors that are absent from grief occurring from a death. Grief due to death is felt in a finite situation that contains an end. It is understood that the one who is gone is gone from the body permanently. Grief due to a breach in trust has no finite or predictable container. The one suffering finds him- or herself in unpredictable circumstances, which often feel very dismantling and excruciatingly unsettling.

Feelings that challenge self-confidence and worth are more common to infidelity betrayal than loss alone. Death is socially expected. Infidelity is shunned. The one who is betrayed is prone to feel guilt, shame, and embarrassment because the situation remains privately hidden or is condemned by a variety of reactions when exposed.

When death is the cause of grief, a solo journey is required. When betrayal is the cause of grief, two people are involved, so the situation is more complicated. Once one is lied to, the relationship is uncertain. This person can’t tell whether he or she is being lied to or told the truth. The one experiencing this challenge is often upset again in the aftermath of the partner relationship. This is different than the one abandoned by a death whose loss cannot re-emerge in a repeating scenario.

Clients with heartache caused by infidelity and betrayal can also go through fight-or-flight syndrome:

Fight: Arguing with, controlling, or managing the person who betrayed me will solve this.

Flight: Leaving will solve this.

Once fight or flight proves useless, a person will seek comfort in other ways. By assisting this person to fully meet the helplessness, sorrow, anger, anguish, disillusionment, and heartache that has come, peace can be found.

I have found that client-centered talk therapy, hypnotherapy, eye movement desensitization and reprocessing (EMDR), and the 12-step program are all deeply valuable for clients healing from infidelity. I also use my own Success Love Now (SLN) process effectively in these situations. Here is how and why each of these methods is valuable.

Someone who is suffering from loss and feeling isolated due to the taboo nature of this loss needs to be witnessed compassionately and caringly. This in itself helps to relieve the tremendous burden one carries from feeling alone. When being accepted within the context and emotions one is truly feeling, without being corrected or judged, peace can start to return. Acknowledging your understanding and compassion for a clients’ diverse set of feelings can be a profound help to a suffering client.

Because the shock of betrayal can be extreme, disrupting normal life in many ways, EMDR assists the hurting person to digest the deep emotions that are arising. Just getting through the day becomes a challenge for people who are betrayed. EMDR makes the healing time for this upheaval much faster in many cases.

Hypnotherapy allows the person who was hurt to re-find stability, meet parts of him- or herself that were hurting before the situation occurred, heal parts of him- or herself that are hurting now, and find a new basis for equanimity that is deeper than the circumstances. Taking a client into a deep, relaxed state in which the client can bring in peaceful parts of him- or herself to help the hurting parts enables a client to rebuild self-esteem and strength.

S-Anon Twelve Steps allow people to find the value in surrender, the gift in their challenge, and the support of others enduring similar pain. Twelve Steps also help the one who was betrayed to find out if addiction was involved in the betrayal, as commonly is the case. Letting your client know that S-anon is an option can be a valuable part of her or his healing process.

SLN provides a new framework for the person to feel empowered and at ease within the undesired circumstances. Encouraging the client to focus on what his/her purpose and aim are for him- or herself and gratitude for the good that is occurring within the context of the undesired happenings is beneficial. This will bring a client out of a victim mode and into a creative mode.

Of course, if the person who was betrayed plans to stay in the relationship, couples counseling and counseling for the one who was betrayed are necessary.

When working with clients who have been betrayed due to infidelity, it is important to understand the complexity of loss, mixed with PTSD, combined with humiliation–this situation causes a long period of overwhelm and readjustment. When the client is treated with compassion, the healing can go well.

Sources:

1. Infidelity statistics. (n.d.). Retrieved August 20, 2012, from http://www.statisticbrain.com/infidelity-statistics
2. Infidelity. (n.d.) Retrieved August 20, 2012, from http://en.wikipedia.org/wiki/Infidelity

Related articles:
Cheating
Can a Couple Recover From Infidelity?
In-Depth Map for Three of the Eight SUCCESS LOVE NOW Steps

According to a new study conducted by Mary Oldham of the Department of Psychology at the University of Sheffield in the United Kingdom, offering clients their choice of appointment time and providing simple reminders are two easy yet effective ways of increasing therapy attendance. Treatment refusal (TR) and premature termination (PT) are two events that can cause harm to a client and therapist. Clients who end their treatment early or refuse treatment never receive the full benefits of therapy and often continue to struggle with persistent emotional and psychological problems. Therapists who experience high rates of PT and TR may lose confidence in their abilities to provide meaningful services to their clinical population. Both of these scenarios result in negative outcomes for the clients, providers, and the community at large. Individuals who need help but do not receive it are less productive citizens and may need to rely on social services for financial aid.

Oldham examined the most effective ways to increase treatment adherence by studying 31 trials dedicated to that very topic. The trials provided data from 4,422 individuals who had a history of TR or PT. She found that interventions designed to address PT worked as well as interventions targeted at TR. The most effective strategies were the simplest. Offering clients their choice of appointment date and time and their choice of therapist reduced TR and PT. Additionally, interventions that educated and motivated clients resulted in lower rates of PT and TR. Another factor that reduced negative treatment adherence was being diagnosed with only one problem. Individuals with multiple diagnoses tended to have lower rates of treatment adherence than those with a single diagnosis. Finally, Oldham found that reminding the clients of upcoming appointments was the easiest and the most effective method for reducing PT and TR. She hopes that her results motivate clinicians and their staff members to adopt these tactics to increase treatment retention. She added, “This review indicates that attendance is a more tractable problem than previous reviews have suggested.”

Reference:
Oldham, M., Kellett, S., Miles, E., Sheeran, P. (2012). Interventions to increase attendance at psychotherapy: A meta-analysis of randomized controlled trials. Journal of Consulting and Clinical Psychology. Advance online publication. doi: 10.1037/a0029630

Related articles:
The Healing Power of the Therapeutic Relationship
The Secret That All Clients Should Know but Few Therapists Share
Why See a Therapist When You Can Just Talk to Your Friends?

You may know someone who is depressed and not know they’re depressed. People expect someone who is depressed to cry a lot, stay in bed all day, mope, or sound like Eeyore from Winnie the Pooh. But depression isn’t always this obvious.

Some people can totally fake it. They can smile and laugh; they can act like everyone else, even while they are in excruciating emotional pain. Occasionally people who can do this end up killing themselves, and no one can believe it. People who are depressed but act like they are fine may not confide in anyone. Usually they find a way to spend time alone crying or letting down the facade and then go back to acting when they have to be with people. I’ve had clients who lived with their families and only found time to cry after everyone went to sleep, and only in the bathroom. The rest of the time they were acting like someone who wasn’t in pain. On top of the pain they already feel, acting happy is emotionally exhausting, and having this secret is isolating. So, faking it can even increase the depression.

Others funnel their pain into anger and people see them rage, abuse, shame, or react with annoyance or irritation to whatever happens around them. They may or may not themselves know they’re depressed, but others often don’t guess how much devastating emotional pain they are in. People may fear them, despise them, or dismiss them as mean. It is very difficult to feel sympathy for someone who is hurting people, and it is difficult to see their vulnerability, so their depression goes unnoticed.

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Still others are addicted to something, and the depression is obscured by the addiction. People with addictions spend most of their time and energy relating to the addiction. They plan to do it, anticipate doing it—these phases excite them and elevate their mood temporarily. Then they use whatever they are addicted to and it boosts their mood. But the thrill wears off, and they are depleted by the effects of the addiction and may also feel remorse or shame, so the depression descends on them, pulling them down like a cement jacket. They begin the cycle again to try to feel better; they plan and anticipate. Their whole life is about running from depression, but it becomes centered around the more dramatic force of addiction, and the depression can be unrecognized. I am not saying that all addicts are driven by depression—depression can also be caused by addiction. But addiction can be a form depression takes that is not easy to identify as depression. I include eating disorders in this category. I also include people who work most of their waking hours.

Depression isolates people. Whether they are hiding from the world in bed, preoccupied with an addiction, pushing people away with anger, or keeping their real thoughts and feelings inside while pretending to be okay, people with depression usually feel very alone.

Depression isolates people. Whether they are hiding from the world in bed, preoccupied with an addiction, pushing people away with anger, or keeping their real thoughts and feelings inside while pretending to be okay, people with depression usually feel very alone. Depression also has a built-in isolating fog quality that makes it very difficult to feel connected to people. Even when people feel safe to express exactly how they feel, it is very difficult for people who haven’t experienced a deep depression to understand how that feels. How can anyone who hasn’t experienced it understand a pain that is as intense as any open-heart surgery without anesthesia, with no cuts or bruises to show? How can anyone who hasn’t experienced it understand the complexity of pain that is not only unbearably intense itself but also complicated by many painful factors like the stigma of mental illness and the confusion of the fact that unlike other illnesses, depression causes behavior changes. People attribute behavior to the moral character of the person, rather than to the illness.

The pain is also complicated by the fact that depression attacks a person’s thoughts and feelings, rather than liver or lungs. Depression can cause a person to think she hates herself or is unhappy in her relationships. It can cause someone to believe everyone would be better off without him, or even that others would be better off dead. It can cause people to feel sad, angry, guilty, numb, or rageful, even when none of this is how they feel when they aren’t depressed.

So what can you do to help people you love who are depressed, if you can’t tell they’re depressed? Ask questions very kindly and listen to the answers very carefully. Empathize with their emotional pain—even if you have to guess at what it might be. Let them know you are there to listen and understand for as long as it takes, and you aren’t taking no for an answer. Of course if you aren’t trustworthy—if you judge them, or talk to others about what they tell you, or interrupt, get impatient, or misunderstand them, then it is better for them to talk to someone who can really listen without any of this. Being a reliable, trustworthy, patient, nonjudgmental listener is the best thing you can do in most cases with someone who is depressed.

A couple of caveats: I am talking about adults—children and teens require some variations. Also, addictions cloud the picture of depression and require their own, very different intervention. Nonjudgmental listening is still essential but may need to be combined with some firm boundary-setting and professional treatment for the addiction.

People who drink coffee usually crave it first think in the morning. Similarly, individuals who enjoy a glass of wine or a cocktail after a long day of work may have physiological cravings during peak happy hour times. And according to a new study conducted by Lydia A. Shrier of Harvard Medical School’s Department of Pediatrics and the Division of Adolescent/Young Adult Medicine at Boston’s Children Hospital, young adults who crave marijuana also do so at specific times of the day. Persistent cravings are associated with high levels of relapse, regardless of the substance. People who crave sweets, alcohol, cocaine, or other substances tend to report that obsessions of cravings for their substance are what preceded their most recent relapse. Some reports suggest that the majority of individuals who receive treatment for drug addiction have cravings when they abstain. This is a primary symptom of withdrawal in drug and alcohol addiction and can lead to eventual relapse. To better understand what causes or increases cravings, Shrier gathered information from 41 young adult marijuana users over a period of 2 weeks.

The participants were cued six times a day, and they recorded where they were, who they were with, their level of desire to use, the availability of marijuana, and mood. Shrier discovered that even though the participants had all been selected because of their current drug use, just over half of them reported any desire or craving for marijuana during the study period. Of those who did, location, companionship, and time were critical triggers. For instance, the participants had more cravings when they were with friends than when they were with parents. Additionally, cravings were more common in the evening than in the morning. The participants in this study may have been engaging in more social activities in the evening and more academic or job-related activities in the morning. This would explain the increase in reported cravings during evening hours, a time that is often viewed as more social. Shrier said, “The association between times of day and increased desire suggests that intervention strategies recommending alternative activities be focused on vulnerable times.” She believes that marijuana use may decrease if individuals are able to reduce their desire for marijuana, especially in situations when cravings are strongest.

Reference:
Shrier, L. A., Walls, C. E., Kendall, A. D. , Blood, E. A. (2012). The context of desire to use marijuana: Momentary assessment of young people who frequently use marijuana. Psychology of Addictive Behaviors. Advance online publication. doi: 10.1037/a0029197

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A client that drops out of therapy is one who does not complete the recommended course of treatment. Many therapeutic approaches, such as cognitive behavioral therapy, do not have a specific treatment deadline, and clients are considered dropouts when they have voluntarily stopped therapy prior to resolving the issues and symptoms that brought them there to begin with. Dropout is a serious concern for the medical community and the general population. Individuals who drop out of therapy are more likely to have future psychological complications and seek services multiple times, which places an economic burden on society. Because they do not learn adaptive coping strategies and fail to address the issues that plague them most seriously, they are likely to be less than productive in their careers, families, and communities. Additionally, therapists who experience client dropout may begin to question their ability to help clients and their own adequacy.

Understanding the factors that contribute to dropout can provide clinicians with the information they need to address the problem. Joshua K. Swift of the Department of Psychology at the University of Alaska in Anchorage wanted to explore this problem further and made it the focus of his most recent study. Swift analyzed over 650 studies that included more than 83,000 clients and looked at factors such as client age, therapy setting, therapist experience, type of therapy, issues addressed in therapy, and clinician definition of dropout.

Swift found that nearly 20% of all the clients in the studies ended their treatment early. He found that some variables, such as therapy setting, influenced the rates of dropout. He also discovered that rates of dropout were highest among the youngest participants and those seeking treatment for personality or eating problems. Swift believes that more work is needed to determine specific nuances that effect retention. He hopes efforts will be aimed at isolating psychological issues, such as anxiety or depression, and approaches, such as psychodynamic or behavioral therapy, in order to get a clearer idea of the different dimensions affecting treatment completion. Swift said, “By paying attention to these variables and making adaptations where needed, clinicians may be able to reduce rates of premature discontinuation in their work with clients.”

Reference:
Swift, J. K., Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology80.4: 547-559.

If you don’t get the right nutrients, your body won’t function to the best of its ability. Some general health conditions can be linked to nutritional deficiency, but it’s up for debate whether the same applies to specific mental health conditions. Some nutrition experts do claim that unique cases of social anxiety can actually be caused by a nutritional deficiency. In the condition several experts refer to as pyroluria, once the nutritional deficiency is taken care of, the social anxiety is relieved. Other experts are quick to dismiss the validity of this diagnosis.

Trudy Scott, a food-and-mood expert who said in an email that she has suffered from pyroluria, is a certified nutritionist, immediate past president of the National Association of Nutrition Professionals, and author of The Antianxiety Food Solution: How the Foods You Eat Can Help You Calm Your Anxious Mind, Improve Your Mood and End Cravings.

“The person experiences shyness, inner tension, and social anxiety,” Scott said in regard to symptoms of pyroluria. “Symptoms usually start in childhood and are made worse under stressful situations. The wonderful thing is that the symptoms can be completely alleviated with taking these supplements: zinc, vitamin B6, and evening primrose oil. People typically start to feel less anxious, less shy, and more social within a week. The important thing is that if you do have pyroluria, you do need to take the supplements always.”

Generally only zinc and Vitamin B6 are recommended for pyroluria, but “gamma-linolenic acid (GLA), found in evening primrose oil and borage oil, is also beneficial for those with pyroluria because its levels are often low, and supplementing with GLA improves zinc absorption,” she added. In her book about anxiety, mood, and food, she wrote a whole chapter about pyroluria.

“I am … very passionate about the subject because I have pyroluria myself and used to suffer terribly from social phobia and shyness, anxiety, unexplained fears, waking with a sense of doom and even panic attacks,” Scott said. “I have used the amazing healing powers of foods and nutrients to completely heal. I now help women find natural solutions for anxiety and other mood disorders.”

She has posted a questionnaire on her website for pyroluria. It includes a long list of symptoms, and if 15 or more items are checked on the list, it is likely a person has pyroluria: http://www.everywomanover29.com/blog/pyroluria-questionnaire-from-the-antianxiety-food-solution/

She said that in research studies, pyroluria is also called “the mauve factor.” “Much of what we know about pyroluria is based on the work of Humphrey Osmond, Abram Hoffer, and Carl Pfeiffer,” Scott said. “Much of the original work was done with schizophrenic patients in psychiatric hospital settings. Although pyroluria was first identified in the 1960s, the medical and mental health communities have been slow to recognize it, and many mental health practitioners and physicians remain unfamiliar with this condition.”

She said she learned about the condition mainly from reading the following books:
The Mood Cure by Julia Ross
Depression-Free Naturally by Joan Mathews-Larson
Nutrition and Mental Illness (1988) by Carl Pfeiffer

Her own book goes into the specific details and biological/chemical/genetic aspects of pyroluria. In her book, she cites research prevalence rates from Joan Mathews-Larson, the author of Depression-Free Naturally. Pyroluria is thought to exist in “11 percent of the healthy population” and “40 percent of adults with psychiatric disorders,” according to Scott’s book. For people with alcohol addiction, pyroluria is thought to have a 40% prevalence rate. However, the prevalence rates do depend on the source. In her own experience as a nutritionist, Scott said about 80% of her clients who have moderate to severe anxiety have symptoms associated with pyroluria.

She added that stress can be a major factor for what age pyroluria develops and that it is a genetic condition that seems to affect more women than men. In addition, people who have pyroluria tend to also have gluten sensitivity, especially if they also are dealing with other issues like depression, anxiety, autism, alcoholism, bipolar disorder, and schizophrenia, according to the book. People with pyroluria may also have digestive problems, and they need to make sure to balance out an increased Vitamin B intake with a higher intake of magnesium.

In the book The Mood Cure by Julia Ross, the author includes a discussion of the prevalence, testing, and treatment of pyroluria, as well as a checklist similar to that offered by Trudy Scott. Ross states that the questionnaire was developed by Dr. Carl Pfeiffer, a clinician and researcher. He wrote the book Nutrition and Mental Illness: An Orthomolecular Approach to Balancing Body Chemistry in 1988.

Ross states in her book that pyroluria is fairly uncommon in the general public, but in certain groups of people (like those who have experienced alcohol addiction), it is more common. “I am just getting familiar with this condition, but I can see that it is an important one for certain people, affecting stress levels and mood generally and preventing full response to nutrient therapy until it is addressed,” Ross wrote in her book.

There are a plethora of articles dedicated to nutrition, diet, and mental health in general, as well as multiple research studies suggesting that certain mental health issues can be improved through natural supplements and a healthy overall diet. “Notably, essential vitamins, minerals, and omega-3 fatty acids are often deficient in the general population in America and other developed countries and are exceptionally deficient in patients suffering from mental disorders,” according to an abstract from a research study in Nutrition Journal. “Studies have shown that daily supplements of vital nutrients often effectively reduce patients’ symptoms.”

Another abstract from a research article in the journal Alternative Therapies in Health and Medicine concludes the following: “Many patients will benefit from the use of specific dietary supplements, such as a multivitamin-mineral high in B vitamins and omega-3 fatty acid,” according to the abstract. “And no matter what the underlying cause of the mood disorder, patients should be counseled about the relationship between food and mood, for the evidence now substantiates what laypeople and medical professionals have long known intuitively: the way we eat affects the way we feel.”

The research, authored by Tieraona Low Dog, director of the fellowship at Arizona Center for Integrative Medicine at University of Arizona, added in the research abstract that the healthiest diet for improving mental health is a “low-glycemic, modified Mediterranean diet rich in fruits, vegetables, whole grains, and seafood (if not vegetarian) and low in processed, refined foods.”

Other experts remain unaware of the condition and are skeptical of its legitimacy. Scott Carroll, a psychiatrist with dual board certifications in adult and child and adolescent psychiatry, said in an email that he is not accustomed to pyroluria and had to look it up on Google to find out what it was.

“Once I saw that it is connected to orthomolecular psychiatry, which I have heard of, I knew it was in the pseudoscience realm,” said Carroll, who is also an assistant professor at the University of New Mexico School of Medicine. “Not surprisingly, it claims to be the cause of a number of unrelated psychiatric disorders, which is typical of pseudoscience disorders. Like so many ‘cure-alls,’ it sounds plausible, but there is no scientific basis to it, and it allows dubious practitioners to prey on desperate, suffering people.”

He said there are certain cases where nutrition can play a part in mood and mental disorders. “Inadequate amounts of Omega 3 fatty acids, especially from fish or krill oil, have been shown to affect mood and anxiety in a broad way of which social anxiety can be a part,” Carroll said. “Also, low folate, low Vitamin D, and low B12 have all been associated with negative effects on mood and anxiety.”

“However, in people with low folate, it is more often a case of a genetic inability to transport the folate molecule into the brain rather than a low blood level,” he added. “In those cases, which often present with chronic depression and anxiety that has never responded to antidepressants, there are folate precursors that are more lipophilic and can diffuse into the brain without use of a transport mechanism.”

Nerina Garcia-Arcement, a licensed clinical psychologist and clinical assistant professor at the NYU School of Medicine, said in an email that she didn’t study pyroluria in school and hasn’t read about it in any research studies after graduating from her doctorate program.

“Based on current knowledge it does not appear to be a legitimate health condition,” Garcia-Arcement said. “Further research is required to further explore and understand whether social anxiety or any other mental health condition could be related to improper synthesis in the blood.  Although this theory seems appealing, being able to ‘cure’ a mental disorder with vitamins or supplements … is unlikely.”

“Causes of social anxiety that have been substantiated by research include chemical imbalances in the brain (i.e., serotonin, a neurotransmitter), inherited traits (genetic and through observing anxious family members), negative life events or experiences, and an overactive amygdala (a part of the brain that controls emotions, including fear response),” she added.

She said that good nutrition is important for overall health, but it’s not necessarily linked to mental disorders. “In my experience, the social anxiety could be traced to other causes, not nutritional deficiencies,” Garcia-Arcement said. “Having a healthy and balanced diet is overall beneficial, but it won’t cure social anxiety or a mood disorder. I am more likely to recommend my clients get enough sun exposure to improve their moods (seasonal affective disorder) than recommend diet changes.”

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