Your therapist, Ron Swanson?

Men often fear that therapy is stacked against them.  Whether it is couple, family or individual therapy, they think that they are entering a domain where their skills and strengths will be counted as liabilities and they will be asked to do things that aren't just difficult or scary but unbecoming.  That isn't a man problem.  That's a therapy problem.  I was talking recently with another male therapist, Dr. Darrell Johnson, a friend and mentor.  I mentioned this campaign to him... (Okay, it isn't Ron Swanson but a Ron Swanson knock-off.)

It is from the Office of Suicide Prevention of the Colorado Department of Public Health and Environment.  It's geared at connecting with men, particularly working-age 25-54 men who are twice as likely to commit suicide as any other age group according to the white paper that was used to develop the Mantherapy campaign (US stats).  Darrell and I talked about the idea that men are typically more resistant to therapy (part of what accounts for their higher suicide rates than women).  I joked that soon it would be possible for therapists to use cookies to give different design templates to their websites so that women and men would be presented with different web sites that are gender specific since too much "feelings" language might be off-putting for men, essentially presenting themselves as Rick Mahogany when men click through.  But the Colorado campaign doesn't seem to have been a raging success despite the high production values.  The Richard Mahogany video that has the most views on YouTube is at around 8,000.  Maybe those are 8,000 saved lives and if so, great, but I don't imagine that therapy's problem with men has been touched much.  I think the character seems inauthentic, not just playfully unreal, and for men or women authenticity in therapy is important. 

There were a few things in the white paper that I thought were really interesting for therapists to consider about working with men, things that hadn't occurred to me despite having worked with boys and men a lot.  One is the value men often place on fixing something themselves and how to make therapy an exercise in 'solving it myself (or ourselves) with help'.  One man said to the researchers of the white paper, "Show me how to stitch up my own wound like Rambo."  Okay, that's some pretty serious hyper-masculinity but the point is that therapy can benefit from emphasizing the client's efficacy in problem-solving with the therapist as trusted assistant. 

The other thing that I thought was really wonderful was the importance some men place on giving back.  I was in Hawaii last year.  A companion and I went kayaking.  We visited a small island and had a great time but when we went to get back in our kayak, we got hit by several waves in succession and my companion got knocked over in the surf and couldn't get up.  I watched, barely able to keep myself afloat trapped on the other side of the kayak thinking I might very well see this strong, capable person drown before my eyes in three and half feet of water.  But before that could happen two kayakers (much more capable than us) grabbed our kayak and my companion, hoisting him out of the water.  I thanked them.  They said, "That's what we do."  They viewed helping as part and parcel of who they were.  I, on the other hand, felt grateful but unsatisfied as they paddled away.  I couldn't pay back the debt I owed them.  Therapy is a uni-directional process as far as help goes; codes of ethics forbid outside relationships so it is very hard for a client to pay his debt with his skills through labour exchange or barter.  I never thought about how important it can be for some clients to be able to show their competency and mastery to a therapist by doing meaningful work or sharing their own products, to give help for help received, and that men might feel that more acutely.  The report points out how central the idea of repaying a debt is to AA, for instance.  Now I am considering requiring clients in some circumstances to agree to pay part of the cost of therapy by "paying forward" to others using their own strengths and capabilities (see the Milwaukee African Violet Queen).  Ron, would like the idea of paying off your therapy by carving duck decoys with kids in an after-school program? 

"I'm a a bit fearful that we are verging on what I call 'feelings territory.'"

Radical Acceptance. Do microbes or the zodiac make you depressed?

There was a neat piece on NPR today about gut flora and mental illness which postulated a link between the health of one's inner beasties and one's mind. 


But before you run out and buy an industrial tub of yogurt and a tempeh starter kit, know that something as immutable as your birth month also impacts your risk for many diseases including several mental illnesses. From the Atlantic...

Many contemporary scientists are loath to admit to anything resembling astrology. “It seems absurd that the month you are born/conceived can affect your future life chances,” write neuroscientists Russell G. Foster and Till Roenneberg in a 2008 study. They then go on to then point out no fewer than 24 different health disorders connected to season of birth, and ultimately admit “despite human isolation from season changes in temperature, food, and photoperiod in the industrialized nations, the seasons still appear to have a small, but significant impact upon when individuals are born and many aspects of health.”

Marsha Linehan, the psychologist who developed Dialectic Behavioral Therapy, used for treating substance abuse and borderline personality disorder, among other mental illnesses, talks about the importance radical acceptance

So what’s Radical Acceptance? What do I mean by the word ‘radical’? Radical means complete and total. It’s when you accept something from the depths of your soul. When you accept it in your mind, in your heart, and even with your body. It’s total and complete.

Linehan does not mean that we accept our brokenness, our faults, our failings and stay there.  As Carl Rogers said in On Becoming a Person, "The curious paradox is that when I accept myself just as I am, then I can change."  Linehan, in a very courageous move, recently talked about her own experiences of mental illness, including many attempts at suicide and her recovery from it which was prompted by a religious vision which included a profound feeling of self-acceptance. 

“I decided to get supersuicidal people, the very worst cases, because I figured these are the most miserable people in the world — they think they’re evil, that they’re bad, bad, bad — and I understood that they weren’t,” she said. “I understood their suffering because I’d been there, in hell, with no idea how to get out.”

In particular she chose to treat people with a diagnosis that she would have given her young self: borderline personality disorder, a poorly understood condition characterized by neediness, outbursts and self-destructive urges, often leading to cutting or burning. In therapy, borderline patients can be terrors — manipulative, hostile, sometimes ominously mute, and notorious for storming out threatening suicide.

Dr. Linehan found that the tension of acceptance could at least keep people in the room: patients accept who they are, that they feel the mental squalls of rage, emptiness and anxiety far more intensely than most people do. In turn, the therapist accepts that given all this, cutting, burning and suicide attempts make some sense.


The idea of radical acceptance, even for the purpose of change, seems profoundly lacking in our thinking about health.  In North America, at any rate, we are meant to view ourselves as our own greatest work of art, as perfectible. 

I am in the change business.  If diet can help people with mental illness then I want to know about it.  But I also believe that sometimes a hyper-developed sense of agency, which is pretty much the modern condition, oddly, keeps people stuck.  Sometimes we have to accept even our darkest feelings, "meet them at the door, laughing, and invite them in" before we can learn what they came to teach us.

The Guest House

This being human is a guest house.
Every morning a new arrival.

A joy, a depression, a meanness,
some momentary awareness comes
as an unexpected visitor.

Welcome and entertain them all!
Even if they are a crowd of sorrows,
who violently sweep your house
empty of its furniture,
still, treat each guest honorably.
He may be clearing you out
for some new delight.

The dark thought, the shame, the malice.
meet them at the door laughing and invite them in.

Be grateful for whatever comes.
because each has been sent
as a guide from beyond.

-- Jelaluddin Rumi,
    translation by Coleman Barks

Poverty, Families and Mental Health

A great blog post called "5 Stereotypes about poor families and education" in the Washington Post a few days ago quoted extensively from a book by Paul C. Gorski titled Reaching and Teaching Students in Poverty.  The excerpt offers a lot of research to dispel some common negative myths about poor people that impact the way schools and educators tend to approach them and how that impacts their experience of school; poor people don't value education, poor people are lazy, poor people are more likely to be substance abusers, poor people are linguistically impoverished and -- the biggy -- poor people are ineffective parents.  

This is a tricky subject because some things about poverty can have an impact on kids' school performance as well as physical and mental health.  Well-intentioned governments and schools generally want to respond to those negative effects in order to ensure that kids growing up in poverty have the best opportunities they can (or say they do, at any rate).  But as Gorski points out fuzzy thinking about how exactly poverty does or doesn't impact kids and families can be deleterious on a classroom or a public policy level.  

Stereotypes can make us unnecessarily afraid or accusatory of our own students, including our most disenfranchised students, not to mention their families. They can misguide us into expressing low expectations for poor youth and their families or to blame them for very the ways in which the barriers they face impede their abilities to engage with schools the way some of us might engage with schools.

The WP post doesn't discuss the tings we do know about the ways in which poverty (or things that are highly correlated with it) impact kids and families though I am assuming the book will do just that.  Paul Tough wrote a great piece a few years ago for the New Yorker called "The Poverty Clinic."  The article looked at a medical clinic which used the findings of the Kaiser Permanente Adverse Childhood Experiences study to treat poor families.  The upshot of the study and Tough's article is that childhood trauma is a huge risk factor for both physical and psychological illness both in childhood and in later life.  Since poor people are much less well insulated against trauma, they are, on average, at greater risk.  Trauma both intensity and frequency are a great predictor of difficulty in school and later life, but not poverty per se.  

The other piece of really interesting research about differences in family style between poor and middle-class families and how that impacts education that Gorski alludes to in the extract, but that doesn't get a lot of play is Anette Lareau's distinction between middle-class "concerted cultivation" versus poor and working class "accomplishment of natural growth."  While not contradicting Gorski, Lareau does portray the poor/working class families in her study as less organized around talk and less at ease with certain kinds of parent involvement (Gorski says that poor families may want to be involved but may feel turned-off by the ways schools invite participation, which tends to be geared towards middle-class parents). 

Finally, one of the things that Gorski doesn't address in the blog post is varieties of poverty.  Because poverty itself is not the cause of academic failure or ill health or family dysfunction, but certain things that are often associated with poverty are risk factors for all those things, we should look at and think about the way differences between poverties impact those factors; for example, not every poor community increases exposure to trauma for kids.  Some poor communities are better at insulating their young against trauma than some wealthier communities.

Who delivers mental health care?

Dr. Suzanne Koven has just written a great blog post that is required reading for anyone who cares about mental health care in North America, called "Should Mental Health Care be a Primary-Care Doctor's Job?"  She points out the degree to which medical mental health care has been downloaded to primary care docs who may or may not feel up to the task. 

I’m comfortable helping people get through life’s more common emotional challenges, like divorce, retirement, disappointing children. If you’re hearing voices, or if you walk into my office and announce that you’ve decided to kill yourself, as someone did not long ago, I know exactly what to do: escort you to a psychiatrist. But what about the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder? Or the businesswoman whose therapist told her to see me about starting an antidepressant? Or the civil servant trying to shake his Oxycontin addiction? They’ve all asked me to treat them because they don’t want or can’t easily access psychiatric care.

Here in Quebec, the recent Bill 21, which regulates the act of psychotherapy, gives physicians automatic access to the title of psychotherapist though their training in mental illness and mental health may be limited depending on what their experience in medical school and residency was.  While there are many doctors who are great psychotherapists and who have taken the time to get trained, becoming a doctor involves training in diagnosis of mental illness and some psycho-pharmacology and only a cursory understanding of different forms of psychotherapy.  (The purpose of Bill 21 is to protect the public by ensuring a minimum of training for psychotherapists.  It has serious ramifications for people who use mental health services but remains largely unexamined in French or in English media). 

Dr. Koven points out that fewer medical students are going into psychiatry in the US (sorry, I can't give Canadian stats) so both the public and general physicians have less access to doctors who specialize in mental health.  I also have seen that there is a feeling among patients that psychiatrists are pill-pushers while a GP may be more accessible and take the time to know a patient better ad this may make people even more likely to rely on generalists.  (My experience of psychiatrists has actually been that they are more likely to prescribe talk therapy with or without medication than GPs, but that is very impressionistic.) 

Recent changes to the way health care is delivered in Quebec make it harder to access a psychiatrist directly through the public system.  In order to see a psychiatrist you must first go to a public health clinic, a CLSC, rather than go to a psychiatrist in the public system directly (except for emergencies).  This can be good because people can be seen by a social worker or psychologist at a CLSC which may be what they need, but it re-enforces the model of psychiatry being practiced only with the very seriously mentally ill or the very wealthy.  Finding a psychiatrist to really follow someone with obsessive compulsive disorder, for example, to ensure that medication is appropriate and effective and to consult with the therapist, whether s/he is a GP or a social worker, is very hard.  It may account for why fewer people want to go into the field, too.  After all, who wants to go into a medical specialty where you are supposed to fathom the mysteries of the human heart and human relationships but are unable to form relationships with patients because you see them on an assembly line, and on top of that, you will mostly see people whose illnesses can at best be managed but are without cure? 

The label of "sex addict" and sex negativity.

Dr. Marty Klein makes a really fascinating argument about the term "sex addiction" in an article in "The Humanist"; that that label  is a way for people not to have to reckon with the conflict between their desire for what certain kinds of sex gives them and the consequences of acting out their desires.    

New patients tell me all the time how they can’t keep from doing self-destructive sexual things; still, I see no sex addiction. Instead, I see people regretting the sexual choices they make, often denying that these are decisions. I see people wanting to change, but not wanting to give up what makes them feel alive or young or loved or adequate; wanting the advantages of changing, but not wanting to give up what makes them feel they’re better or sexier or naughtier than other people. Most importantly, I see people wanting to stop doing what makes them feel powerful, attractive, or loved, but since they don’t want to stop feeling powerful, attractive or loved, they can’t seem to stop the repetitive sex clumsily designed to create those feelings.

He goes on to argue that this condition of wanting certain things sexually and not wanting to take responsibility for the consequences is made more troublesome by a sex-negative culture which punishes people for wanting any kind of sex or relationship that isn't socially sanctioned. 

...the diagnosis of sex addiction is in many ways a diagnosis of discomfort with one’s own sexuality, or of being at odds with cultural definitions of normal sex, and struggling with that contrast...

The culture today communicates two out-of-sync messages about sex pretty strongly; one, that we should be ecstatically sexually fulfilled all the time and two, that non-socially-sanctioned sex is highly dangerous and scary (gay, non-monogamous, kinky).  And there is the meta-message which says that commenting on the discrepancy between these two messages -- "Everybody may not be sexually and romantically fulfilled with one, opposite-sex partner for the rest of their lives" -- is not allowed.  A million romcoms have taught us that everyone will end up in a monogamous, same-sex couple and will never feel the desire to masturbate or fantasize about other people or look at pornography because they are so fulfilled.  According to Marty Klein, the label "sex addiction" leaves us stuck in that double bind rather than helping us step out of it. 

Emotional Intelligence

Great piece about the benefits and pitfalls of teaching emotional intelligence.  I kept asking myself, "what about the role of parents?"  Schools are asked to do an awful lot and parents modelling emotional intelligence for kids is extremely powerful and needs to be supported.  Nevertheless a great read by Jennifer Kahn in the NYTM.   

Depending on our personalities, and how we’re raised, the ability to reframe may or may not come easily. Richard Davidson, a neuroscientist at the University of Wisconsin-Madison, notes that while one child may stay rattled by an event for days or weeks, another child may rebound within hours. (Neurotic people tend to recover more slowly.) In theory, at least, social-emotional training can establish neurological pathways that make a child less vulnerable to anxiety and quicker to recover from unhappy experiences. One study found that preschoolers who had even a single year of a social-emotional learning program continued to perform better two years after they left the program; they weren’t as physically aggressive, and they internalized less anxiety and stress than children who hadn’t participated in the program.

It may also make children smarter. Davidson notes that because social-emotional training develops the prefrontal cortex, it can also enhance academically important skills like impulse control, abstract reasoning, long-term planning and working memory. Though it’s not clear how significant this effect is, a 2011 meta-analysis found that K-12 students who received social-emotional instruction scored an average of 11 percentile points higher on standardized achievement tests. A similar study found a nearly 20 percent decrease in violent or delinquent behavior.