Extinction is good for you.

Why do most people bounce back from a traumatic experience after a few weeks or months when others struggle for years with anxiety or PTSD?  What protects some people from the effects of trauma?  What can we do to promote resiliency from trauma? The answer might have to do with 'extinction.'

In psychological parlance 'extinction' can be a good thing.  Extinction means 'unlearning' a conditioned response.  Remember Pavlov and his dogs?  Ring the bell and feed the dogs, eventually the dogs will salivate at the sound of the bell.  That is conditioning.  Well, after a while if they get their food without the bell, the conditioning wears off and the dogs don't salivate anymore, and that is extinction learning; learning that something that was once associated with an experience may not be connected to that experience.

Maladaptive trauma responses, including disorders like PTSD, probably have something to do with conditioned response.  People with PTSD may associate all sorts of things with the original trauma so they are triggered to re-experience the trauma by a smell or sound, or they seek to avoid being in situations which call to mind the trauma, even though objectively those circumstances aren't dangerous.  Richard Bryant, a researcher into responses to trauma, has done a really smart prospective study that suggests that a person's pre-trauma capacity for 'extinction learning', his or her ability to 'unlearn' the connection between a negative experience and the circumstances surrounding it, is very predictive of the ability to bounce back from trauma.  He describes it at about 31 minutes of this video.  The whole video is interesting but this piece is only about four minutes.  

Here's the study for those of you interested in checking it out.  Bryant doesn't talk about what predisposes people to be better or worse 'extinction learners.'  Some of it probably has to do with genetic factors.  I would be curious to know to what degree cognitive flexibility, the ability to change one's ideas about the world, correlates with extinction learning.  Cognitive flexibility can be enhanced by all sorts of things.  If you want to test your cognitive flexibility, some of these tests, like the Stroop test, are good measures.  In the interests of full disclosure I did pretty badly on the Stroop test.  Not sure what that means for my chance of extinction.  

Too much social awareness and too little; Autism and Borderline

I work with a lot of kids with Autism Spectrum Disorders (ASD) in the context of family therapy.  One client of mine will sometimes say something pretty innocuous and then suddenly get worried.  He looks at me anxiously, trying to read my expression.  He asks me “Are you mad? Did I do something wrong?”  He feels like the world is filled with unexpected land-mines. Social situations seem to follow weird rules that everyone but him knows intuitively.  People often get angry at him for mysterious reasons, so I might as well.  This is pretty common for people with ASDs.  They have a tougher time with something called “mentalizing,” which means understanding that other people have different mental states -- knowledge, thoughts and feelings -- than themselves. (I wrote in a previous piece about Theory of Mind, which is very similar to mentalizing. There is a great video demonstrating what this looks like in kids.)  People with ASDs can find it really hard to figure out what those other mental states might be, based on cues that most of us read without thinking about it much like tone of voice, facial expression or posture. 

Some neuroscientists think that the neurology of people with ASDs is different from other people, that they may have fewer 'mirror neurons,' neurons that are thought to help with connecting to another's experiences on a totally unconscious, physiological basis.  Prominent among these is VS Ramachandran, who, in addition to being one of the foremost neuroscientists today, and an interesting philosophical mind, has maybe the coolest accent of anyone I have ever heard speak.

Mirror neurons are pretty spectacular according to Ramachandran, but others dissent.  One of the biggest doses of cold rain on the mirror neuron parade is the fact that we lack clear evidence that they exist in humans.   

Whatever the reason, people with ASDs do really poorly on a relatively new test for reading social cues called the Movie for the Assessment of Social Cognition or MASC. MASC is a really neat psychology test that lacks the flash of fMRIs but actually quantifies people's understanding of social situations very well.  The subject is shown a video of a social situation and asked a series of true or false questions about the mental states of the people in the video.  What is really interesting to me is what researchers have found out about people with Borderline Personality Disorder (BPD) when they take the MASC test.  

Among other things, BPD is characterized by very conflictual interpersonal relationships.  This great animation outlines some of the things that go on for people with BPD and the criteria for diagnosis.  

People with BPD do very poorly on the MASC test but for almost exactly the opposite reason than people with ASDs. While people with ASDs tend to mentalize poorly -- that is to consider and evaluate correctly the inner experiences of the people in the video -- people with BPD tend to “hypermentalize.”  They are very tuned in to the mental states of others, perhaps too tuned in.  Some research indicates that people with BPD may actually be better at correctly “reading” other people's emotional states based on limited information than non-BPD people.  But like many people with ASD, people with BPD can find the social environment confusing and overwhelming, not because they have too little information to understand what is happening, but too much.  I suspect they are also lopsided because their hypermentalizing often tends towards the negative; that is they read negative cues very clearly but positive cues get less focus.  

Think about how many quick, frustrated glances or disapproving sighs a person might encounter in the social landscape in a typical afternoon.  People who don't have BPD may register them almost unconsciously, as subtle social cues to "hurry up", "hold on a minute" or "give me some space".  Those things help most of us adjust our social behaviour.  But people with BPD experience each negative micro-expression like an angry, screaming tirade leaving them as bewildered as the young boy with ASD asking, “what did I do wrong?”

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.””

— http://www.theatlantic.com/health/archive/2013/11/your-zodiac-sign-your-health/281358/

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. ”

— http://www.dbtselfhelp.com/html/radical_acceptance_part_1.html

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.

NYT http://www.nytimes.com/2011/06/23/health/23lives.html?pagewanted=3&_r=0

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

Priming and Prejudice

If you have never done so, watch this video, then meet me down below and we'll talk. 

Pretty cool, right.  So aside from being a neat little feature of how our minds work what does this have to do with families and couples?  This experiment is a great way of demonstrating "priming".  We are focused on what we are primed to experience and miss what we aren't primed to see.  In the case above we are primed to see basketballs not gorillas.  Having our limited attention focused on the basketball means that we have less attention for noticing the bizarre detail of the gorilla.      

This has very real implications for human interactions.  Confirmation bias is a kind of priming in which we give great weight to cases that confirm an idea we have about the world and discount cases that don't confirm our idea.  If I believe that tall people are untrustworthy, I will see examples of tall people behaving in untrustworthy ways and view them as representative, but I will tend to discount examples of tall people behaving altruistically.  This explains why more pernicious prejudices like race prejudices become re-enforced and are so hard to break.  Here's a great example of racial priming. 

These aren't bad people, but both black and white people are primed to see a young, white guy as a parks employee and a young, black guy as a thief.  If you want to check out your own priming on race and a variety of other social factors, check out ProjectImplicit and try one of their tests that allows you to assess how your implicit, unexpressed values line up with your expressed values. 

Priming happens on a micro level in a couple or family, too.  When the relationship in a couple or between a parent and child becomes fraught with bad feelings, a person becomes primed to see the negative qualities or behavior they expect and -- like with the gorilla -- may completely miss unexpected, positive moments for which they are not primed.

In "How to Talk so Kids Will Listen and How to Listen so Kids Will Talk," Elaine Mazlish and Adele Faber talk about "catching" kids being good; noticing and calling out when a kid does the right thing.  They present it as a way for kids to feel that they can succeed, which is important.  But just as important is what "catching" a kid doing good does for a parent.  It re-primes him or her. 

If you find yourself counting basketball passes all the time with your spouse or kid -- watching for them to do the expected and annoying thing -- re-prime yourself.  Look for good, look for gorillas.  They're more common than you think.  

Do you love schools? The energy of teens? Teachers who care? British Accents?

I am loving The School (Educating Essex).  Nothing I have ever seen captures what schools feel like, for good and bad.  This is a perfect rebuttal to most depictions of teens and teachers on TV.  You must stick around for "Am I amused?" at 9:30. I am waiting to see a social worker/school counselor. 

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.

Most disasterous parent-child sex talk ever?

Talking with kids about sex can be tough for parents even when we think we're ready for it.  Julia Sweeney gives the best (or worst) account of having the sex talk with a child ever. 

I actually think listening to this is a great way to prepare yourself for talking with kids about sex.  Once the topic comes up, kids, especially young kids may ask all sorts of questions that we might never expect, but that are pretty obvious if you take some time to consider it from their perspective.  After all, everything about sex seems pretty unlikely to an eight year old. 

Also her account is loving and humorous and sort of makes the point that we all make mistakes when we talk about sex with kids, and if we have a loving relationship with our kids, we will get lots of chances to go back and talk more.  The importance of having an ongoing dialogue with your kids about sex was demonstrated by a 2008 study done by researchers at Ste. Justine hospital, here in Montreal.  That study found that while parents assumed their adolescents looked to friends and celebrities to shape their attitudes towards sex, teens (the study was of teenage girls) report that it is their parents who are their most significant role models, but that despite that they do not feel comfortable talking with them about sexuality.  So take heart, your child will look to you more than peers or the popular culture for her ideas about sexuality but you should start laying the groundwork for conversations about sex early.