Is Multiple Personality Disorder Real? - The Response

In April 2011, I wrote a post called "Is Multiple Personality Disorder Real?"   It is the third most popular post I've written here and certainly generates the most polarized comments / emails.   While I encourage you to read the original if you're interested in the following response, the gist is that Dissociative Identity Disorder (DID) - which was once called Multiple Personality Disorder (MPD) -  could potentially be Borderline Personality Disorder peppered with some delusional qualities. 

One very interesting & thought-provoking comment from 9/25/2012 inspired me to write this (belated) response.

Comment:
This blog post reads like it was written by someone who's never read a book or an article on DID, who's never worked with people with DID, who's just making wild assumptions. There are people dx'ed with both DID and BPD. There are also people dx'ed with BPD who don't have BPD at all, but have DID. You also make no mention of PTSD which all DID patients have, but not all BPD patients have. Look at somewhere that actually treats DID and PTSD specifically like the trauma Ward at Sheppard Pratt. But your theories seem a little half cocked.

This is my response:
Fair enough - I've admittedly not had much experience with DID - however; allow me a belated response (apologies for the delay).

First, I was generally very impressed when visiting Sheppard Pratt in May 2012.  My impression was that they offer top-of-the-line treatment.

As for DID though, I have read a bit about it.  For a summary, I would see Prof. Rich McNally's book "What is Mental Illness?" from 2011, copyright, President and Fellows at Harvard College.

In short, the book explains right after the book Sybil was published, "from near-nonexistence, MPD spread throughout North America, with the number of diagnosed cases soaring to 50,0000."  And then the "epidemic of MPD ended abruptly" because a study showing that asking leading questions is more likely to "create false memories than to recover them" (Ceci & Loftus, 1994).

The book also reads "MPD therapists inadvertently undermined the credibility of their own field when they began helping patients recall alleged memories of satanic ritual abuse" (McNally, Remembering Trauma). And that the FBI failed to uncover any physical evidence of these types of abuses (Lanning, 1992).

Interestingly enough, stories about abuse and trauma Sybil herself endured were also unfounded.  What seems to be the (even more disturbing) truth is that Sybil sought treatment with Dr. Cornelia Wilbur, who appears to have implanted false memories with the (unwitting) use of leading questions and social positive reinforcement.  When treatment tapes of the sessions between Wilbur and Sybil were researched, convincing evidence of this was revealed.  The book also states "indeed, Sybil admitted in writing to Wilbur that she had manufactured her MPD symptoms."

As such, while the symptoms of DID are in the DSM-IV, this does not mean that the disorder is not socially constructed, at least for the vast majority of cases.

[By the way, I'm not saying that there was never an organic (non-socially constructed) case of DID out there.  Saying that 100% of DID cases are socially constructed is a bit like meeting 50,000 Elvis impersonators in the year 2013 and then concluding Elvis Presley never existed. It stands though, that the ratio of hypothetical Elvis impersonators to Elvis Presley himself is still 50,000:1.] 

If someone presents with a case of DID, undoubtedly the situation is severe; however, I would argue that give the citations provided above, the idea  that the etiology (or cause) of the disorder is organic seems dubious at best.  Of course, understanding etiology is extremely important for treatment - especially if the treatment itself is indicated as a possible cause of the disorder, as was in the case of Dr. Cornelia Wilbur and Sybil.

For the cases that are not organic, but socially-constructed - which the evidence seems to suggest is most of them - perhaps a BPD identity disturbance / delusional quality may be present.  That's all.

The Difference between Thoughts and Voices

Short note: For psychologists, I'm sure this post isn't incredibly enlightening.  It is simply intended to be informative for a general audience.  As I learn more about working with schizophrenia, I thought I'd share my experiences here.

The Difference between Thoughts and Voices

Thoughts:
- You can't hear thoughts
- Thoughts can be about anything
- You've had thoughts your whole life
- Thoughts don't have a gender
- You can try to focus your thoughts on one topic (e.g. when problem solving a task)

Voices:
- You can hear voices
- It is someone else's voice
- There is typically a gender of the voice
- The volume of the voice can be loud or soft
- The voices seem to mostly tell you to do specific things / make commands / be judgmental
- Voices can be suggestive
- Voices can narrate what you're doing
- It feels like you can't control when the voices come or the content of what they're saying
- You didn't always have voices, but they started later in life

Related to this last bullet point, it seems important to connect the onset of the voices with mental illness.  First, not everyone is fully aware or willing to admit mental illness, but talking about the onset of voices is a good way to get your foot in the door.  It also seems useful to draw parallels between when the voices started and stress levels at the time.  This provides further evidence that the voices are part of a mental illness and not "real."  In session discussion should also focus on how much patients believe the content of the voices and how compelled they feel to act on the voice's commands.  I always make it a point to emphasize that one could have a voice without believing it was true or needed to be acted upon.

In short, a therapist can teach patients to that voices are part of mental illness, one does not have to believe what the voice is saying, and they don't need to act on a command from a voice.

P.S. If anyone has questions or even some good additions to add to the list, please feel free to leave a comment.

Recruiting for an Eating Disorder Study

If you ever had an eating disorder, you can participate in research at Mt. Sinai in NYC for up to $750. We're also looking for controls, so if you've never had an eating disorder and are interested, let us know too!

Contact: Sydney.Shope@mssm.edu. Thanks!

Dysregulation of the Anxiety System & Bipolar

As per usual, I'm trying to focus on work now, but get completely derailed with a thought I feel the need (compulsively) to blog about.

I saw that someone somewhere on a remote part of the globe was reading a post I wrote a while ago postulating that fear was the first emotion to appear on the evolutionary scene. I decided to revisit it. Here's the link: http://taradeliberto.blogspot.com/2011/03/first-emotion-fear.html

While rereading the post, I had the thought that bipolar disorder may result from a dysregulation of the anxiety system. Long story short, in depression, we see that prolonged anxiety can lead to chronic sadness (via chronic exposure to cortisol and what I conceptualize as over-use of the hypothalamus-pituitary-adrenal axis). We can also see that exhilaration and anxiety are quite similar emotions. Combining these two thoughts, perhaps bipolar disorder could arise out of the dysregulation of a primary anxiety system - sometimes leading to chronic sadness and other times leading to chronic exhilaration.

Interestingly, bipolar is pretty hereditary, but like most psychiatric disorders, it is thought to be prompted by none other than stress, perhaps indicating that it stems directly from some a dysregulation of the anxiety system.

I realize that this is being done already, but the fact that stress / anxiety can trigger the onset of disorders might be a signal to look at how anxiety relates to the course of the illness (with the consideration that anxiety could be the ultimate primary emotion). In this case, while stress may trigger bipolar disorder, lack of ability to regulate anxiety may maintain the behavior. While research in which I am involved examines reward sensitivity in bipolar, I'm wondering if a layer beneath reward sensitivity is anxiety sensitivity, being that we're conceptualizing anxiety as the ultimate primary emotion in this post.

I also realize that to say anxiety dysregulation may prompt bipolar disorder because stress prompts the onset utilizes circular reasoning. But circular reasoning notwithstanding (lol), I still think this is interesting to consider anxiety sensitivity as it relates to two separate constructs of bipolar - both onset and course of the illness.

Ok, back to work.

Triggers - Avoid or Expose?

I was just thinking about the practice of identifying and avoiding triggers in therapy. Sure, inherently harmful triggers are best avoided... but what about triggers that are what we call "conditioned stimuli?"

[For the non-psychologists out there: some of us are triggered by certain things that are actually harmless, but during the course of our lives, we somehow came to associate them with feeling like crap. For instance, walking by a restaurant you used to frequent with an ex could trigger negative emotions. The restaurant itself is harmless, but you've been conditioned to feel sad when walking by it. As such, the restaurant is now a trigger.]

Some therapists may urge their patients to simply avoid all triggers. Sure, this sounds like a good idea, but is it truly helpful? If the patient is in acute / reactive pain, then throwing some more negative experiences their way probably isn't a good idea. But typically, I think that systematically exposing people to triggers, just like you would to anxiety provoking stimuli, would lead to habituation.

While this may be common practice for treating some disorders, it doesn't seem to be the case for all of them (i.e. eating disorders). For instance, when a particular food may trigger a binge, the general advice simply seems to be to avoid that food. Well, I'm just not so sure.

Sensory Integration and Self-Injury

I spent the last semester working with children who have autism.  During this time, I heard the term "sensory issue" a bunch of times, but had no clue what it really meant.  Even after asking questions about it, I never felt like I really understood it.

I ended up learning the most about sensory integration issues at an unsuspecting event - at a writer's conference in NYC.  There, I so happen to have met Nancy Peske, the co-author of the book, Raising a Sensory Smart Child, and a mother of a child with the conceptually elusive sensory integration issue.  I figured she'd be the perfect person to ask about this stuff.

I ended up learning that some people are prone to either seek out intense stimulation or find even the most mild sensations aversive.  For instance, some children have an extremely high tolerance for what would cause most of us pain.  Conversely, the same child may find light tickling painful or aversive.  Although many people with autism have these types of sensory integration issues, we also see this in people who don't happen to have autism.

Relevant to my past research, we find that children who engage in self-injury are more likely to have a high pain tolerance and engage in repetitive behaviors.  While we previously thought that having a high pain tolerance was caused by repeated episodes of self-injury, I'm wondering if actually there is an underlying sensory integration issue here.  [In fact, we're finding that the traditional tolerance theory is not supported.]

On top of that, we have been conceptualizing repetitive behaviors as a precursor to self-injury; however, now I'm thinking that perhaps they both emerge out of the same sensory integration issue that may have been present from before / soon after birth.

And speaking of birth, in Deliberto & Nock, 2008, we report that in utero complications are seen more in children who engage in self-injury than in controls.  Like repetitive behaviors and in utero complications, these findings are also seen in people who have autism.  Although these data are correlational, the relationship among in utero complications and repetitive behaviors, self-injury, and autism is worth considering in my opinion.

In short, I'd bet that both self-injury and some of the underlying commonalities between this behavior and autism are sensory integration issues relating to touch.


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Why Do People Talk about Cutting Themselves?

I just received the following inquiry: I know some one thats very public about cutting themselves. Is this normal? And why do you think this is?

Here's my answer:

Good question. Although I cannot assume I understand this specific person, I can speak generally about the topic of openly discussing one's own self-injurious behavior.

My first inclination is that the person may be seeking what we call "social reinforcement." There are two types of social reinforcement - positive and negative.

What we call "positive social reinforcement" is what people not in the biz call "getting attention." This would come in the form of sympathy, interest, concern, or even people expressing shock. Particularly if a person feels disconnected / a lack of social support (and want these things), they may be prone to be seeking interaction with other people in this way.

So what we call "negative social reinforcement" does actually not mean punishment. In my experience, people in the public misuse the term "negative reinforcement" quite frequently. Negative reinforcement simply means to remove something aversive or to get out of a responsibility. For instance, an adolescent working on a boring group project might tell her peers that she's a "cutter" so they put less of a workload on her. In this example, if the teen gets out of doing something boring, she is negatively reinforced for telling people she cuts.

This brings us to an interesting point. It is my opinion - which is not shared among people with whom I've worked - that when people are socially reinforced (either negatively or positively) for telling people they self-injure, it isn't necessarily the cutting itself that is affected. What I think is more influenced is the actual disclosure of the behavior. This would mean that if someone is socially reinforced for telling people they cut, the actual act of cutting wouldn't necessarily increase, but the number of times self-injury is discussed would increase. To be crystal clear, I think that social reinforcement may shape the largely impulsive behavior of cutting itself, but not as strongly as the seemingly more deliberate act of discussing the behavior.

It is my opinion that people primarily engage in self-injury for emotion regulation purposes. In other words, to decrease their anxiety or to pull them out of a disoriented state (to learn more, I posted a link about this at the bottom of the page). It doesn't make sense to me that people engage in self-injury just so that they can receive attention for it later. My intuition tells me that the reinforcer of social approval is too far removed from that actual act of cutting to be incredibly potent. To my knowledge though, no research has been conducted to support this. In fact, self-report studies show that people report thinking they engage in self-injury to gain approval, therefore, it is advisable to take this into consideration when considering the thoughts previously expressed.

Perhaps self-injury can start out so that one may gain approval (positive social reinforcement) or even get out of something (negative social reinforcement). It could also be the case that someone starts cutting just for the emotional effects, but then starts telling people about it. I just can't buy into the idea that the only reason someone would cut is for social reinforcement.

Anyhow! I digress. Back to your question. It could be the case that this person is trying to connect with people, shock them, or remove his/herself from responsibility. On the other hand, perhaps he/she is just trying to work through previous shame about the behavior and finds it liberating to talk about it. I really don't know. But these are my best guesses!

Speaking to your question regarding whether or not it is normal: based on no data but my experience, about half of people who cut themselves report telling other people, while the other half don't tell anyone but maybe a mental health professional. While I'm not sure how normative it is for people to talk at length about their self-injury, I have some thoughts about this.

We can't make assumptions that talking about engaging in self-injury is necessarily a maladaptive / bad thing. For instance, perhaps the person will end up getting into the right treatment and get support for stopping the behavior. And as previously mentioned, perhaps the person used to feel much shame about the behavior and is working through it by speaking about cutting. Who knows?

On the other hand, one could make the case that if the person is socially reinforced for disclosing that he/she self-injures, the behavior could be maintained. I'm just not sure exactly why this person may be openly discussing engaging in self-injury.

As you can imagine, it is quite complicated!

Great question though. I've never been asked this.

To read more check this out: http://taradeliberto.blogspot.com/2011/02/why-do-people-cut-themselves.html

For Subscribers

For subscribers, I ended up changing the post about the evolutionary reasons we obsessively check Facebook quite a bit. Check it out here:
http://taradeliberto.blogspot.com/2012/04/keep-them-coming-back-for-more_22.html

The Evolutionary Reason We Obsessively Check Facebook

Today's topic is how we're evolutionarily programmed to obsessively check Facebook.

Let's just say that you log on to Facebook and get a good laugh out of a friend's status. You log on a few more times that day, but nothing is interesting. But of course, before going to bed, you log back on one more time just in case. And lucky you - you get another late night chuckle.

First, in this little story, the funny statuses play the role of the reinforcer. Second, the fact that you never know when someone is going to write something clever makes the reinforcer intermittent - or, in other words, random. Put them together and what do you get? A little term us psychologists call intermittent reinforcement.

So the interesting thing is this: when we are intermittently reinforced, we tend to display obsessive behavior (e.g. gambling). Following the rule that intermittent reinforcement leads to obsessive behavior, in this example, never knowing when you're going to read something funny partially explains why we tend to check Facebook all the time as a species. [We also find humor, human interaction, and gossip particularly rewarding.]

So what may the evolutionary advantages to intermittent reinforcement be? Well, I'm not sure if there are too many evolutionary advantages to obsessively checking Facebook, but there certainly are for the underlying mechanism.

Specifically, I was thinking that animals may have evolved to become sensitive to intermittent reinforcement because if we become more persistent in the face of scarce reinforcement / resources, we may increase our chances of success.

Let's consider the definition of perseverance: steady persistence in a course of action, a purpose, a state, etc., especially in spite of difficulties, obstacles, or discouragement.

In that definition, if "difficulties, obstacles, and discouragement" is conceptualized as a lack of reinforcement, then "persistence in a course of action" can be viewed as the somewhat obsessive behavior seen when intermittent reinforcement is given.

While perseverance (with a positive connotation) is readily associated with success, before today, I never considered perseverance as the behavioral result of an environment that is intermittently reinforcing. I'm guessing that will power comes into play too... but honestly, who really knows?

Now, while being sensitive to intermittent reinforcement may be helpful for us to persevere when times are tough, this tendency likely shaped by evolution won't serve us well in every scenario.

There is definitely a darker side to all of this. For instance, if you're more sensitive to intermittent reinforcement, you might be more inclined to stay in a roller coaster relationship, become a compulsive gambler or get engrossed with more trivial matters to increase your mood (e.g. check Facebook more times than you'd like to admit).

We typically think about engaging in these types of activities as a means to avoid feeling negative emotions like boredom, sadness, etc. It may certainly be the case that we engage in behaviors like obsessively checking Facebook to both avoid life and gain pleasure. At the same time, the obsessive nature of Facebook checking may be attributed to the underlying process may be one of intermittent reinforcement.

On a related note, rather than viewing psychopathology in terms of reward sensitivity, I wonder if sensitivity to specific types of reinforcement (or "schedules" as we call them) matters. Namely, sensitivity to intermittent reinforcement may be at the root. Food for thought.

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[And some food for later thought: perhaps this whole idea of valuing one's own naturally persevering nature somehow relates to asceticism. Together they combine to a pretty intense personality that is sensitive to reward.]

Teaching a Little Guy to Recognize Emotion

Here on this rainy lazy Sunday in NYC, I was drinking my usual morning green tea and thinking about the cases I've seen of alexithymia - or the inability to recognize emotions - in children.  What do we do about alexithymia?  Well, definitely the usual stuff like playing games like emotion charades where we have to guess what emotions / feelings we're acting out, practice problems solving / acting out solutions to various conflicts, etc.  But what else?

Here's a made up case to illustrate my thoughts:

Let's say that I'd been treating a 8 year old boy with alexithymia with the usual techniques until one day his mother asked to talk to me womano-a-womano.  She says that he doesn't understand important feelings she has about a specific family situation and takes the opportunity to tell me about her emotions.  So I go into session and directly discuss what mom might be feeling in these tough family scenarios.  The boy is surprised to learn how she might be feeling and feels a bit badly about his behavior.  Then we discuss what he can do differently in the future that takes his mothers emotions into consideration.  During the next week's session, mother reports that the boy was appropriately attentive to her from the moment they left therapy and throughout the entire week.

Now, even though our hypothetical session - that is a hybrid of multiple sessions with various patients - apparently produced the most effective behavior change outside of session, it was probably the most (mildly) aversive session we ever had.  Compared to past sessions where I have been teaching through games, this was no walk in the park.

During a game like emotional charades, the emotions remain impressionistic by nature. So where do we go from there? Sure this may be a good starting point and we also spend some time discussing issues that are upsetting outside of the session, but what about evoking real emotion in session?

By discussing the feelings that his mom might have, a little light bulb went off in his head.  He first reported feeling sad, but after some pressing, he also reported feeling a little bit guilty about his lack of attentiveness to his mother. After all, we are talking about a very kind child, here.

Notably, those emotions of sadness and guilt were freshly created as a direct result of newly learned content in the session. These emotions were not re-conjured from past events outside of session, nor impressionistic. Something to think about.

Because this session was mildly aversive though, my concern for next week was that he would not want to come back. After all, in his mind, we typically just play games. (Sure, these techniques can produce some change, but it is my opinion that they remain surface.)

Flying in the face of my nagging worry, this little guy was actually quite eager to return to session the following week. I suppose that I'll never be sure as to why. We can only speculate that perhaps it was because of a long standing therapeutic rapport and a learning history that coming to therapy is fun. A second option is that he did not experience the sadness and guilt intensely enough for it to deter him longer term.

But what about the results of Walter Mischel's studies?  We know some children can appreciate something more aversive & meaningful in the long-term, but not a barrel of laughs in the short term. 

Maybe this little guy appreciated learning something new and subsequently having his environment change.  After all, mom did say things were much better at home following that session.

Who knows?

To summarize, there are three ways of dealing with emotion in session:
1) evoking then processing new emotion in session as a result of new information / insight
2) rehashing previously felt emotion
3) creating impressionistic expressions of emotions

Maybe #1 is preferable.  Something to think about.

That "Gut Feeling" is Actually in Your Gut

I'm spending this particularly sunny Saturday in Manhattan doing some literature reviews near an open window overlooking people eating at an outdoor cafe`on 3rd avenue. Unbeknownst to them, I've been watching and wondering about the connection between the food they're eating, their bellies, and their brains. I know I shouldn't get derailed from finishing my work, but I couldn't resist writing this post.

I just came across a review paper called "Gut feelings: the emerging biology of gut-brain communication." Cool stuff. Apparently, there has been talk since about 1850 of a nervous system I've never heard of before: the enteric nervous system (ENS). Technically, it is considered the 3rd branch of the autonomic nervous system, which I'm certainly familiar with, but still! The ENS seems a bit too important for me to have been enveloped in the field seven years before learning about it. It could just be me... but I'm guessing the folks in psychology are not all that knowledgeable of the ENS.

That being said: the ENS, - or the interaction system between the brain and the gut - is referred to as the 'second brain' because it is similar in complexity to the one we have in our heads. It turns out that the second brain may have a pretty big impact on emotions, motivation, and [get this] intuitive decision making. In other words, the gut is quite literally involved in making gut decisions.

Who would've thought? Actually, the guy who coined the phrase "gut feeling" may have.

Consider the fun little notion that maybe we have been able to identify that intuitive decision making comes from the gut all along, without ever having scientific evidence. I love the idea that purely being mindful of your own physiological sensations can be an accurate source of information. How incredible.

Another interesting piece of knowledge this article has to offer is this: disruption of the ENS is associated with inflammatory gastrointestinal disorders, obesity, and eating disorders. To me, this certainly makes a lot of sense!

Specifically relating to over-eating, the paper proposes that the underlying biological mechanism is the mismatch between the big expected reward from eating food, and the relatively small actual reward experienced. The idea is basically that people keep thinking they are going to really enjoy food, are left unsatisfied, and keep coming back for more. While this may certainly be a big part of the picture, I have some other ideas about this... Something to think about for later.

Reference:
Mayer, E. (2011). Gut feelings: the emerging biology of gut-brain communication. Nature Reviews, 12, 453-466.

But The Job Market is Tough

Without structure, money, or the feeling of efficacy that comes with working, unemployed people can understandably slip into a depression.

But what do you do when someone tells you that they just can't get a job because of the job market? One option is to ignore this and try to convince the person that it will all be fine, but my guess is that you might not win yourself a fan. When people validly point out that the job market stinks, it 100% must be acknowledged. We are in hard times here.

But here's the catch: clients sometimes say "but the job market is tough" almost as a reason not to submit applications. There is a "what's the point?" feel to it, which is definitely a signature sentiment of depression.

If the person leaves the session just feeling validated in thinking the job market is tough, they'll probably end up feeling temporary relief after having vented, do nothing to better their situation, and end up more depressed. Be careful not to let "but the job market is tough" become an excuse.

So what is a good alternative mindset?

If the job marketis tough, you need to put that much more effort into applying than you would otherwise, not less.

If you're old, changing fields, have been unemployed for a while, or whatever the case may be, you must try even harder. Accepting that it is going to be tough and moving forward despite rejection seems to be the most functional way to go.

It is a time to go all in.

Best Social Phobia CBT Book

This is a great self-help book for anxiety!

Therapy and Eastern Religion

As I mentioned in the post, Near Death Euphoria and the Link to Suicide, I love www.Reddit.com. On this site, a member asked me about the connection between CBT and Eastern Religions. This was my response:

So, there have been three "waves" of CBT. The first was behavior therapy, the second was cognitive behavior therapy, and the third is mindfulness/meditation related.

The Third Wave CBT approaches are very tied into Eastern religion. The names of the most well known Third Wave approaches are Acceptance and Commitment Therapy (ACT; pronounced "act"), Compassion Focused Therapy, and DBT (which I mention elsewhere on this blog). I am a huge fan of Third Wave approaches.

The cognitive Second Wave approaches work on correcting "irrational" beliefs (e.g. I am a worthless person). For instance, we might examine the evidence for and against the argument that you're worthless. As it turns out, once you think about it, maybe you're not really all that worthless.

But the Eastern-influenced Third Wave CBT treatments emphatically do not aim to correct irrational beliefs!

Third Wave approaches mainly focus on noticing thoughts like "I'm worthless" and trying to change one's relationship to the thought, but not the content of the thought itself.
For instance, a Third Wave approach might simply focus on the fact that "I'm worthless" is coming into the mind and that it isn't a particularly useful thought to attend to. The treatment would aim to pull the person out of their head and into contact with the present. So instead of attending to the thought "I am worthless," a person may be encouraged to shift the attention to the breath, for example.

Third Wave approaches offer a lot more than just this, and are very rich approaches, but I think this represents the general idea.

If you're interested in learning more, I highly suggest reading The Compassionate Mind and The Compassionate Mind Approach to Overcoming Anxiety.

For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.

"Suicide is Selfish"

I often hear people say things like "suicide is the most selfish thing you can do" and "suicidal people must not care about their families at all."

Well, I just don't think that is the case.

First of all, many do not have families who are particularly supportive, which may be part of the problem in the first place. In fact, many times people who attempt suicide are surrounded by people who are extremely abusive. Especially if the person is a teenager or has limited resources, they may see no way out.

And even if people who have attempted suicide do have people in their lives that are supportive, the person may be truly in so much psychological pain - e.g. they may be bombarded with flashbacks of a very traumatic event or paralyzed by depression - that it might be nearly impossible to take into consideration the perspective of a loved one.

On top of this, some people may feel so worthless that they think ending their lives will actually be doing their loved ones a favor. What's even more upsetting is that in some situations, the person's perception may be accurate - it isn't always, but it could be.  Stigma against people with mental health is strong and I'm sure some family members might consider a person with mental health issues to be a burden.  Of course, this isn't always the case, but it's certainly a possibility.

Please note that whether or not a person's family actually does believe them to be a burden has no bearing on whether or not a person should kill themselves.  Clearly this question is out of the depth of this blog post.  In this post I am merely illustrating reasons why it is myopic to negatively judge people who have suicidal thoughts.  I've heard stories so horrific, it seems incredible that a person could have any will to live at all.  It is not a therapist's job to judge whether or not a person should kill themselves.  It is our job, however, to do everything possible to teach skills that can make life more bearable.

My advice is simply this: don't be so quick to judge.

Eating Disorder Statistics

Just came across this great resource for eating disorders. Please check out the website for the National Association for Anorexia and Associated Disorders, Inc.

Near Death Euphoria and the Link to Suicide

I was asked by a friend if I ever came across someone who attempted suicide not to escape suffering, but because they knew it would feel good.  Although not suicidal, the person asking the question was curious because he had experienced a near-death situation in which he was injured and felt euphoria.

I thought this was a really thought-provoking question. The link between near-death euphoria and suicide never crossed my mind before.

This was my response:

I have heard of people recounting similar types of experiences, but I had never considered the link between near-death euphoria and the intention to commit suicide.

A brief discussion of Thomas Joiner's theory of suicide is in order. The basic gist is that people may build a tolerance for the negative feelings associated with hurting / killing themselves by engaging in self-injurious or thrill seeking activities. While it is not necessarily intentional, the negative feelings about death may lessen over time.

Let's just say a person regularly sky dives. Then, for whatever reason, they become suicidal. If you're already used to jumping out of planes, the idea is maybe you won't be that scared to jump off of a bridge.

There is another relevant example to this discussion as well. Namely, if a person regularly cuts themselves (without intent to die) when they're upset, they may not be scared to make life-threatening incisions when suicidal urges come up.

While I formerly thought of this concept as similar to "building up the courage" to attempt suicide via repeated episodes of cutting / dare-devil behavior, this question has me thinking differently. Perhaps there is an additional component here that is consistent with Joiner's theory.

When people cut their skin with no intent to die, it is thought that endorphins are released. This would create reduction in the negative feelings that may prompt self-injury, like shame, anxiety, sadness, etc. Perhaps people also feel mild euphoria, or positive feelings, from the endorphins. This might suggest that for some, self-injury has at least two psychological functions - reducing negative feelings and increasing positive feelings - perhaps produced by the same biological mechanism (i.e. endorphin release).

In any event, a link between injuring oneself and feeling good is formed. Maybe this association generalizes to suicide in the sense that injuring yourself is linked with feeling good.

Now, getting more to the point of suicide, endorphins are not only relesaed during self-injury, but during a traumatic / near-death event as well. This is very interesting to me because a link can be formed between feeling good and death, specifically. In the sky diving example used above, an association is formed between feeling good and jumping from a height, but not necessarily death. In the case of a traumatic event, the link is formed between feeling good and specifically being near-death.

While people may not report chasing the feeling of euphoria that comes with being close to death, if they've experienced it, the drive for this positive feeling could theoretically propel future suicidal behavior. Whether or not the person is aware that they are driven to suicide because of past feelings of euphoria when close to death, it could be a biological function maintaining the behavior.

In short, while I had formerly thought of suicide as a behavior maintained by the function of wanting to escape pain, this point raises the question of whether or not people want to commit suicide to actually feel better. Again, while I don't think people would necessarily report wanting to die to feel that euphoria, it could influence their suicidal drive and behavior.

[For people familiar with psychology lingo on this blog, the function may not necessarily just be automatic negative reinforcement, but automatic positive reinforcement as well.]

Truly, a fascinating point. Thank you so much for asking.

For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.

CBT Resources

New Harbinger Publications has a wonderful resource for people with a variety of concerns including, but not limited to, bulimia, anorexia, panic, ADHD, sexual disorders, etc. It discusses each problem and what the most effective treatment for the consumer is. Click here.

I absolutely love this. Easy-to-read consumer resources describing the most effective treatments out there are few and far between. I hope you find this helpful! If you have any questions, please let me know.

The Dissertation Meter

My dissertation is currently at 84 pages. And that is just the introduction!

Really excited about my topic - the psychology of dieting. I can't wait to blog about the results in about a year from now. Only 250 pages of writing left!

Is There Anything to be Learned from Freud's Oedipal Complex?

Ever wonder if what happened between Oedpius and his mother could happen in real life? Well, apparently it can. And there is a name for it: genetic sexual attraction.

Genetic sexual attraction occurs when genetic relatives meet for the first time in adulthood and an attraction develops. Although it is a rare occurrence, there has been an increase in the number of reported cases in recent years, typically as a consequence of adoption (according to Wikipedia).

I'm no fan of Freud, but it kind of makes me think.

It should definitely be noted though, that for the vast majority of people, it is thought that living in close domestic proximity as children become desensitized to later attraction. This hypothesized phenomenon is known as the Westermark effect. It only pertains to children being raised together, and does not take into consideration whether or not they are genetically related.

I'm not so much wondering about whether or not there is unconscious attraction between members of domestically-cohesive family units in the way Freud talked about it, but how the concepts of both genetic sexual attraction and the Westermarck effect can relate to normative relationships.

Sure, there have been documented accounts of attraction in types of incestuous relationships, but this certainly isn't the norm. Nor do I think this is due to under-reporting! And no, I'm not so sure that a lack of awareness of unconscious motivations is the reason either.

I think it might go something like this:

The Westermarck effect occurs for most people, but there might be a genetic reason why it doesn't kick in for some. I'm guessing this might be the case for the people in a documentary I watched - two genetic siblings who were raised together, eventually developed a relationship and started a family. [What was your physiological reaction to that little story? That's your Westermarck effect in action.]

So while there are probably genetic components coming into play when we see a lack of Westermarck effect, I'm guessing there might be some environmental components at work as well. I'll spare you the details of my thoughts about this, though! Suffices to say that there is usually a mix of genetics and environment resulting in any behavior - normative or not. [Basically, I'm guessing certain conditions can prompt this behavior. I also think that a lack of development of the Westermarck effect could be observed in people who are attracted to people in roles similar to that of a parent (e.g. the classic example of women without a father figure dating a much older man).]

Ok, so while the Westermarck effect (and any generalization about attraction to people in parental roles) may be the norm, what about the genetic sexual attraction sometimes seen in some people who are adopted?

Well, despite the popular cliche` that opposites attract, I'm not so sure. I've certainly come across research saying that people tend to pair off who are similar across many different areas. As you've probably experienced, bonding can occur when you have similar thoughts to someone else. Sure it would be boring if you were exactly the same, but I'm guessing you're probably more similar to the people you're close with than different.

Basically, if you're genetically similar to someone that you meet in adulthood, you could actually be very similar to them, being that genetics play such an important role in personality formation. An account from an adopted woman about her eventual relationship with her genetic father, described a close bond forming because she was more similar to him than anyone she had ever met.

In short, I don't think that we all have suppressed genetic sexual attraction - probably due to the Westermarck effect developing (and most of the time generalizing to people in similar roles). I'd imagine that people are simply attracted to people who directly or indirectly validate them because of similar attitudes.

For more posts from The Psychology Easel, visit the homepage.

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As a side note: the problem of marriages or relationships going stale because more of a sibling relationship can develop, may be an interesting generalization of the Westermarck effect. I wonder if some have a stronger inclination for this effect (perhaps couples with a lack of sex drive). It may also have something to do with early development. Different types of effects could theoretically occur (e.g. quick forming attraction and then the Westermarck effect kicking in). Who knows? Something to think about.

Stop Complimenting Me on How I Look

P.S. Here's another observation: extreme discomfort with compliments over time in people with eating disorders. Eventually, it just doesn't feel good to get those addictive compliments any more. Maybe this is a sign of improvement?

I think a recognition that this whole game is dangerous and shallow might precede this phenomenon. At the beginning of a drug addiction, people might think that it is all fun and games. Eventually, they can reach a point of developing an aversion, after all of the consequences come to fruition. I think it is the same for eating disorders.

The drug is achieving incremental goals of deprivation and social approval. In cases I've seen, it appears that the aversion to social approval piece comes first, followed by a disregard for monitoring food intake - but only in people who have truly recovered.

Eating Disorders - Are They Really about Control?

by Tara Deliberto

The concept that eating disorders are all about control never sat well with me.  Specifically, the explanation that people with eating disorders "can't control anything in their lives, so they control food," seems a bit too... poetic.  I understand the general idea, but it seems only to hit the target. I prefer the bull's eye.

Rather than simply increasing control, they way I perceive it, eating disorders seems to be more about the asceticism component. For those unfamiliar with this term, asceticism is the practice of depriving oneself of worldly pleasures. As it applies here, asceticism would involve depriving oneself of things that taste good. While it may not sound like fun, there is definitely a rush that comes along with achieving a goal in line with your values.

If your value is looking good by societal standards (i.e being thin), then you'll feel good about taking that self-depriving step towards trying to lose a bit more weight - e.g. passing on dessert. There is definitely some psychological reward from having this Spartan mentality. On top of this, if you value achievement and hard work, it seems you'll certainly at an increased risk of deriving a lot of pleasure from controlling food intake.

Ok, so we have identified two fundamental components so far:
1. valuing looking good by societal standards (i.e. thinness)
2. putting in lots of effort to achieve a goal

So, moving on!  If you have these values coupled with an environment that is chaotic and/or not rewarding, I'd imagine you'd be really looking for a way to feel good somehow. Because it might be difficult to feel good with a dearth of positive things in your life, you might start to adapt. Maybe you'll start getting your kicks from deprivation rather than your run-of-the-mill pleasures.

Perhaps you decide you want to start looking good because then you'd be happy. Why not try to lose some weight. Ok, so you limit your food. It sure feels good to be in control and achieve a goal.

Fast forward a few weeks. You lose some weight. People start to notice. "Wow, you look great!" Man, those compliments feel good. [And not only that, maybe all those self-esteem killing negative comments about your appearance disappeared too.]

Wham! Eating disorder.

I'd imagine there is a cycle where psychological reinforcement from depriving oneself and looking good feed off each other. The more you deprive yourself, the more compliments you get etc. Over time, depriving oneself is just linked with feeling good. Especially if that is the primary way you can feel positive, I'd imagine this whole deprivation/compliment reinforcement cycle mess is quite addicting. People look to score small amounts of pleasure by depriving themselves, while chasing the big goal of all those compliments and social approval.

While I'd love to speculate more, I have a research proposal to write tonight!

So, to wrap up: it doesn't seem to suffice to say that eating disorders are about "control."  There are certainly other areas to be addressed in treatment, but areas to be targeted rather than simply "control," might be:
1. Valuing what society deems as attractive
2. Valuing extremely perfectionistic work towards achieving goals in line w/ the above value
3. Getting high off of asceticism
4. Getting high off of compliments
5. Potentially not receiving reinforcement and/or deriving pleasure from other areas

In short, this notion that people can't control anything in their environment so they control food, is too poetic for my taste!

Ok, back to writing my research proposal on disordered eating! That's all for today.

For more posts from The Psychology Easel, visit the homepage.


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P.S. Note to self: Return at a later date to examine which of the components listed above are:
1. necessary-but-not-sufficient
2. necessary-but-can-be-sufficient
3. not-necessary-nor-sufficient-but-can-pop-up.

Quickly, it appears that valuing what society/someone in particular deems attractive is necessary-but-not-sufficient due to the sharp increase in eating disorders as societal ideals changed. Unless, of course, the disorder developed primarily to look unattractive & functions to protect the person from maturity/ sexual abuse. The second component is probably necessary-but-not-sufficient only in anorexia nervosa - where people end up drastically committing to deprivation. With bulimia nervosa / EDNOS, it could exist, but vacillate, or be complicated by a compulsive nature etc.

Thank You

Dear Readers,

Thank you so much for supporting this blog during the holiday season and purchasing items off of Amazon after clicking on the sidebar links. The proceeds earned will support the broke graduate student who writes this blog.

Thanks again!

Check out the homepage here.

-Tara

Yet Another Reason CBT & ACT are Compatible

Every now & again on this blog, I'm going to really dork-out and get technical. While most of the posts are certainly for the general public, this one is coming from my inner Ph.D.-student.

While folding laundry, I was ironically in my head thinking about the concept of coming into contact with the present moment. This is the thought that indirectly caused me to put my shirts in the sock drawer: CBT instructs people not to ruminate about the past or worry about the future, while ACT provides a substitute behavior (i.e. mindfully coming into contact with the present moment). In other words, roughly speaking, CBT works from the negative and ACT works from the positive in terms of action.

This is yet another reason why I think CT might be useful for some people before an ACT intervention. Allow me to explain. If you were writing a research proposal, for example, first you'd go through all of the problems with the past research and explain why it isn't sufficient. After this, you'd go onto explain exactly what you intend to do instead. Therefore, in order to make some changes on a research level, first you need to understand the problem, then you do something new. Similarly, I think cognitive techniques are useful in explaining what does not work, while ACT is really good at providing what does work.

Of course, this is not to say that out-of-the-office and on-the-spot cognitive disputation isn't ineffective. In fact, I really think it is - especially when one is either first grappling with identifying maladpative cognitions or is having a particularly difficult time. The point is that after one has identified a maladaptive cognition and worked out why it isn't effective, it is helpful to then learn what to do next (i.e. to shift into the present moment). In this way, I think ACT techniques are perfect for where CBT leaves off.

Ok, back to laundry!

Self-Injury as an Inborn Fail-Safe

Where do we get the idea to eat or have sex? Maybe we don't. As Pinker argues, we're not a blank slate. Perhaps the impulse to engage in self-injury when under extreme emotional distress is also inborn.

We are starting to understand the havoc stress wreaks on the body. We are also starting to understand the strong endogenous physiological calming effect self-injury prompts.  In this context, I wonder if self-injury acts almost like an inoculation - when given a small amount of manageable physical adversity, the body's soothing and contentment system is able to overcompensate and fortify itself. Maybe the body intuitively knows to default to self-injury under periods of stress because there are dramatic and sudden decrease anxiety due to increases in endogenous calming agents, being that stress is particularly harmful to the body. [There's something about stress triggering autoimmune diseases here that should be looked at. Perhaps it isn't a coincidence that Benadryl can be used both as an antianxiety as well as an antihistamine.]

After all, humans are not the only animals that engage in self-injury (e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2486411/). My first published study (cited in TIME here) mentions that a certain percentage of people report getting the idea to engage in self-injury from an outside source; however, the other side of that is that some people report never having learned the idea from anyone. Perhaps it is, in fact, an inborn impulse we have that is defaulted to in times of stress because it is protective to the body against stress. This is not to say, of course, that some people don't get the idea to cut from other people. Surely this must be the case. But what about the people who spontaneously start cutting without outside influence? How can that be explained?

I'm beginning to think that the impulse to hurt oneself is a hardwired fail-safe.

Is Multiple Personality Disorder Real?

Although it is very rare, early in my career I met two (different) people with Dissociative Identity Disorder (DID; formerly known as Multiple Personality Disorder). The first person I met with DID was a patient at a clinic in Harvard Square, where I was conducting research. Over the course of my two years there, I watched her slowly unravel from displaying one personality to many. By the time I left, she had the voice and demeanor of a seven year old child. Frankly, witnessing this was quite unsettling.

The second person I met with DID was in the psychiatric emergency room at Massachusetts General Hospital, where I was working on another study. I remember the conversations amongst the staff about her case well - some thought she was faking it, while some thought a diagnosis of DID was legitimate.

In short, this is what I think:

People with Borderline Personality Disorder, which is characterized by self-injury, suicide attempts, extreme mood swings, and stormy relationships also has another very important feature that is often less discussed - identity disturbance. Basically, very different personae are displayed depending on the situation. As Kiera Van Gelder describes in The Buddha and The Borderline, a memoir about recovery from this disorder, she would be a hippie one day and a goth the next if it would get her the sexual attention she wanted. In other words, she would drastically change her personality from day to day (in this case, it was for social approval).

The problem is this: A therapist looking at someone who is a goth one day and a hippie the next might conclude that these are just various forms of the self that need to be expressed. (Yikes!)

While chameleoning can be viewed as adaptive in a sense, the person with BPD / identity disturbance seems to be paying little attention to whether or not they actually enjoy a given activity they are engaging in for social approval. Often, people use these different personae as a tool - and a tool only. The who acts as a hippie today has no real affinity for hippie culture in itself. Expression of one's "hippie side" is resoundingly not to be encouraged.

Introducing certain types of therapy that emphasize different parts of the self to people who already have identity disturbance, may cause further polarization. The patient may be reinforced for behaving in certain ways and expressing themselves from various personalities. Hence, the development of DID. Without a question in my mind, this is what happened with the first patient with DID I watched unravel - she initially had a diagnosis of Borderline Personality Disorder (w/ the identity disturbance feature) - and in two years time (after "parts therapy") she had multiple personalities.

People with identity disturbances crave belonging and unity of their behaviors by definition. Slapping a label of DID on someone who is desperately trying to figure out who they are is dangerous. The person knows that a lot effort needs to be put in to establish a sense of self. These uncharted territories of not living for social approval are scary. This unifying label is an excuse to avoid all the anxiety that will come with establishing a sense of self. It is easier to exaggerate the different forms of self that already exist and diverge further.

In the effort to display many personalities, a unifying role of being an interesting patient is maintained.

While the presentation of someone having several personality disorders is certainly real, I highly doubt this is organic. It seems to me that this disorder is related to the same underlying identity disturbance seen in Borderline Personality Disorder. In fact, I'd be willing to bet that a very large number of DID cases are really Borderline cases gone horribly astray due to treatment with talk therapies that have not been supported by research.

I'd also like to add that after having worked with people who have schizophrenia, there is a definite psychotic flavor to DID as well. My gut feeling is that the core underlying feature is the identity disturbance seen in BPD on top of a psychotic tendency to believe what the mind is constructing. It is these two underlying features that combine to the expression of different personalities. In no way do I think there are actually two different personalities encased in one person. In short, I'd reason that DID is simply a specific form psychosis with the core BPD component of identity disturbance.

In treatment, instead of focusing on expression of various external presentations, focus should be on developing a sense of self. Figuring out what the person likes independent from the approval or opinions of others seems vital.

Lastly, unlike depression or anxiety, there is an ego-syntonic feel to multiple personality disorder. In other words, people like having the disorder to some degree and want to continue any associated dysfunctional behavior. Another example of ego-syntonic disorders would be anorexia, where people typically want to continue restricting food intake. In the case of DID, people want to keep their multiple personalities, as they are potentially useful in different circumstances. As such, the expression of different personalities should be particularly discouraged by all staff members at a facility once rapport has been developed and treatment is underway.

Sex - Benefits of Talk Therapy Over Medication

Unlike stereotypical versions of talk therapy where a doctor claims you want to have sex with your mother, a newer treatment called Cognitive Behavioral Therapy (CBT), has been shown by plenty of studies to actually work.

Not only that, it changes your biology. Unlike other talk therapies, this type of treatment involves active learning and homework. As such, it can cause beneficial increases in the size of your brain that controls complex thinking - the cerebral cortex. In fact, CBT has also been shown to be just as effective as medication, just with longer lasting effects.

I would imagine that CBT continues to be beneficial after ending treatment because the time was taken over numerous sessions to rewire the brain. On the other hand, medication may act more by forcing it to function differently for a short period of time. Many drugs also come with a lot of negative side effects.

Unlike a lot of depression medications, CBT just doesn't numb your sexual experience. As Kiera Van Gelder so eloquently describes in her fantastic recovery memoir, The Buddha and The Borderline: "Sometimes when I see his body or smell his scent, I want to consume him with all of my senses. Then, when we meet skin on skin, it's like hitting a thick glass wall. 'It's the medication.' I tell him."

Although it may be advisable for some people to be on medication while in CBT, if you are choosing between talk therapy and drugs, make sure to do your homework. Trying a CBT therapist before medication might be a favorable option for you.

For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.

Thoughts on Secret Fears of the Super Rich

by Tara Deliberto

I came across this article "Secret Fears of the Super Rich," and thought it was pretty interesting. I posted a link to it in an online forum, and one of the readers responded with this Ayn Rand quote: "Only the man who does not need it, is fit to inherit wealth, the man who would make his fortune no matter where he started."

Here are my brief thoughts on this marvelous quote from a psychological perspective:

Being in my line of work, I'm acutely aware of the fact that people need to build their own sense of mastery. Without mastery, feelings of helpless set in and a general lack of motivation is fostered. Translated into clinical terms, people become depressed and anxious. So perhaps if an individual is given everything, their sense of mastery can be diminished because they have not had to take opportunities to succeed on their own.

There are several possible reasons why these opportunities are not taken. For one, when the bar is set so high by a family member who built a fortune, it may be too frightening to even approach success. It is seems safer not to attempt anything at all and live a comfortable life. But is it better for one's own well being to never have tried?

While fear of failure might drive this behavior, the possibility also exists that it is that once wealth is attained or inherited, there may simply be no perceived need to achieve. Perhaps if the same person who inherits wealth and chooses not to engage in tasks to build mastery is put under real pressure, he or she might very successfully build resources. But without ever needing to, attempts are not made to earn one's own living.

In short, I'm conceptualizing two paths, the first would be an anxiety-avoidance path while the second is a contentment/maintenance path.

Whether or not they want to, people who inherit money may benefit from continually engaging in mercenary tasks where failure is possible along with adopting an accepting attitude that they may never achieve at the level of their family members. The idea is that when any amount of success is achieved, their own sense of mastery may increases, motivation can ignite, and life many feel more purposeful.

I think this idea fits nicely w/ Ayn Rand's - one needs to be motivated to achieve for their own sense of self-worth. Sometimes having an inheritance can take away one's own sense of importance while increasing entitlement. While importance and entitlement are often linked, perhaps they are very different constructs. While a person may not view themselves as being meaningfully able to contribute to the world (importance), they may think they deserve everything (entitlement).

Does A Therapist Judges You?

Today I received a question from a man in Mumbai asking if I went into being a psychologist so I could be in a position to judge people. He expressed the sentiment that everyone must understand that we are in no place to judge others and that he prefers a live at let live philosophy.

Here's my response:

Thanks for the post. Since many people share your opinion, I think this question is particularly important to address.

I can understand that without an introduction to the type of treatment I practice, one may assume therapists just want to judge people. In fact, it is just the opposite! People come into my office with a series of judgments about themselves that we work together to debunk. I've seen people who have made wonderful contributions to society but seem to think that they are completely worthless. My job is simply to neutralize judgments. We help people to stop harshly judging themselves so that they can function better and suffer less.

While many people are not in need of treatment, I'm afraid that many people are seriously troubled and on the fence abut whether or not they should end their own lives. With suicidal people, a live and let live philosophy wouldn't exactly work out. And just because someone is contemplating suicide, does not make them worthless and deserving to die, it just means they are suffering from what can feel like a tortured internal experience. They come to treatment of their own volition because there is a piece of them that wants to get better. Therapists don't force clients into treatment.

There have been many research studies on the type of therapy I do showing that the techniques are in fact useful in helping people build a life worth living. Therapy, when practiced well, is much more than a series of judgments - it is an effective way to retrain people's thoughts and behaviors.

Acceptance and Commitment Therapy is Officially Listed as Effective!

Great news! The United States Substance Abuse and Mental Health Services Administration (SAMHSA) has now listed Acceptance and Commitment Therapy (ACT), a therapy I practice that is based on Eastern Mindfulness techniques, as an official treatment that has been shown by research to work!!

This is part of SAMHSA'sNational Registry of Evidence-based Programs and Practices (NREPP). What a wonderful initiative. Bravo.
http://174.140.153.167/ViewIntervention.aspx?id=191&

The Relationship between Negative Thoughts & Serotonin

I'm happy to be a member of an online community where some intellectual forum discussions are generated. In this setting, a question was posed to me pertaining to the relationship between negative thinking and serotonin from Scott in Auckland. Since other people may be curious about the same topic, I thought I'd post my response here.

Reply:
I absolutely love this question! The interplay between what we do as psychologists and biology is one of my favorite topics. How we are trained through all of our collective learning experiences to think - and more specifically, appraise, evaluate, and interpret - has a direct effect on our physiology and biology.

For those of you not familiar with Cognitive Behavioral Therapy (CBT) it involves very active Socratic questioning on the therapists part about thoughts the patient currently has. This type of therapy is in stark contrast to old-fashioned Freudian type therapies that mainly just involve combing over events of your past. If a patient comes into my office and says "I'm a loser," my response would be "Oh, yeah? It must stink to think that. But what is the evidence that you're a loser?... Have you ever won anything?... Even if you are a loser now - whatever that means - will you always be a loser?" etc.

After all this questioning, we usually end up laughing together about what I ridiculous statement "I'm a loser" really is and how true it can feel. Through this process, the rift between what our mind thinks and what is actually true is created. After the initial separation between thought and belief is fostered, we go come up with rational responses to these types of negative automatic thoughts like "I'm a loser" and practicing mentally rehearsing the rational responses as homework.

So, that is a brief description of the cognitive piece of cognitive-behavioral therapy. Interestingly, the behavioral piece has been shown to be more effective than the cognitive piece at changing the interpretation of thoughts. Let's take, for example, someone who has social phobia. You can tell them that their phobia of talking to other people is silly all you want, but they still may not believe you. The best thing to do is act.

We start small. I might grab the secretary into the therapy room and ask her to have a 5 minute conversation about something like traveling with the patient. After five minutes, the secretary says it was lovely chatting and leaves. Now, that wasn't so bad was it?

Then as homework assignments, the patient is to engage in social activities, starting with a small anxiety producing task, and working their way up to doing something very scary like public speaking, over the course of weeks. In this way, their own thoughts are directly challenged by the outcome of their behavior. They always think it will be worse than it ends up being. In this way, they engage in little "behavioral experiments" that directly test their maladaptive beliefs.

It is worth noting here that while the behavioral piece has been shown to be more effective, people may not be willing to engage in the behavioral piece without both a strong rationale for it. It is my opinion that going through the cognitive part of the therapy and disputing thoughts that automatically pop up is an extremely useful first step that must be taken with a vast majority of people before jumping into the behavioral piece. In fact, a client of mine expressed this sentiment completely of her own accord to me today.

While we have discussed both the cognitive and the behavioral piece at this point, there is a third very important piece that changes our relationship to our thoughts - Eastern mindfulness practice. Learning to be aware of our thoughts and release the less useful ones is extraordinarily helpful as well. As a side note, I practice letting go of thoughts every day during yoga, which I use as a moving meditation more than exercise. '

I'll talk more later about integrating these components of treatment, but for now, back to your question! There have been many studies showing that CBT is as useful as treating depression as antidepressants; however, CBT has the added effect of continuing to work even after treatment ends. In terms of whether or not it increases serotonin in the synapse, there are huge ongoing clinical trials in the U.S. examining this right now. So far the evidence points that learning to regulate your emotions through these types of treatments does effect serotonin.

Here's a link to clinical trial information.

Do We Have The Ability to Change?

Similar to the last entry, here I repost my responses to questions posed to me in a forum thread from Eline, whose blog you can find at (http://businessbabyandblog.blogspot.com/).

Eline's Question:
My knowledge of phychology is at best very basic, but I do find it a fascinating subject, and I'm also interested in coaching, and I'd love to know what you think about a question that I have asked myself lately... On the one hand, the hypothesis is that there is high hereditability for almost everything (including personality), and that anything non genetic comes from non shared environment, and thus that personality traits are stable over time. On the other hand, I believe in free will, and that it's possible to change your values, beliefs, thoughts and actions. Taking it further, if you believe in free will, to what extent could we use the plasticity of the brain to shape and transform our personality ourselves? I'm thinking, with so many self-help books on the market, what proportion of identity is really up to us?


My Reply:
You ask a very interesting question! Speaking very broadly - from a combination of fancy statistics and studying identical twins who were adopted into different families, we have estimates that genetics and environment contribute about equally to various personality traits, behaviors, and disorders. Let's first discuss these factors before getting into free will.

From an evolutionary perspective, this makes sense. It is favorable to survival to have some traits passed on from one generation to the next. On the other hand, there needs to be some room for adaptability.

In some people personality traits are really stable across time; however, stability cannot be confused with heritability. In other words, just because something is stable, doesn't mean that it is inherited or genetic. For example, someone could have experienced something extremely traumatic early on in their childhood and would remain fearful and avoidant their entire lives. In this case, the environment would be the main contributor to a fearful and avoidant personality. While this is true, a complex interplay of genetic and environmental factors after the trauma may also maintain a fearful personality.

As someone who studies the treatment of "personality disorders," which are considered to be such stable disorders that they are part of one's personality, I can tell you that personality disorders are not stable over time. A very difficult disorder to treat called Borderline Personality Disorder - which involves suicidal tendencies, behaviors like cutting, chronic feelings of emptiness etc - has been shown to be effectively treated with a talk-therapy called Dialectical Behavior Therapy (DBT). This suggests, that even very difficult and stable traits can be changed with a psychological treatment. Because it is obviously not gene therapy, therapeutic change can be viewed as the environment (along with the individual) shaping behavior.

As I mentioned on this thread where this blog post originated, the mind and body are shaped by the environment. Talk-therapies and experiences can actually re-wire the brain. So even if we're born with a genetic predisposition to something, we can mold it, within certain limitations that are hard to estimate, with experience. There is, however, very likely an element of choice in whether to proceed with and effective treatment.

Although this is likely the case, free will is a really difficult topic to discuss with confidence. We are often very influenced by factors completely outside of our awareness. We also make up reasons for why we do things, when we really have no idea why on earth we do. Many cleverly designed studies have shown this.

With that being said, my own ideas on free will are this: when we become aware of our thoughts and actions, perhaps through the practice of meditation, we have an increased ability to choose. As we hone this ability, over time, we become less like a pinball careening towards different springs that just send us hurling in random directions. We can shape the way in which are brains are rewired by choosing to practice a craft, studying a topic, or participating in an effective treatment like CBT or DBT where psychological management skills are learned.

Eline's Repsonse:
How interesting! Thanks for such a complete answer! I just completed an introductory course in psychology and am having a hard time putting the pices together. What you say really makes sense..

Now I'm thinking about meditating again, I did it for a while, but never really made it a routine or a priority.. :)

My Response:
Eline, my pleasure! If you have any more questions, this thread is here :)

I absolutely love meditation - I research, practice, and teach it. I just wrote an article about meditation here:
http://www.tidytemple.com.au/AnnouncementRetrieve.aspx?ID=45454

If you have the time to check it out, let me know what you think!

Eline's Response:
Great article! I used to share the same misconceptions you address, and I'm sure there are many like me.. I also like the idea of starting with 2 minutes, I started directly at 15 and found it really long, maybe that's why I stopped

My Response:
Thanks for the positive feedback, Eline! It is much appreciated.

The First and Ultimate Primary Emotion - Fear

A member of an online community to which I belong posed this very interesting question to me on a psychology thread: Could fear be the origin of the entire spectrum of human emotion?

My answer:
Very thought provoking question. Fear is certainly what we consider a primary human emotion (among other emotions, e.g. happiness, anger, and sadness). Thinking about fear as the first emotion to appear in living things evolutionarily though is interesting.

[When we talk about origins, there are two types: a single person's individual origins and evolutionary origins. Being that each person comes into the world with a complex nervous system, it doesn't make sense to think of fear as being each individual's ultimate primary emotion. Considering this question in an evolutionary sense is far more interesting.]

In an evolutionary sense, fear is - of course - vital. Fear as a threat detection and deflection system certainly seems to rank #1 in terms of importance.

In fact, earlier in the thread in which this blog post originated, I discussed Kandel's Nobel Peace Prize winning work on the "memory" of slugs. The response that sea slugs can "remember" to recoil after being pinched in the gill is certainly very interesting. While this borders on what may seem like a classical conditioning response, there could be the beginnings of fear like responses here. [In terms of fear and how it relates to memory, it may be interesting to note here that fear evokes a release of calcium in the brain that leads to highly ingrained encoding of information.]

Although Freud might have said that sex drive is more primary, I'm not so sure. Perhaps fear responses were actually first to develop evolutionarily and reproduction urges (which aren't really emotions anyhow) came about later. But sex, and it's relation to love, seem way more advanced than fear. As far as a sea slugs is concerned - it is a hermaphrodite so a drive to (at least) seek out sex probably isn't that developed.

Along with sex, maybe other positive emotions simply aren't as necessary from an evolutionary standpoint. In fact, maybe emotions from being comforted and soothed developed after fear as a way to reduce and control it. Paul Gilbert Ph.D. talks about the importance of the physiological Soothing and Contentment System - but soothing from what? My guess is anxiety / fear - which was on the scene first.

Along with positive feelings of being soothed, exhilaration or happiness might also be linked to fear. Just think about the last time you were on a rollercoaster. Since the feeling of fear seems more important than exhilaration, it may be the case that feeling exhilaration developed out of the fear system.

[Hm - just had a thought about bipolar disorder and the sadness and happiness responses being a result of a dysregulation of anxiety systems, one that leads to prolonged depression and the other that leads to constant exhilaration. Anyhow - back to the original question.]

After talking about some positive feelings and the link to anxiety, let's consider anger. We know that someone's "threat detection system" is activated when they're angry. In other words, they may feel anxiety, and anger is the motivator to act. Therefore, the argument could be made that anxiety is first and anger has developed secondarily in the more advanced fight or flight system. We now have two options in response to anxiety: fight (anger) or flee.

Ok, now let's shift from talking about fear arising first on the evolution scene, to fear underlying our everyday experiences now.

For fun, let's consider the link between fear and depression as a psychiatric disorder. When first reading this question, my mind immediately jumped to the link between these two things. Prolonged fear / stress releases enormous amounts of cortisol, which impairs the functioning of the brain (for the scientifically curious - along the Hypothalamic Pituitary Adrenal axis) and leads to depression. Therefore, prolonged fear / stress is experienced first, and we think this is one route to depression.

Now, I realize depression is a psychiatric disorder linked to sadness, but it is not sadness itself. Therefore, saying fear always prompts sadness would not be a logical inference per se. On the other hand, these symptoms may be intimately linked whereas fear sometimes comes first. For instance, one may experiencing horror at the loss of a loved one first, and then deep sorrow. Typically people don't go straight to sad. There is usually shock (perhaps an anxiety response) and then sadness kind of sinks in either seconds, minutes, hours, or days later.

Flipping back into evolutionary terms, it seems that sadness is quite an advanced emotion compared to fear. While I can imagine an insect having a developed reactionary response with the rudimentary beginnings of a fear system, I can't necessarily picture a sorrow system.

In short, I think the case can be made that fear (as it stems from stimulus / threat detection) may be the ultimate primary emotion.

Amelia's Website

Here is a link to my very talented colleague's website. She has some really great studies on emotion regulation available on it. A link to her website can also be found in the a section on right-hand column of this blog entitled "Other Psychology Blogs & Websites."

Why Do People Cut Themselves?

by Tara Deliberto

Celebrities like Megan Fox, Angelina Jolie, and Demi Lavato have all purposely cut themselves. But why?

Well, it isn't all that clear. And the answer "they do it just for attention" doesn't make too much sense.

Sure, getting attention could be part of the answer, but it's not that simple. If you've never cut yourself, consider this: of all the things you could possibly do for attention, is carving your skin with a razor really at the top of the list? Probably not.

After researching self-injury for several years, one thing seems certain - cutting immediately halts emotional pain. It might seem backwards that physical pain stops psychological pain. But we need to take a closer look.

Starting Generally

I would actually say a major contributing factor to self-injury is actually our tendency to make things too simple. Allow me to explain. Although judging what is right and wrong is super complicated - hence the whole legal system - we are quick to slap labels on people like "good" or "bad." But life is more nuanced than that! Of course labeling helps us communicate, but a lot of very important information gets lost when we stamp something as "good" or "bad."

More Specifically

Now getting more directly to the point of this post, the very same language we use to describe our world and communicate ideas to others, is used to communicate to ourselves. We think in words. We label ourselves as good or bad. We tell ourselves we are good or bad.

And what people are telling themselves right before they cut is nearly unbearable to hear. I'd imagine their mind is shouting things at them like "You're a worthless bitch. How could anyone love you? You disgust me."

The thing is, I don't think I've ever met a totally worthless, unlovable, and disgusting human being, whatever that is. It is usually very clear from a third party perspective that the self-talk of a person who cuts, is incredibly harsh and one-sided. Despite this, people go on labeling themselves anyhow.

Not only do people who cut tell themselves abusive things, they believe them too. This is a very important distinction. Once people learn to determine the difference between having a thought and believing it in therapy, we usually see symptoms improving a lot. It is one thing to think "Wow, I am a bad person," acknowledging it as just a thought, and moving on. It is another thing to think "Wow, I am a bad person" and believe it.

With a new understanding of abusive self-talk in the mind, let's shift to discussing the body.

The Body

Let's just say you're strolling along, thinking about how beautiful the sky is, when you walk into a telephone pole. The second after your toe smashes into the pole, are you still thinking about that beautiful sky? Probably not. You're just thinking about how much your damn toe hurts.

Now, what if you were thinking about how you're such a selfish slut? What if you believed it? Would you rather be in the emotional anguish that comes along with berating yourself or would it be easier to have your toe hurt?

Yeah, that's what I thought. You'd rather stub your toe, wouldn't you?

Right after the body sustains an injury, it is kind of hard to be caught up in your thoughts. The physical pain provides a mental break from really horrible self-talk. The pain becomes a vacation.

[It is worth mentioning that even if the emotional pain isn't necessarily tied to what some people might call irrational thought (but is from an actual loss or event), it still be halted by self-injury. Usually though, I'd bet there is some degree of extreme thought causing the pain to be increasingly intense.]

Now back to talking about cutting for attention. Sure, people could also be cutting for attention, but the picture is clearly a lot more complicated. On either side of the spectrum, you may have people who solely for attention, and on the other, people who cut and have never told anyone. Most likely, people cut for several reasons. Now, let's take this discussion a bit further from here.

While it seems that verbal thoughts like "You're a worthless cow" repeating over and over might be an important factor, there are many more pieces of the puzzle.

The Physiology of Self-Injury

There are some non-human primates, especially neglected ones, who tear out bits of fur when they're distressed. They actually harm themselves.

[Side note: The thought of a neglected monkey pulling out tufts of fur can be pretty upsetting, cant it? Unfortunately, while it is easy for some of us to have sympathy for monkeys who hurt themselves, it is more difficult to take a non-judgmental stance towards humans who cut.]

While these neglected monkeys harm themselves like humans, they don't have language capacities like us. Therefore, it's not very likely that abusive self-talk leads to self-harm in non-human primates. Percentage wise, the non-human primate self-injury may be maintained much more by the emotional, rather than a linguistic or symbolic system.

While language is a new development on the evolutionary scene, emotions are not. Emotions have been around for a while, without the complication of human language. As any loving pet owner like myself could tell you, animals have emotions.

What happens on a physiological level after someone cuts is not currently understood; however, my guess is that there is a release of endorphins, which make you feel good. We also know that heart-rate dramatically drops after cutting in people who often self-injure.

In short, on a mental/language level as well as an emotional level, there is likely some serious relief occurring right after cutting.

Wrapping Up

The way I see it at this particular point in time, is that very upsetting abusive self-talk is immediately halted, there a shift of attention to the cut, and endorphins are released, which serves to calm the body further.

Of course, the reasons people cut are diverse and they change over time. This may not be true for everyone. For instance, people may also cut to feel something if they're feeling nothing or numb. An additional reason people report cutting is to punish themselves. Perhaps sometime soon I'll write about these functions as well; however, it seems to me that the main function of cutting is to help reduce negative feelings in the moment.

Thankfully though, wonderful treatments like Dialectical Behavior Therapy (DBT) have been invented to help with cutting. If you or someone you love engages in self-injury, there are wonderful resources available. Go online and find a DBT therapist near you or join a DBT Skills Group near you.

Blog Info

For more posts on self-injury, check out The Psychology Easel's Self-Injury Section.

Feel free to follow me on Twitter at @TaraDeliberto and subscribe to this blog in the right sidebar.

Do You Self Harm?

If you engage in self-injury, an excellent resource is S.A.F.E. Alternatives, an absolutely wonderful organization devoted to the treatment of self-injury (you can visit their website at http://www.selfinjury.com/).



Also, a very helpful book on directly treating self-injury is Bodily Harm. Select this book in the icon above to purchase.

The best treatment for cutting is Dialectical Behavior Therapy (DBT).  Find a DBT therapist near you.

The Next Evolutionary Step for Humans

by Tara Deliberto

Recently a friend asked me what I thought the next evolutionary step for humans would be. My answer: the ability to be mindful. Most of us go through life without being present in the moment. The ability to have awareness of our own thoughts opens the door for greater control. Afterall, medititation increases the very part of the brain that is newest on the evolutionary scene - the neo cortex.

A Remaining Thought on Control

by Tara Deliberto

Today my meditation and yoga teacher described that the point of the practice this: to use the mind to release the mind. I think that pretty much sums it up.

Yoga (and life) is learning to find the balance between effort and ease.

Control

by Tara Deliberto

While new Western treatments incorporating the use of mindfulness techniques have an emphasis on decreasing control, many practitioners and patients alike are confused by the apparent increase in control over thoughts and emotions it fosters.

By increasing one's awareness of the thoughts, bodily sensations, and interaction between the two, one creates distance between the mind and what is produced by the body. This naturally produces an increasing sense of mastery over the self, which in essence is control. If you are able to focus your attention on your left pinkie toe during a meditation, for example, you are absolutely controlling your thoughts.

Now, if meditation fosters control of the mind and has been shown by numerous studies to be extremely effective in treating psychological disorders, why is control generally considered to be a bad thing? Why do third wave treatments proudly claim to decrease control? Well, when people attempt control techniques such as forcefully suppressing thoughts or changing their environment in a service to avoid their emotions, it generally leads to more suffering. This type of control, which is likely mediated by absolutes or black and white thinking, is what I like to think of as ineffective control. It doesn't allow for the experience of emotions. This is what mindfulness-based treatments decrease. While people may actively try and control their experience by using alcohol to avoid emotions, for example, those who overuse this strategy and are labeled alcoholics are typically said to be "out of control." Used in this way, the phrase "out of control" implies a lack of mindful control over the attempts to ineffectively control one's emotions.

Conversely, learning to mindfully control one's attention has been shown to be a favorable strategy in coping with a very wide range of problematic behaviors. It also does not involve black and white thinking. There is an emphasis on being aware of one's thoughts, bodily sensations, and experiences, without actively trying to change what cannot be changed. The difference between trying to control one's experience through the suppression of emotions versus through active focus on present are extreme; however, (if you ask me) both are technically control strategies. The latter type of strategy though, leaves room for the experience of negative emotions and thoughts when avoiding them would lead to more struggling. This is effective and adaptive.

It should be noted, however, that avoiding negative emotions may be a very favorable strategy on some occasions - for example, a woman may avoid continuing to feel negative emotions brought on by an abusive husband by leaving. In my experience some mindfulness practitioners actually misapply the idea that one should experience negative emotion by encouraging clients to endure painful situations when in reality, their patients are actually avoiding another set of negative emotions such as loneliness or fear of the unknown. It is tolerance to this latter set of emotions that needs to be fostered. Eagerness in encouraging clients to experience any negative emotions must be curbed with reason and a careful examination of what types of emotions are functional to avoid. Strict adherence to any set of rules without individual reasoning is certainly not favorable.

In the literature and when discussing attempts to change one's experience from what it has been, I think techniques should be labeled as ineffective control strategies or mindfully aware control strategies on an individual and situational basis.