Category: AmazingBrains

Start School Later

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Start School Later

I know it’s been awhile since I last posted, and it’s because I’ve been working on two pretty big projects. I thought I’d announce the first one here, as it’s ready to at least begin…

Soon, I’ll be starting a public education project to share the research about the benefits of starting high school at 8:30 or later. (I even got back on Facebook for this purpose. I hadn’t been on Facebook since my 10 year old was born – HA!) 

The body of research is huge and well established – teens go through (like all mammals do!) the adolescent sleep phase shift – a natural, developmental, biological delay in sleep drive and change in circadian rhythm that means they get sleepy later and become alert later. (See… you really WEREN’T just being lazy or undisciplined!) Teens also need more sleep than adults, or even older children – an average of about 9.25 hours/night! 

So, asking teens to be alert for driving or school at 7:30 is really like asking adults to be alert for driving or work at 3:30am! 

Research shows that delaying high school start times until 8:30 or later:

  • improves academics (less tardiness, fewer absences, higher GPAs, higher standardized test scores, better graduation rates, etc…)
  • improves teen physical health (healthier BMI, less obesity, less screen time, more physical activity, better dietary choices, reduced substance use, reduced risk taking, fewer accidents, fewer injuries, etc…)
  • improves teen mental health (less depression, less suicidal thinking and planning, less anxiety, improved mood, better emotional regulation, better coping strategies, improved teen-family interactions)
  • improves teen behavior (better decision making, less risk taking, less juvenile delinquency, fewer suspensions, better classroom behavior, less risky driving and sexual behavior, etc…)

Here, you can read a research summary that I put together specifically for my district (FBISD), but that is full of research relevant to any school district. 

And here, you can watch some videos (2-12min) that I put together, fleshing out some of the research a bit more, as well as addressing myths/misconceptions and common concerns/possible solutions. 

I’m still working on finishing up one other big project, and then I’ll get back to regular posts – I have tons in my mental queue, but just don’t have time to get them written out just yet. 

Comment below: Do you know any additional research I’ve missed? What time did you start high school? What time do your kids start? What other concerns do you think parents/teachers/etc have? Is there anything else that deserves a video that I don’t have posted yet? 

 

 

 

 

 

 

Misophonia

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Misophonia

Misophonia, or “hatred of sound,” is characterized by selective sensitivity to specific sounds accompanied by emotional distress, and even anger, as well as behavioral responses such as avoidance.

Or, as my 8 year old says, “Just thinking about the noise makes me die! Not literally. Metaphorically.” (Because yes, we do have ‘speaking accurately’ as a family value. What can I say? I’m a psychologist and a super-nerd.) Note, she says this while holding her ears and writhing. She follows up, “It’s like the sound goes inside my ears and then it gets in my body and makes all my muscles squeeze.” She squeals, like she’s something between angry and afraid. 

Yes, my darling. I hear you. For me, it’s like the sound goes inside my ears and then scrapes down all my nerves through my spinal cord. My teeth clench and my eyes close and my neck twists and my hip flexors tighten involuntarily. My autonomic system starts kicking in, but my brain has trouble turning that into a well-labeled emotional experience – something like completely irrational, slightly panicky anger disgust that’s not quite anger because I can’t quite get the cognitions to line up right.

For my daughter, it’s the sound of rubbing the seatbelt fabric. For me, the sound of a pencil writing on paper. For my husband, the sound of a rubber ball bouncing. 

If you’ve experienced this, you probably know it by now. But you can read more about misophonia here. Though it’s experienced by tons of people, it’s pretty new in terms of research and diagnostics. There is some cool brain data about the experience. It’s difficult to categorize, but if it’s significantly impairing a client’s ability to perform their basic life roles, it could probably be diagnosed at this point as Other Specified Obsessive and Compulsive Related Disorder. Though, I imagine in a decade or so, we’ll have a whole section about sensory issues and it’ll fit better there.  

Treatment is up in the air at the moment, though physicians, audiologists, and mental health folks are working on it. In our world, definitely there’s a place for distress tolerance work and maybe exposure & response prevention. But the place I’ve done the most clinical work on misophonia is couple’s therapy, believe it or not! Oh yes, most people can tolerate the discomfort on their own, but when it’s their partner making the sound, it takes on a whole new life! 

This is an experience that needs to be handled gently and cooperatively. (I mean, like we want everything handled in couples’ therapy, honestly!) The person who does not understand this probably needs to hear some of the science from us and be assured that their partner is not just making up their distress. The distressed partner probably needs to work on their distress tolerance and be sure they aren’t using their distress as a weapon. I will say that I have found that asking for a small behavior change when it’s possible is often easier, and that couples rarely want this to be the main issue. So, if the one partner could just not chew gum, that’d be great. Or throw away all the pencils with no eraser left – they’re just pencils! Consider ways to handle this issue as quickly and pragmatically as possible. Also, use it as an opportunity to talk about legitimate partner differences in experience! 

 

 

Comment below: Do you have this experience? For which sounds? Have you had clients bring it up, ever?

Post Concussion Syndrome

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Post Concussion Syndrome

Diagnostics is always more complicated then it seems – more like a DND roll than a simple symptom checklist or binary “has it” or “doesn’t have it” question. Here’s a great example:

 

Post concussion syndrome (PCS, or postconcussional syndrome) is a relatively vague set of symptoms that can continue to occur well after someone has had a head injury. The symptoms are wide and many of them are mental health symptoms, which is why it’s especially important for us to know about it. A headache is usually accompanied by symptoms like:

  • sleep problems
  • depressed mood
  • irritability
  • anxiety
  • trouble concentrating
  • difficulty with memory

Sound familiar?! YIKES! 

In fact, it’s so closely associated with other mental health conditions that 10-20% of student athletes meet criteria for it… even if they haven’t had a head injury – just because they’re stressed and somewhat sleep deprived! So, it’s important to consider all facets of this diagnostic mess!

 

 

PCS codes in ICD-10 as F07.81. Now, we probably wouldn’t want to diagnose Postconcussional Syndrome…. but we very well might want to put it in as a Rule Out or make a referral for additional testing/diagnosis with a physician or neuro specialist. 

 

We definitely want to have a question on our intakes that helps us keep this possibility in mind. For example, on my regular intake I have this question:

Have you experienced:
– chronic headache, migraine, vision changes, loss of consciousness, or dizziness?
– changes in your vision, hearing, other senses, or movement? (e.g., blurry vision, ringing in your ears, difficulty swallowing, trouble speaking, weakness or paralysis)
– difficulties with your memory, planning ability, or thinking clearly?

If so, when did you experience these symptoms and for how long?

That allows me to consider PCS, along with some other potential issues such as mild neurocognitive disorder and functional neurological symptom disorder (formerly conversion disorder). These answers can also “flesh out” other conditions, such as chronic headache associated with generalized anxiety disorder or difficulty concentrating as part of a depressive disorder. Loss of consciousness sometimes maps onto a substance use disorder. It’s a big question, but it gives lots of data and paths to follow-up on during the actual intake. 

Comment below: What are some of the diagnostically oriented questions you have on your intake? 

Phrenology

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Phrenology

If you aren’t familiar with phrenology, it’s a frankly brilliant pseudoscience from the early 1800’s that we completely dismiss now. But, today, I want to talk about how it’s brilliant.

The basic premise was that different parts of the brain handled different tasks/ personality structures and therefore you could determine a person’s faculties or traits by examining the shape of their skull. Of course, we know that’s not true now – growth in a certain area of the brain doesn’t make it bigger, but rather more densely populated with neural connections and/or better myelinated. But WOW… why do we summarily dismiss the outrageous assertion that the brain is an organ with many parts that serve different functions?! That’s basically the birth of neuroscience right there!

The reason I feel so passionately about phrenology (and why I like to keep a phrenology bust in my office), is because is science is always valuable, never perfect, and continually growing. And that’s a message I really, really want all of my clients (and all of us therapists) to know! Not just about science, but in the larger sense of the message “not to let the perfect be the enemy of the good.”

Comment! What’s something in psychology that we don’t really give a lot of credibility to anymore that has still helped you?

 

 

 

 

Rule of Three

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Rule of Three

I want to talk about the idea of false dichotomy, because they’re both so easy and so destructive.

The tendency to falsely dichotomize (AKA splitting, black-and-white thinking) has been a central issue in psychotherapy since Freud, Kernberg, and Klein. You’ve got two hands and two eyes and two brain hemispheres. There are “two sides to every story.” It so often seems like there is yes-and-no, for-or-against, right-or-wrong. Worse…. Conservative-liberal, masculine-feminine, us-them.

And that’s probably because our brains – beautiful, complex systems that they are – often use dichotomization to help us live faster in the world. (More on this in a future post.)

This happens often, and to our detriment. (Serious statisticians seem to be the only people who really know this!) Clients limit their own options, we constrain our therapeutic directions, and we stifle our diagnostics and conceptualizations.

And the trick to not falsely dichotomizing is oh-so-simple. Just make the rule of three. All questions have at least 3 answers. Don’t do an ethical decision making model without at least 3 choices of possible actions to evaluate. Put at least 3 empty bullet points on your treatment plan template. Make a deal with your consultation partner – not just playing devil’s advocate (which is a great role for them), but playing the role of horizon-broadener. When you create counterthoughts in cognitive work, make at least three. Prep all of your clinical worksheets to match. When you evaluate the “B” in the REBT method, identify at least 3 possible beliefs. When you delineate clients’ values in ACT, make 3 the minimum magic number for actions-in-pursuit-of-values. When you and a client are interpreting a dream, include at least 3 hypotheses.

Don’t worry… you won’t end up limited to just 3 and end up unwittingly stuck again. Three gets you out of falsely dichotomizing and things really open up from there.

 

Comment: When have you noticed false dichotomies in session?

 

 

 

Easier to believe what we fear

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It’s easier to believe what we’re afraid of…

It’s easier to believe what we’re afraid of, than what we hope for. (Almost always, for almost everyone.)

I can’t tell you how much it changed my practice when I realized this phenomenon, and began explaining it to clients. Here are two ways to think about it.

 

  • Let me tell you a story about evolution. (Just a story, mind you. This isn’t the time to get bogged down in phyla and epigenetics and all that.) Long ago, there were two kinds of people. One group of people saw a coiled vine and assumed it was a coiled vine. They were promptly bitten by a sneaky snake and all died. Thus, they have no living descendants. The other group of people saw a coiled vine and jumped away, thinking it was a snake. They did a lot of unnecessary jumping, a little necessary jumping, and a lot of staying alive and going on to make babies. They are our great-great-grand-cestors. So, we’re all evolved to be a little jumpy (get it? “jumpy”? haha!).
  • If you don’t like to think about it think way, you can also think about it from a very pre-frontal cortex, literature informed stance. Humans tend to be risk averse – a loss of $5 is more distressing to us than a gain of $5 is joy-inducing. In any given situation, we’re likely to put more emphasis on what we could lose than what we might gain. Fear and aversion conditioning (under most circumstances) also happen faster than other kinds of associative learning. So, if you mistake a snake for a coiled vine once and have a near miss – you’re quick to avoid vines in the future. (But you don’t so quickly change your approach to potential snakes when just one turns out to be a vine – thank goodness!) So, it’s easier to believe what we’re afraid of than what we hope for.

 

Let me just give you a few examples of application:

I know you’re already thinking of your classic GAD catastrophizer. Good, that’s #1.  Also, this leads to exacerbated social anxiety, as clients overestimate the likelihood of negative judgment. It contributes to the ever-building cause-effect sequences in OCD, because clients misjudge the likelihood that events are related. Phobia maintenance, misinterpretation of panic symptoms, etc.

And it’s not limited to anxious clients. This is the dad who can’t listen to his teenager’s needs because of his fear for her safety. It’s the workaholic (whose husband is in therapy because she can’t squeeze it in) who doesn’t realize she has a dual income family. It’s part of what maintains the hopelessness of your depressed client, the migraines of your “under-adequate”-mom client, and even the frantic relational grabbiness of your client with BPD.

Also true in your couples – when one partner is afraid of being cheated on again – he wants to hope it won’t happen again, but it’s much easier to be afraid that it will. When sex is painful, she wants to hope that it won’t be next time, but she’s afraid it will be. That’s easier to believe, and that leads to tension, and that leads to more pain. When he has an erectile “failure,” it’s harder to hope it won’t happen than to be afraid it will, and that leads to performance anxiety, and that leads to more “failure.”

It’s the beginning of so many self-fulfilling (self-defeating!) prophecies. And while we can’t change the fundamental neurology (and maybe don’t want to), bringing our own and clients’ awareness to this little quirk of our brains can help us all to pause, and bring a little more prefrontal cortex to our otherwise limbic reasoning. Here are a few specific things that can help:

 

  • Accept their fears with gentleness, and help them to extend self compassion
  • Work on reducing the actual and/or perceived consequences of the feared event
  • Co-create strategies to gain information that will help client evaluate potentially fearful situations
  • Teach this phenomenon to help clients reduce their emotional reasoning

 

Comment below with examples of how you’ve seen this in action with your clients!

 

 

 

 

Seven +/- Two

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The Power of 7 +/- 2

(How Working Memory Works in Therapy)

How many things can you remember to get from the grocery store without writing it down? Well, never mind, I guess I already gave you the answer. Obviously, it’s 7+/-2. Or it is for most people.

And you probably learned about this in your intro psych class in college. But how is it meaningful in therapy, you ask?

It’s meaningful because your brain, and your clients’ brains, are pinball machines. You can really only hold about seven pieces of information in your brain at a time, and relatively small pieces of information at that. And they just “bounce around in there,” ad infinitum, unless we do something intentionally to get them out. And here are three ways that we can capitalize on this quirk of our brains in therapy.

 

#1: Journaling

I know that you already know that journaling is awesome. I know you could extol its benefits to almost any client, I know that you’ve seen it work its magic, maybe in your own life, and (because I’m a therapist, too) I also know that you sometimes recommend it for clients as homework just because you don’t know what other homework to give them. (We all do it!) And that’s OK, because journaling is pretty safe and, let’s face it, it sort of is magic. What you might not realize is how the 7+/-2 function of the working memory plays into the effectiveness of journaling, and how you might be able to use it even more intentionally and beneficially than you have been. One of the ways that we can get those bouncing pinballs inside our brains to get out is to write them down. I’m sure you’ve given this assignment to your anxious clients who have trouble getting to sleep at night because their pinballs are all the worries that they have about the next day. And you encourage them to put a pen and paper next to their bed, so that they can write down any anxious thoughts that they have or anything they need to remember for tomorrow, temporarily letting it go so they can sleep. Great!

Occasionally, that has unintended consequences. And you have a client who, instead of staying up for two hours thinking about the same five worries over and over, stays up for five hours writing down all the worries that came up after they wrote down the first five. And while they don’t like that very much, that’s part of the magic. When those five, seven, or nine thoughts keep bouncing around, they don’t leave any space for anything new. They don’t leave any space for other worries or concerns, and then those get kind of trapped, unexpressed, maybe even living inside and wreaking havoc on the client’s body. (More on this kind of thing in another post.) So they are not aware of, and cannot make you as their therapist aware of, all of their legitimate concerns. Journaling helps them to flesh all of those out. As if that weren’t enough, those seven pinballs also keep other new thoughts from coming in. Hopeful thoughts, new solutions, brilliant ideas, etc. So, one of the ways that we can take advantage of the 7+/-2 principal in therapy is to use journaling in a targeted way, whenever we want to give clients freedom to explore both the true breadth and depth of their concerns and also open them up to new possibilities.

 

#2: Healthy Conflict

Ok, how often have you had a couple in therapy and they’re discussing their latest argument, and the one of them who remembers everything perfectly (because there’s usually one) pulls out some exact quote from the other person that was really hurtful, and then the other person says, “ok, yes, but I was mad, I didn’t mean it!” And naturally this never satisfies the hurt partner, and they don’t believe them.

(Let’s be very honest, how often have you said that? And you know you didn’t really mean it, and your partner doesn’t buy it. And how often has your partner said that, and you didn’t buy it? Hmmmm?)

Let’s put this in the context of 7+/-2. When we’re upset about something, we ruminate. It’s one of the easiest times to see 7+/-2 in action. One thing that our boss/mother/partner/kid/etc. says – we just repeat it over and over along with a refrain of “how dare they,” and a chorus of “I didn’t deserve that.” That’s it. Over and over. And that’s bad enough by itself, right?

But then, we actually bring it up with the other person. And as we are “having our say,” we start with all of those things (pinballs) that have been bouncing around. After we say them out loud… That’s right, they’ve made a way for brand-spanking-new thoughts. Brand new thoughts with brand new words that we haven’t taken the time to decide whether or not we want to say. And because all of those pinballs have just made space, in the heat of that moment, all of these new, unfiltered, unevaluated, and probably regrettable words just fall out. That’s what’s happening a lot of the time when we say “I was mad; I didn’t mean it.” And you know what? It’s pretty much true.

We really don’t want to base our jobs on an unedited report that we threw together at 2am without really thinking about it. That’s not our “real work.” Our real work is composed, thoughtful, edited for appropriateness, thorough, concise, and clear. That’s what we want our bosses to judge us on. Our best. And that’s what we want to give to our partners, and what we want them to judge us on as well. So, you can teach this to couples along with other techniques for conflict management (more on this in another post), and help them to keep their pinballs from falling out and rolling all over the floor.

 

#3: Person Centered Therapy

PCT is just magic right? Right. But seriously, past the humanistic underpinnings, have you ever wondered-in a technical sense-how person centered therapy works like magic? I think I have an idea. Just an idea of mine, mind you. But it’s based on the 7+/-2 principle. And it goes like this:

What are the main techniques of PCT? Silence, reflection, paraphrasing, summarizing. (Remember, in honest-to-goodness Rogerian PCT, even questions aren’t very present.) So, what do these techniques to do? First, silence allows clients space to get the first seven pinballs out of their heads. Then, reflection allows them to know that their pinballs are safe, not going anywhere, and you create a holding space inside the session for those pinballs to live for a while, almost like little sticky notes. Lo and behold, the client suddenly has more access to their own genuine thoughts and feelings that have been locked up behind those first 7 thoughts. Great! So they can put even more pinballs out into the session with you – emotions, ideas, etc. – that they may not have had access to before. Like journaling, that might be therapeutic enough on its own.

But PCT goes further. When several of those pinballs/sticky notes get out into the space between you, it’s time to paraphrase. When you paraphrase, it’s like taking a couple of sticky notes, condensing them, and putting them together on one index card. Imagine, just by paraphrasing, you might take 30 of your client’s sticky notes and turn them into 15 index cards. Then what? Summarizing. When we summarize, and draw together common themes, it’s sort of like taking those index cards, condensing them even more, and maybe stapling them together. So, by the end of one session, you’ve let a client have access to much more of their internal experience, maybe even some of their inner wisdom, you held all of it safely in the session with you, and you’ve condensed it and given it back to them in packages small enough and few enough that they can make a new 7 +/-2 and they can re-organize their internal experience. That gives them more “brain space” for knowing themselves well, entertaining new ideas, in essence… space to grow.

 

Now, go do magic with the power of 7+/-2. Comment with how it works out for you!