Tag: InterestingResearch

Deranged, Inhuman, Disgusting

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Deranged, Disgusting, or Inhuman

In other words, deserving of your contempt.

(If you haven’t read Crazy, Stupid, or Awful, you might want to read that one first. Crazy, Stupid, Awful means you probably are thinking of your partner as a “Them” instead of thinking about the two of you as a “We” or an “Us,” but some careful, attentive, open listening might suffice. Like in They Might Be An Alien)

But contempt is something a little different.

 

The Gottmans (e.g., Gottman, 1993) really brought the idea of contempt onto the couples’ therapy scene, a kind of relational filter that says “I’m better than you, and you don’t deserve my basic respect.” Sometimes, it looks like sarcasm or condescension (speaking as if your partner really is stupid, or worse). Sometimes, it’s withdrawal (because you believe that your partner really is disgusting and you can’t stand to be around them). Sometimes, it sounds like demeaning put-downs (because you think your partner is just a real piece of shit). It’s dehumanizing (e.g., Kteily et al., 2022). And that’s a much bigger problem than thinking they’re a decent human being who you just really don’t understand or agree with. 

 

The impacts of contempt are probably quite a bit broader than just in couples’ relationships, too. As therapists, we need to be on the lookout for contempt of partners, but also of kids and bosses, among others. And there are some pragmatic things we need to think about – when parents are using sarcasm, condescension, demeaning put downs, and/or withdrawal/neglect with their children… we need to intervene strongly and quickly to help them make changes. Eye-rolling, name-calling, and that pinched-face look of disgust need to be taken with plenty of seriousness. When it’s someone talking about a coworker, boss, friend, etc., the easiest solution might be to simply get out of that situation or relationship… contempt (like real burnout) is pretty damn hard to come back from.

 

But then, we also need to look at the underlying cognitive structures that support contempt… Contempt “implies sense of superiority over [other people], pessimistic feelings about their possibility of betterment, detachment from them, and avoidance driven by detachment (Miceli & Castelfranchi, 2018). So, I’m going to go ahead and say (maybe outrageously?!) that contempt is never rational. So, to be clear, I’m not saying that anyone should stay in contact with someone they feel contempt toward. Maybe the contempt goes along with other thoughts/feelings that are quite reasonable and dictate that the appropriate behavior is detachment (e.g., an actually abusive partner, an actually unfair and unpleasant working environment). But that sense of down-to-the-ground superiority of one (aggrieved) person over another? Mmmm… that’s a tough sell for me. Dehumanizing a human being doesn’t fit the logic I understand. 

And there are personality structures, too. It’s possible to have a contemptuous “personality” (or long term attributional style, maybe?). Sometimes, that goes along with narcissistic and antisocial stuff (esp when the dispositional contempt is typically outwards), but sometimes the contempt is directed inwardly at the self, as well! (see Schriber et al., 2017). 

 

I’m sure how you choose to work on this depends on your theoretical orientation… I just wanted to take a minute to bring it to the forefront and make sure we’re not letting some important signs pass us by! 

 

Comment below: What other markers of disgust do you see in clients? Do you ever find it easy to blow those off? How do you work with clients on these deep cognitive structures? 

 

Gottman, J. M. (1993). A theory of marital dissolution and stability. Journal of family psychology, 7(1), 57.

Kteily, N. S., & Landry, A. P. (2022). Dehumanization: Trends, insights, and challenges. Trends in Cognitive Sciences, 26(3), 222–240. https://doi.org/10.1016/j.tics.2021.12.003

Miceli, M., & Castelfranchi, C. (2018). Contempt and disgust: The emotions of disrespect. Journal for the Theory of Social Behavior, 48(2), 205-229. https://doi.org/10.1111/jtsb.12159 

Schriber, R. A., Chung, J. M., Sorensen, K. S., & Robins, R. W. (2017). Dispositional contempt: A first look at the contemptuous person. Journal of Personality and Social Psychology, 113(2), 280-309. doi: 10.1037/pspp0000101. 

 

 

 

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? 

 

 

 

 

 

 

Big Pharma & Non-conditioning Shampoo

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Big Pharma & Non-conditioning Shampoo

 

I’ve been promising a “Big Pharma Rant” for a long time, and today I’m really inspired. Well, I’m inspired enough to start – I think it’s going to end up being a few mini-rants, which is probably better anyway. 

 

Here we go. See this conditioner bottle? (Yes, this post is born from an honest-to-goodness “shower thought.”) These folks did research, so that they could print the results on their bottle and get you to buy it. 

97% less breakage*

With an asterisk. Geez, at least they put an asterisk and then tell you right then and there what it’s compared to…. the mega-super-ultra-anti-breakage-shampoo-plus-conditioner-used-as-a-system vs. a non-conditioning shampoo. 

Listen, that’s not a super fair comparison. Using a non-conditioning shampoo is probably actually even worse for breakage than using no shampoo at all, but does anyone who is looking for super-ultra-mega-anti-breakage conditioner not already use conditioner? Don’t you really want to know if this conditioner is better than your regular conditioner?! 

(Side note: They pretty much all do this, and so I’m not really calling out a specific brand. If you recognize this bottle, I actually happen to love it and would highly recommend.) 

Ok, how does this relate to Big Pharma? Well, pharmaceutical companies often will compare their active medication product to a placebo. And that’s certainly better than not doing that. But that’s not REALLY what you want to know, is it? Don’t you want to know if an antidepressant (with all of its attendant side effects) improves depression more than, say, a 10,000 lux lamp that costs $40 and you only have to buy once? Or more than walking 3x/week? Or 16 weeks of CBT? Or, heaven forbid – a course of psychodynamic therapy?! Don’t you really want to know that before you spend thousands of dollars out of pocket getting transcranial magnetic stimulation? Or before they add an antipsychotic medication to your regimen? (This isn’t even getting at things like how long the benefits of medications vs. therapy last and how much they cost over time. Spoiler alert – therapy’s better on both metrics!)

But they’ll never do that. In the same way that the Uber-Fancy-Conditioner won’t ever make a comparison to The-Other-Uber-Fancy-Conditioner… because they know they won’t come out on top, or they know the differences will be so small that it won’t be worth the money they put into the study. So, we have to go find that research ourselves (I’m back to pharmaceuticals, btw – I don’t imagine you’re actually going to find conditioner-research!), and sometimes help our clients evaluate it, too. 

There are at least 4 more mini Big Pharma rants to come, so stay tuned! And, believe it or not, I’m not actually against the use of effective, well-prescribed, thoughtfully-considered psychotropic medication. Maybe I should I do a post about that, too.

 

Comment below: It would be awesome if you were to post here any additional research you come across about non-pharmaceutical treatments for depression and how they compare. There are just way too many for me to include today! Or any other comments, as always! 

 

 

 

 

 

 

Productive Purposeful Pleasant

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Productive – Purposeful – Pleasant

After ending last week’s blog, I realized I haven’t ever posted about this little language-based motivation/behavioral activation technique that I sometimes use with clients. Probably because I really don’t like it when people make (or especially seem to force) alliteration or acronyms, and I don’t want you to think I did that! Haha! This actually just popped up in a session one day, fully formed (fully P’d!) and it has been useful several times. 

This little technique seems to be sometimes beneficial with clients who have mild/moderate depression, the kind of anxiety that keeps them sort of paralyzed (not catatonically paralyzed! Just keeps them from moving forward effectively), and some who deal with procrastination. (Although straight mindfulness is good for all of these, too, especially procrastination.) 

The technique is really simple – it just involves (Step 1) taking the things on the client’s to-do list (whether that is take a shower and check the mail in the case of depression or the long list of household chores or whatever), and dividing them into these categories, or labelling them… is the task Productive, Purposeful, or Pleasant? (or some combo?)

*Wouldn’t it be nice to have lots of things on the list that are all three?!*

Step 2: Just take anything else off the list! What’s it doing on there, anyway?! This can sometimes bring a sense of relief and permission to clients who need it. 

Step 3: Make sure there are items in every category, especially the pleasant category! (This is a kind of sneaky way to measure anhedonia and sometimes to figure out distress tolerance ideas!) 

Step 4: Invite clients, in session if it’s possible or as homework, to choose items from anywhere on the list.

I often start with Productive… is there anything on there that they have the motivation/energy/etc. to do right now? If they can, they often feel a sense of accomplishment and also relief from “checking something off the list.” It’s ok to make use of session time to get this started! Do they need to make a dr’s appointment – just have them call, right now! Do they need to update their credit card information on their bill pay? OK, do it! 

If not, how about something purposeful (meaning tied to values, even if it doesn’t “get things done”)? Is there a value of relationships or being a kind person – choose text a friend from the list (add it right in the moment if it comes up!) Is there a religious/spiritual value – choose read a scripture verse. Is there a value of being a good parent – write a sticky note for your kid and put it in their room. Is there a value on making progress in therapy? Listen to your affirmations, read a few pages in the homework book, etc. Make sure that plenty of these are easy, low energy, low cost options. (This is a kind of sneaky way to get to identification of values, as well, which can be helpful in most cases.)

Nothing doing there, either? Well, no problem! Because you have a list of activities that are for nothing but pleasure! Encourage clients that choosing something from the pleasure list is OK! (There might be a little bit of cognitive work to do here, about being “allowed” to do something for pleasure when there are things on the productive list. And one of these days I need to do a post on how “laziness” is just a really good energy management strategy! HA!) But remember – doing something is better than doing nothing, and often increases motivation and productivity in the long run. Even if the pleasant thing is doing “nothing,” like taking a nap, sitting quietly, etc., doing it mindfully is a positive step! 

Comment below: What do you do to help clients with behavioral activation? 

 

 

 

 

Preposterous Quotes – Worry

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Actually, worry is a PERFECT use of imagination. In fact, it may be the most evolutionarily sound reason to have an imagination at all! The ability to “predict the future” accurately as it relates to potential dangers and obstacles is incredibly valuable, and that’s what imagining is! How else could we planfully navigate the world? 

Of course, lots of other wonderful and more pleasant uses for imagination. And overusing imagination to predict dangers/obstacles that are highly unlikely can be problematic. (That does happen quite a bit – in fact, in clients with GAD, 92+% of worries don’t materialize!) And catastrophizing… usually not helpful. 

But I have found that it can be helpful to clients who struggle with worry to both learn why their worry (in realistic quantity) is valuable, as well as learning to harness their imaginations for other productive and pleasant purposes! 

 

 

 

 

Best Quick Tips Ever Volume 2

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Best Quick Tips Ever (Volume 2)

Here are some more super quick, highly accessible techniques that we could be teaching clients! (Remember, don’t use these if the underlying theory isn’t already part of your clinical repertoire, please!) If you haven’t seen Volume 1, see those here. 

 

  • Imagine Yourself on a Hot Air Balloon (or Better Yet, Sitting on a Satellite) – This is an old Stoic notion, “Plato’s View” (more about that here) that current research also suggest can quickly reduce distress. This visualization exercise allows you to change perspective, throwing even the deepest, most overwhelming pains into relief against all the rest of what’s happening in the world.     
  • Half Smile – A DBT classic, this is possible the quickest and most available emotion regulation technique of all! The brain and body work both ways, you know! 
  • Sunlight – 5-15 minutes in the sun is enough to boost serotonin and improve mood. Add to that the fact that you’re probably removing yourself from a less pleasant situation to a more relaxed/pleasant situation by going outside (yay, behaviorism works!) and getting a little nature fix (bonus mood enhancer!), and it’s even better. 
    • Also, as a reminder, regular moderate sun exposure helps prevent depression, and if you do it in the morning, helps to improve sleep! Oh, and cognitive function! And work satisfaction!
  • Jumping Jacks (any kind of intense exercise immediately) – Even five minutes of intense exercise can improve mood in several ways – by “using up” stress hormones if they’re present (yes, that’s a gross oversimplification), by getting you out of a stressful or uncomfortable situation (unless you’re going to bust out some crunches right in the middle of the stressful work meeting), and/or providing an intense enough distraction to act as a distress tolerance skill.
    • And, over time, a really excellent treatment and prevention strategy for depression! (WAY better than antidepressants) 
  • Say the Thing, Out Loud. Even to Yourself. Especially to Yourself. – That icky feeling is more tolerable once it has words that go along with it (especially if it has accurate words that go with it). But, emotional labeling acts as an implicit emotion regulation strategy, and it’s relatively effortless. Plus, the benefits of expressive writing (decreased anxiety, depression, negative rumination, and improved mental and physical health, including enhanced immune functioning) extends to speaking aloud as well!  
  • Drink a Whole Glass of Water – not only does this just give you a tiny break from whatever stressor you’re in, it’s an opportunity to engage in basic self care and possibly to engage in a mindfulness practice. But there’s also research showing that being even a little dehydrated can contribute to fatigue, low alertness, and negative mood. So a simple glass of water might help you feel better, and help you gear up for more active coping! (Also, many of us work in environments where this is something we could even offer clients in session.)

Comment below: Your ideas for super cool, underutilized quick tips? Or have you ever used any of these with clients? 

 

 

 

Supplements are a thing

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Supplements Are A Thing

And it’s worth knowing about, because your clients might bring it up.

ETHICS NOTE: Don’t recommend them! That’s outside our boundaries of competence!! If you want to help clients in other areas, become a teacher of how to recognize credible sources and read the scholarly literature!

Here I’ll give you some research about mental-health related supplements that have happened to come up from my clients recently (links attached, of course!!). Probably this will end up being a series, but who knows? 

 

Comment below: Any supplements your clients are talking about, that you’ve looked into? Share your info! Anything you’d like me to look into for a future post?  

 

 

 

Book Announcement

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So… I did a thing…

Here’s a book! I wrote it. 

ROUTLEDGE published it, and the level of fanciness I feel saying that is not measurable. 

It’s a lot like this blog, only you can get it in paper and you have to pay for it. Oh, and it has no pictures. 🙂

Actually, it’s much more comprehensive and better structured than the blog, though the writing style is a lot the same and the idea is the same – let’s BE BETTER THERAPISTS. Let’s use theory and research and our colleagues to help us do that. 

Therapists, in general, I think will really like it and get a lot out of it. So will advanced practicum students and interns. 

At any rate, I’m supposed to tell important people. So, there you go! 

It is available at Routledge and through Amazon! Oh, and if you go to the new Book page on the blog, there’s a coupon code! 

 

 

Best Quick Tips Ever (Vol 1)

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Best Quick Tips Ever

 

There are a bunch of super effective, super-fast, super-easy techniques for stress reduction, emotion regulation, and more that therapists just aren’t teaching clients! Why?! I think it might be because people don’t know about them? Here’s a list of a few of my favorites, each with a little video. Well, except for the really self-explanatory ones. For those, I’m attaching some research because it’s hard to imagine these commonplace little tactics are actually effective! 

(Ethics moment – definitely don’t use these if the underlying theory isn’t already part of your clinical repertoire, please!)

 

  • The Dive Reflex – If you’re a mammal (and you are), and you’re stressed, put your face into cold water for 30 seconds. Instant changes in the stress response, thus calming anxiety and other dysregulated emotions. 
  • The Physiological Sigh – You do this, unwittingly. It’s that sobbing sort of thing you sometimes do in the middle or near the end of a big cry, or you at least do it in your sleep! It’s like taking 2.5 inhales and then a long exhale, repeat 3-5x. The end. Really good for quick emotional calming. (Side note: In real life, when your body does this naturally, it’s more like 1.5 inhales, but when I’ve taught it in therapy, clients are usually breathing very shallowly, and teaching them to do this consciously, 2.5 seems to work better – the first inhale to baseline, the second to what feels like “capacity” or a “deep breath,” and then that last little bit that “overinflates.”)
  • List 3 Things You’re Grateful For – Lots of research about this, but here’s a fun study about how gratitude reduces Repetitive Negative Thinking and thus reduces depression and anxiety. Even a single, small intervention, like listing 3 things you’re grateful for in the moment can change perspective and improve mood. 
  • If you already do EMDR, consider the Flash Technique – it’s like a quickie version of reducing SUDS, without processing the actual trauma (but has some limitations, of course). Remind me one day to do a post on what actually makes EMDR work (which isn’t bilateral stimulation).
  • Call a Thought a Thought – the simplest  of cognitive defusion strategies. Notice you’re thinking thoughts. Then say it to yourself, “I’m noticing I’m thinking XYZ,” or even “That’s just a thought.” Crazy powerful, quick, and accessible anytime. 
  • Controversial but interesting…. Take a Tylenol – Acetaminophen (paracetamol) reduces the pain of social rejection and of making tough decisions. Careful, though – it may also increase risk taking, reduce empathy, and decrease the intensity of positive experiences, as well. (And, of course, mind the risk of overdose!) 

Comment below: Share your favorite, research-based “quick tips” for clients!  

 

 

 

Telephone = Telehealth

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Telephone = Telehealth 

You might remember my rant about telehealth, fondly or irritably, but here is a little follow-up. One of my suggestions to clients when they begin telehealth is to mention any tech issues (e.g., lag) immediately, rather than waiting and tolerating that relational discomfort. I am willing to spend up to five minutes (but no longer!) working on a tech issue for telehealth. (Consider that, at some point, they’re paying us for IT work, which is definitely outside our boundaries of competence! Haha!) After then 5 minute mark, or after exhausting the typical fixes, I do something wild… I just call them on the phone.

Besides a large body of data indicating the usefulness of telephone consultation, and the history of telephone as the primary form of telehealth work, I came across a delightfully interesting study, with this main finding: 

Voice-only communication elicits higher rates of empathic accuracy relative to vision-only and multisense [voice and picture] communication both while engaging in interactions and perceiving emotions in recorded interactions of strangers. … Voice-only communication is particularly likely to enhance empathic accuracy through increasing focused attention on the linguistic and paralinguistic vocal cues that accompany speech. (Kraus, 2017)

That’s cool, huh?! Addresses one of the (apparently imagined!) 

Note that this research did not address the difference between voice only and face-to-face communication, which still has a lot of benefits over not being present, including client mimicry (e.g., Salazer-Kampf et al., 2020), interpersonal synchrony (e.g., Rennung & Goritz, 2016), neuroception of safety and social engagement cues (e.g., Porges, 2004), etc. So, I’m not suggesting that telephone is better than being in person together. Just that, if telehealth is necessary, phone might be an acceptable, or more than acceptable, choice!  

Comment below: Have you had great/not-so-great telephone sessions? What helped you have a good experience? 

 

 

 

 

References

Kraus, M. W. (2017). Voice-only communication enhances empathic accuracy. American Psychologist, 72(7), 644-654. doi: 10.1037/amp0000147

Porges, S. (2004). Neuroception: A subconscious system for detecting threats and safety. Zero to Three, 24(5), 19-24.

Rennung, M., & Göritz, A. S. (2016). Prosocial consequences of interpersonal synchrony: A meta-analysis. Zeitschrift für Psychologie, 224(3), 168-189. doi: 10.1027/2151-2604/a000252

Salazar Kämpf, M., Nestler, S., Hansmeier, J., Glombiewski, J., & Exner, C. (2020). Mimicry in psychotherapy – an actor partner model of therapists’ and patients’ non-verbal behavior and its effects on the working alliance. Psychotherapy Research. Advance online publication. https://doi.org/10.1080/10503307.2020.1849849

Why do we yell? (Just a theory!)

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Why do we yell? (Just a theory!) 

Specifically, this idea came to me during some couples’ work. Why do people yell at each other (and this probably goes for parents/kids, too…) 

Here’s a theory I have. 

Animals vocalize in lots of ways. But when do they “raise their voices”? What does the animal research say about this? (e.g., Seyfarth & Cheney, 2003) First, there are two issues here with my reading of the literature – one is that I’m not super familiar with the comparative (i.e., animal) psyc research and the other is that animal research is always observational and about making inferences – can’t ask them any questions! Just bear that in mind. But from what I can glean, animals probably get loud in three circumstances/for three reasons:

 

  • To demonstrate aggression, especially when they feel underpowered (i.e., actual predators who are about to eat prey are sneaky and quiet, but an animal that is afraid it’s about to get killed or eaten may get loud to try to discourage a predator)
  • To sound an alarm, either to warn others of their kind that there is a danger approaching or to call for assistance
  • As part of display meant to push another animal of its kind down the social hierarchy, in a competitive way 

So, whether or not this is precisely accurate, it has been an interesting topic of conversation with my couples. I explain this idea and then make it a little human…

“Is it possible that when people raise their voices, it’s because they’re feeling underpowered and they need a show a vocal strength because their argument isn’t strong enough on it’s merit? Might they get loud because they feel like they’re in danger and actually crying for help from their partners? Or sometimes maybe they just want to diminish their partner – try to shut them down by proving they’re more important, stronger, or otherwise farther up in the hierarchy?”

Then, after there is some buy-in, I bring it to the personal/situational level: “So when you raised your voice just now (or last night, etc.), which of those reasons resonates most with your experience?”

  • Sometimes they reluctantly identify that they lost their cool because they could tell they were losing the argument. That can open the door for looking at the merits of both positions in the less-intense therapy environment. 
  • Sometimes they reluctantly identify it as feeling in danger and crying for help, and that opens a door for softer emotions from them and softer responses from their partners. 
  • Sometimes they reluctantly admit that they wanted to push their partners down, they just wanted to win. And sometimes they try to wiggle out of that by saying “I raised my voice because they just weren’t listening to me!” (Which is a sneaky way of saying the same thing… I deserved to be heard more than they deserved to be heard.) 

Yeah, no one seems to really jump enthusiastically into any of those explanations. But they give clients food for thought, sometimes they come around later or bring it up in a later session. At the very least, it prompts a discussion about the process of the conflicts, and that’s usually a therapy win! 

 

Comment below: Do you happen to know more stuff about animals (esp mammals) vocalizing loudly? I’d love to hear it! (Not including the monkeys that scream for sex – haha!) Or, how do you help couples begin to address the process rather than just the content of their conflicts? 

 

Seyfarth, R. M., & Cheney, D. L. (2003) Meaning and emotion in animal vocalizations. Ann N Y Acad Sci., 1000, 32-55. doi: 10.1196/annals.1280.004. PMID: 14766619.

Photo credit – Joshua Cotten

 

 

 

 

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? 

Online Resources and Apps (Vol 1)

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Online Resources and Apps (Vol 1)

Honestly, I’m not a huge fan of online resources. Let me make a caveat – we’ve known for a decade that things like internet-delivered CBT can be effective for depression and anxiety (e.g., Farrer et al., 2011), and that can be a life saver for someone who doesn’t have easy access to therapy. It’s just that when I have in-person clients, I much prefer for them to have resources that we have created together or that I have made personalized for them. 

BUT… it’s 2021 and I’d have to be living under a rock to not engage with some of the really good stuff that available online and on apps. But… it’s 2021, which means the problem isn’t the availability of mental health resources/apps, but sifting through which ones are actually good! 

My requirements for resources/apps that I’ll suggest to clients are that they are (1) FREE, (2) EVIDENCE BASED (as appropriate), and worthwhile based on my actually trying them. (Like recommending books, I have an ethical problem with recommending something I haven’t fully tried). 

That said, here we go, in no particular order: 

Online resources:

Ali Mattu’s videos – You’ll have to browse around a bit to find the topic you client needs, but these are very well done and super on point from a research-based standpoint. The dive reflex episode is one of my favorites. 

Kristen Neff’s Self Compassion exercises – exactly what you think, better researched and less saccharine than Brene Brown, totally free. 

This free online course in Acceptance and Commitment therapy from Public Health Wales is pretty cool and comprehensive!

Now Matters Now is a great resource related to suicidal ideation, for clients and clinicians. 

I’m looking for some good DBT resources, btw. These videos are ok, but I’d like something more personable and more interactive. Please comment below if you know of any! 

Apps: 

Comfort Talk – this is an all-business, nothing-woowoo trainer in self hypnosis. Great research evidence! 

All of the VA apps are empirically supported and they’re nicely done. I like the CPT  and substance use apps as an adjunct to therapy sometimes, but the CBT-I (insomnia) is the one I recommend most. You don’t have to be a veteran to use them! 

Insight Timer – I’ve liked this one for a long time, mostly because of the variety of meditations that are available and the ability to search based on how much time you have. Great free alternative to apps like Calm and HeadSpace. 

Fluid – This is just a little app that lets you play with fluid dynamics (with lots of customization for time, color, etc.) It’s great for mindfulness work, and nice for clients who might otherwise fret while waiting in a line. It’s entrancing! You can see a screenshot above. 

Done– I searched HIGH and LOW for SO LONG looking for a simple, free app that would allow clients to easily track how often they do XYZ – whatever we’re working on. The free version of done is more than adequate – it’s perfect! 

 

 

 

Comment Below: What online resources or apps have you found to be helpful? Bonus if they’re free and evidence based! 

Preposterous Quote – Regret

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Um… sort of.

First of all, after people make choices, they can frame the choice event in terms of what they chose, or in terms of what they did not choose (Valenti & Libby, 2017).

Second, the research is a little more nuanced than that. Yes, “inaction” regrets last longer and are accompanied by a stronger feeling of loss. (Also, we’re more likely to regret non-fixable than fixable situations, and women are more likely to have relationship-related regrets while men are more likely to have work-related regrets. Sorry, I hate it when research supports “stereotypes,” too!) (Morrison & Roese, 2011)

Second, to the degree that we regret more the choices we didn’t make, it’s sort of because of a cognitive fallacy. When we make a “safe” decision and it turns out well, we’re happy with the outcome. When we then find out (or even imagine!) alternative outcomes that would have been better (this is called counterfactual thinking), we feel regret (that is, regret for the thing we “didn’t do” that would have led to the better outcome) and view our own, positive outcome less positively. (Seta et al., 2015)

When we make a “risky” decision and it turns out well, we are both happy with the outcome and relieved that it didn’t turn out badly. When we make a risky decision that turns out badly, we’re unhappy with the outcome, but more likely to use the information for: 

  1. making sense of the world
  2. avoiding future negative behaviors
  3. gaining insight
  4. achieving social harmony
  5. improving ability to approach desired opportunities (presumably because we regret past passivity) (Saffrey et al., 2008)

Add all of that to hindsight bias, and this whole subject is a real mess! 

 

 

Morrison, M., & Roese, N. J. (2011). Regrets of the typical American: Findings from a nationally representative sample. Social Psychological and Personality Science, 2(6), 576–583. https://doi.org/10.1177/1948550611401756

Saffrey, C., Summerville, A., & Roese, N. J. (2008). Praise for regret: People value regret above other negative emotions. Motivation and emotion, 32(1), 46–54. https://doi.org/10.1007/s11031-008-9082-4

Seta, C. E., Seta, J. J., Petrocelli, J. V., & McCormick, M. (2015). Even better than the real thing: Alternative outcome bias affects decision judgements and decision regret. Thinking & Reasoning, 21(4), 446–472. https://doi.org/10.1080/13546783.2015.1034779

Valenti, G., & Libby, L. K. (2017). Considering roads taken and not taken: How psychological distance influences the framing of choice events. Personality and Social Psychology Bulletin, 43(9), 1239–1254. https://doi.org/10.1177/0146167217711916

 

 

 

 

 

First, do no harm.

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First, do no harm. 

Despite the DoDo bird’s insistence, not all therapies are created equal. 

This won’t be a post explaining evidence based practice, or common factors, or how diagnostics should impact our therapy plans, or how psychodynamic therapy gets an undeserved reputation just because CBT is easier to manualize. (All possibilities for another day!) For today, I think it’s worthwhile to talk about how sometimes we had really interesting ideas and they turned out to be wrong. Some therapies have evidence demonstrating not just that they don’t work as well as other therapies, but that they don’t work at all or they actively damage clients! YIKES! 

Examples that might surprise you?

  • Critical Incident Stress Debriefing for PTSD
  • Grief counseling for normal bereavement
  • Relaxation treatments for panic disorder

Check this article by Scott Lilienfeld out here. 

 

Comment below if there’s one of those other topics you’d like me to write about, or if you have ever gotten training in any of these harmful therapies, or (heaven forbid!) you know someone who uses them.