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My Father’s Flag: Reflections on Veteran’s Day

Wednesday, November 11th, 2015

My father chose February in which to die: Columbus, Ohio’s cruelest month. At least, on the day he was laid to rest, the sun shone magnanimously. When we arrived at the cemetery, I was surprised to see three uniformed Navy soldiers.

081111-N-2013O-003 My dad was a Navy veteran of World War II. He served for several years toward the end of the war, later telling us, “I wouldn’t take a million dollars for the lessons the war taught me, and I wouldn’t take a million dollars to do it again.” That said, the experiences he shared were mostly positive; more McHale’s Navy’s PT 73 than JFK’s PT 109. And his time in the service stayed with him. As he aged, my dad always wore a ball cap while boating, defending his balding pate from the sun. And it was always cocked jauntily to the left. I asked him one time why he wore it like that and he recalled being disciplined more than once for thus insouciantly tipping his Navy “Dixie cup” cap, like Steve McQueen in The Sand Pebbles. “After I got out of the service,” he said, “I vowed that nobody was ever going to tell me how to wear my hat again.”

On this cold winter morning, following the religious ceremony at his gravesite, the Navy personnel engaged in their military ritual. First was the playing of taps. Granted, its plaintiveness was diminished by the fact that it came from a boom box, but, “Hey,” joked my brother, “It’s not like he was a General or something.”

I found the handling of the flag that draped his coffin more moving. With reverence and precision, the soldiers lifted it carefully, folding it in tight triangles, ending with the blue field of stars. A soldier knelt before my mother and presented it to her, “on behalf of a grateful nation.”

I did not follow my father in service to our country. The Vietnam War ended just as I was turning seventeen. Over the course of my career as a mental health counselor, though, I have treated many of the survivors of that conflict, and over the last few years, a new procession of wounded warriors has begun. I never leave an encounter without thinking that, had I been a year or two older, my own story might have been quite different. Animal House might have metastasized into Apocalypse Now.

When my mother died, the flag – which she had wrapped, rather incongruously, in an old plaid sheet – was one of the first things I took with me. It now resides in a bottom dresser drawer in my bedroom. On each of the fourteen Veteran’s Days since my father’s passing, I take out the flag and remember his service, I recall his stories, and wonder about ones that he didn’t tell. I say a prayer of thanks to him, his comrades, and those who continue to serve.

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The Baker Act and Mental Health Court in Sarasota

Sunday, August 4th, 2013

130804 mental health court

Prior to 1971, the laws in Florida regarding due process and civil rights of persons in mental health facilities – which dated back to 1874 – were in a sorry state of affairs.  With signed affidavits by three laymen and the approval of a county judge, you could be committed to a mental health hospital.  There was no specific period of commitment before a person’s confinement would be reconsidered by a judge. The standards were so lax that, reportedly, the crony of a local judge would periodically have his wife committed so he could carry on a dalliance with another woman. 

All this ended in 1971 due to the work of Florida state representative Maxine Baker, who spearheaded the passage of the Florida Mental Health Act. Referring to the treatment of persons with mental illness before the passage of her bill, Representative Baker stated, “In the name of mental health, we deprive them of their most precious possession – liberty.”   The Baker Act, as it would come to be known, prohibited the indiscriminate admission of persons to state institutions or the retention of persons without just cause.  The law also prohibited the placement of persons with mental illnesses in jails, unless they had committed criminal acts. (more…)

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True or False: Scientists Study How We Remember

Tuesday, July 30th, 2013

In the 1958 film Gigi, an older couple recalls in song how they met decades earlier:

  • Him: We met at nine
  • 130730 memory4Her: We met at eight
  • Him: I was on time
  • Her: No, you were late
  • Him: Ah, yes, I remember it well
  • Him: We dined with friends
  • Her: We dined alone
  • Him: A tenor sang
  • Her: A baritone
  • Him: Ah, yes, I remember it well

It’s happened to all of us.  I will attend my 40th high school class reunion next week, an opportunity for memories that are anywhere from pleasantly fuzzy to outrageously inaccurate.     “The vagaries of human memories are notorious,” wrote James Gorman recently in the New York Times.

Many years ago, when I was trained as a psychotherapist, the role of memory was undergoing a radical transformation.  Child sexual abuse was being addressed in psychotherapy and in our culture as never before.  The diagnosis of Multiple Personality Disorder (MPD), a condition that develops in the mind of victims to cope with chronic trauma, was increasingly popular, earning even its own scholarly journal.  

The diagnosis of MPD was based on the theory that trauma victims would dissociate, cordoning off life-threatening experiences into fractured slivers of personality.  The construct, while labeled by some as fashionable and unscientific, was actually first identified by Pierre Janet in the late 1800’s, then called hysteria.  In the 1980’s the term became so popular that the definition itself fractured into overinclusive and underinclusive camps.

Of particular controversy was the validity of memory.  Recollections of sexual abuse by a family member, ritual Satanic abuse and sex cults created alarming reverberations through the culture.  Could all of these be true?  The revelations destroyed families and even communities.  To combat these accusations, alleged offenders coined the term False Memory Syndrome, suggesting that not all memories, however vivid, were true.  Therapists sniffed at this sacrilege, calling it the “Perpetrators Club.”  Not being believed, they said, retraumitized the victims of abuse.

Of course, this was true.  However, the truth of what actually happened was much more difficult to determine.

Not only are false, or mistaken, memories common in normal life, but researchers have found it relatively easy to generate false memories of words and images in human subjects. But exactly what goes on in the brain when mistaken memories are formed has remained mysterious.

130730 memory2Now scientists at the Riken-M.I.T. Center for Neural Circuit Genetics at the Massachusetts Institute of Technology say they have created a false memory in a mouse, providing detailed clues to how such memories may form in human brains. Mr. Gorman wrote about the study this week.

Edvard I. Moser, a neuroscientist at the Norwegian University of Science and Technology, says that although mice are not people, the basic mechanisms of memory formation in mammals are evolutionarily ancient. At this level of brain activity, he said, “the difference between a mouse and a human is quite small.” In both, memories form in an area of the hippocampus called the dentate gyrus.

“What I find fascinating about this,” Dr. Moser said, “is that you actually can point to a physical substrate to memory.” Neuroscientists have long talked about this, but Dr. Moser said the recent research is the closest they have gotten to pointing to a spot in the brain and saying, “That is the memory.”

130730 memory3All of us long to know the exact details our story, from the adopted child to the traumatized teen to the aging patient.  Usually, we never get our wish.  But we get something better: we have the blessing to rely on the support of friends, family and professionals.  I know from years of experience in the consulting room that when we share our story – whatever details we do have – we heal.   I am always honored and humbled when individuals choose to involve me in that process, and am reminded of what Ram Daas said: “We are all just walking each other home.”

For more about trauma treatment in Sarasota, read on.

 

 

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Did Bath Salts Cause Zombie Attacks?

Wednesday, July 24th, 2013

130723 zombie2A few months ago, I received a call from a local journalist.  It wasn’t the first time, but I’m always flattered when I’m called upon for my expertise and experience.  The subject is usually related to some trend or event that sells papers or garners viewers, but I confess I was taken by surprise: the reporter wanted to talk about zombies. 

New York and Miami had recently seen attacks where – in a psychotic rage – suspects had attempted to eat the face off an unwitting victim.   The culprit in both cases seemed to be bath salts.

“Let’s get down to the question everybody is dying to ask,” he said. “Will using bath salts make me eat my spouse’s face off?”  Yes, I told him, but only under some very specific conditions.  You’ve likely combined it with other psychoactive chemicals, you’re already suffering from some preexisting mental illness, and your spouse richly deserves it.

Kidding aside, the truth is the person most likely to be hospitalized or die from bath salts is not some faceless victim: it’s you. Symptoms you can expect from ingesting this drug are hallucinations, agitation, suicidal thoughts, chest pains, high blood pressure and rapid heartbeat.

130723 zombie1Bath salts is the street name for the latest type of designer drug. It comes in several forms and can be snorted, swallowed or injected. A designer drug is a derivative of an existing psychoactive drug that has been chemically modified with the goal of preserving the mind-altering properties of the original while skirting drug laws. In other words, if I can change a few molecules in the lab, I have a ‘legal’ drug that I can sell for low cost at high profit anywhere from convenience stores to specialty head shops. Bath salts contain two psychoactive chemicals that are synthetic forms of the Khat plant, which is typically found in East Africa and is illegal here. Why is it called bath salts? Nobody really knows, but my guess is because it trips off the tongue easier than 3,4-Methylenedioxypyrovalerone.

So who uses bath salts?  Typically people who have already been immersed in the drug culture for some time.  Your maiden aunt isn’t going to walk into 7-11 and say, ‘Hey, I think I’ll try bath salts!’  But frequent drug users have become inured to the legal and social prohibitions of using drugs, and even common sense has taken a hit. So you’re dealing with a population that isn’t going to listen much to warnings about this stuff.

As far as I can tell, there haven’t been any reports of drug fueled cannibalism in Sarasota, so you probably don’t need to worry about being attacked. But bath salts are far from benign.

130723 zombie3The constant change in formula is hazardous. Think of the movie Multiplicity: Michael Keaton, a busy suburban dad and husband, makes a copy of himself to take charge of things while he’s at work. It works beautifully, so he makes another clone. And another. With each iteration, though, the copy degrades, with unexpected and calamitous consequences. It’s the same with designer drugs, but without the humor: You never know who made it, how far this version is from the original, the potency and what side effects you can expect. Substance abuse is my field — I’ve been around long enough that I don’t consider myself an alarmist, but this stuff scares the bejesus out of me.

I think I’ll stick to my current drug of choice: a Skinny Vanilla Latte.

For more information on bath salts, read on.

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Belief In God And Psychotherapy

Tuesday, July 23rd, 2013

130722 ReligionFor psychotherapy, God has always been a problem.  Among the scientific theories for understanding human behavior, the acknowledgement of the supernatural is generally lacking.  Freud, the founder of our profession, saw God as an illusion based on the infantile need for a powerful father figure.  To him, religion was a convenient instrument for controlling people – the institutional representation of the super-ego, or conscience.

Belief in God and psychotherapy share significant traits:  hope, redemption, change, and their similarities spawn a slippery slope.  Thus, every psychotherapist must come to grips with this pesky interface, for even Darwin, the secular scientist, observed, “A belief in all-pervading spiritual agencies seems to be universal.”

A good percentage of therapists who hold strong religious faith unabashedly integrate it into their practice, convinced that faith trumps theory.  Others steer far clear of the subject, believing that the power and influence incumbent in the therapist’s role is too potent to tread the hallowed ground of religion.  A psychiatrist I trained with years ago acknowledged the power of belief, although he was scrupulously agnostic. At times, rather than explain to a patient the biological mechanisms of neuroscience, he would leverage the patient’s own belief system.  Handing them a pill, he would say, “Let’s try this.  It just might work.”

130722 Religion1

Dr. Viktor Frankl

Logotherapy, a branch of existentialism founded by Viktor Frankl, seems to allow for both positions.  Dr. Frankl posited that finding the meaning and purpose in one’s life is the task of living, and of psychotherapy.  He said there are two paths to meaning:  finding meaning that already exists in God (the teleological approach), or finding meaning in one’s own existence (the mechanistic approach).

In a 2011 Gallup poll, 92 percent of respondents stated they believed in a personal God.  So simply ignoring The God Problem seems  either impractical or specious. God is simply too ubiquitous – inhabiting even the consultation room.

Belief in God and psychotherapy has not been studied much, but recent research published in The Journal of Affective Disorders may start a new conversation.

Scientists at Harvard Medical School examined relationships between belief in God and treatment outcomes, and identified mediating mechanisms.  Belief in God, treatment credibility/expectancy, emotion regulation and congregational support were assessed prior to treatment.

130722 Religion2“Patients who had higher levels of belief in God demonstrated more effects of treatment,” said the study’s lead author, David Rosmarin.  “They seemed to get more bang for their buck, so to speak.”

Of those who expressed the strongest belief in God, half also had very high expectations for the treatment, while 8% had very low expectations. In contrast, of the patients who said they had no belief in God or a higher power, only about 5% had high expectations for the treatment. Belief in God and psychotherapy, but not religious affiliation, was associated with better treatment outcomes. With respect to depression, this relationship was mediated by belief in the credibility of treatment and expectations for treatment gains.

So at least acknowledging the role of faith in psychotherapy now has some science behind it.  Whether this is because of Pascal’s claim that there is a god-shaped vacuum in the heart of every man, we may never know. Maybe it’s as simple as my mentor claimed: “This just might work.”

For more on faith-based therapy in Sarasota, read on.

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Science Finds Evidence of Depression in Young Children

Friday, July 19th, 2013

130717 Depression in Chidlren.It’s easy to feel ambivalent about psychotropic medication.  Pharmaceutical manufacturers, insurance companies, and the American Medical Association are some pretty undesirable sorts, and their misdeeds are well documented.  In 2007, Purdue Pharma, its president, top lawyer and former chief medical officer paid $634.5 million in fines for claiming that Oxycontin wasn’t dangerous. There have been reports of unethical experimentation and clinical trials by pharmaceutical companies in Africa using spurious informed consent methods.  And insurance companies? Don’t get me started.  Michael Moore did a scathing expose of this unholy trio in the documentary Sicko.

But it’s also true that psychotropic medications serve a valuable role in the treatment of mental illness.  With suicide as the 10th leading cause of death in this country, and depression affecting one in five people sometime during their lifetime, we can’t let our prejudice get in the way of saving lives. 

Our antipathy toward psychiatric medication is never more acute than when we talk about treating our children.  The field suffered a setback several years ago when it was suggested that the use of antidepressants in teenagers actually increased the risk of suicide.  The correlation was not conclusive, however: a 2003 study by the U.S. Food and Drug Administration (FDA) found that no completed suicides occurred among nearly 2,200 children treated with SSRI medications. But about 4 percent of those taking SSRI medications experienced suicidal thinking and some suicide attempts, twice the rate of those taking placebo.  Still, everyone agrees that the risk should not be ignored.

130718 depressed teenAnother complicating factor is that – as every parent of a teen knows – emotional lability is one of the hallmarks of adolescence.  So what do we expect “normal” to look like in our youth?  Certainly we don’t want to medicate away developmentally appropriate teenage angst because we find it inconvenient.  But sadness and depression are not synonymous, and we ignore depression in children at their peril.

This week, the science of brain chemistry helped dislodge some of the fear and prejudice related to depressed kids.  The news, published in the July issue of The Journal of the American Academy of Child & Adolescent Psychiatry, stunned lay observers and professionals alike.   Using functional magnetic resonance imaging, researchers have found brain changes in preschool-age children with depression that are not apparent in their nondepressed peers. Researchers examined 23 children 4 to 6 years old who had been diagnosed with depression and 31 of their healthy peers. Researchers used well-validated tests to diagnose depression.  None of the subjects were taking antidepressants.

130718 teen depressionThe children underwent M.R.I. brain scans while viewing pictures of happy, sad, fearful or neutral faces. The researchers found that the right amygdala and right thalamus activity was significantly greater in the depressed children than in the others, a finding that has also been observed in depressed adolescents and adults.  This may be the earliest evidence of alterations in functional brain activity in depression using Magnetic Resonance Imaging.  The findings also raise the intriguing possibility that disrupted amygdala function is a depression-related biomarker that spans development.

As an addictionologist, this study is particularly fascinating to me.  Successfully treating depression at an earlier age might prevent teens from self-medicating with alcohol and drugs and progressing into active addiction.  What an exciting time it is to be working in this field!

If you are concerned that your child might be depressed and want to know what do to, read on.

 

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Advances in Treatment of Depression

Friday, July 19th, 2013

130718 depression txI was born in 1955, as the Dark Ages of mental health treatment in the 20th Century was coming to an end.  There were 600,000 mentally ill people – 356 per 100,000 – more or less permanently hospitalized in public or private asylums.  Those ravaged by severe and persistent mental illness couldn’t walk the streets without being victimized, being arrested for crimes big and small, or worse.   With our limited understanding of mental illness – even though the standard of care varied widely -hospitalization was actually the most humane form of treatment available.

Over the next few years, medications that would manage depression and psychosis came into popular use, and these folks were  deinstitutionalized, and treated in community mental health centers.  (President Kennedy, who had a sister with mental illness, enacted the nationwide system.)  Not much progress was made in the next two decades with regard to medication.  The side effects of antidepressants were often worse than the cure, so many continued to suffer, or self-medicated with alcohol and other drugs.

As Viet Nam ended, a whole new population of hurting souls were searching for solace.  Depression, Posttraumatic Stress Disorder and addictive illness plagued these walking wounded, and the existing system and treatments provided, in most cases, cold comfort.

Psychotherapy was making advances, though, and cognitive behavioral therapy now offered relief to many whom depressive thoughts and beliefs had incapacitated.  Albert Ellis’s Rational Emotive Behavioral Therapy (REBT) also changed lives.

What makes mental illness – and treatment of depression in particular – so challenging is the wide disparity in presentation. There is a high degree of variation in symptoms, course of illness, and response to treatment, indicating that depression may have a number of complex and interacting causes. This intricate constellation posed a major challenge to researchers attempting to understand and treat the disorder. But in the 80’s, scientists began to better understand the role of the brain in mental illness.    This, with the advent of Selective Serotonin Reuptake Inhibitors (SSRIs) like Prozac presaged the second wave of treatment advances.   Relief for mild to moderate depression as now available to millions.

Recent advances in research technology are now bringing scientists at the National Institutes of Mental Health closer than ever before to characterizing the biology and physiology of depression in its different forms, and to the possibility of identifying effective treatments.

 One of the most challenging problems in depression research and clinical practice is refractory (hard to treat) depression. While approximately 80 percent of people with depression respond very positively to treatment, a significant number of individuals remain “treatment refractory.” Even among treatment responders, many do not have complete or lasting improvement, and adverse side effects are common. Thus, an important goal of NIMH research is to advance the development of more effective treatments for depression — especially treatment-refractory depression — that also have fewer side effects than currently available treatments.

130718 Depression BrainNIMH is far from the only place advances are being made.  Evidence from neuroscience, genetics, and clinical investigation now demonstrate conclusively that depression is a disorder of the brain. There are new conceptualizations of the pathogenesis and pathophysiology of major depression.  With this, new medications are being developed.  The neuropharmacology of affective disorders is a rapidly advancing field of scientific interest.

Genetics research indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. Studies of brain chemistry and of mechanisms of action of antidepressant medications continue to inform the development of new and better medical and psychotherapy treatments.

Modern brain imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters — chemicals used by nerve cells to communicate — are out of balance. Soon, and certainly during my lifetime, a clinical psychotherapist will not begin a course of treatment without first looking at the patient’s brain scans.  More people will find relief, and more lives will be saved.  I look forward to that day.

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