Handling Depression

Biofeedback: Using Your Mind to Improve Your Health

Biofeedback: Using your mind to improve your health

Biofeedback can help you to use your mind to manage certain medical conditions. Find out which ones, whether it’s right for you and how it’s done.

Have you ever wished you could simply will your symptoms to disappear? With biofeedback you may be able to do just that by harnessing the power of your mind to help improve your health.

Biofeedback defined

Biofeedback is a type of complementary and alternative medicine called mind-body therapy. It’s designed to enable you — in mind-over-matter fashion — to use your thoughts and will to control your body. Biofeedback is based on the idea, confirmed by scientific studies, that people have the innate potential to influence with their minds many of the automatic, involuntary functions of their bodies.

To help you develop this ability, a biofeedback specialist uses signals from special monitoring equipment to teach you to control certain body functions and their responses, such as: 

Brain activity
Blood pressure
Muscle tension
Heart rate
Skin temperature
Sweat gland activity

You can use biofeedback to help treat many physical and mental health problems when you’ve learned to recognize and control these functions and responses.

Why it’s done

Biofeedback can be particularly useful in treating stress-related conditions, and clinical trials are evaluating it in the treatment of many other conditions, including:

Asthma
Headaches
Hot flashes
Raynaud’s disease
Irritable bowel syndrome
Nausea and vomiting associated with chemotherapy
Irregular heartbeats (cardiac arrhythmias)
Chronic low back pain
Chronic constipation
High blood pressure
Incontinence
Epilepsy

Biofeedback may appeal to you for several reasons:

It may reduce, or even eliminate, your need for medication.
It has the potential to help conditions that have not responded to medication.
It helps put you in charge of your own healing by providing measurable feedback, which allows you to monitor your progress and learning.
It may decrease your medical costs.

Risks of biofeedback

Biofeedback is generally considered safe. It should generally not be used, however, if you have depression, psychosis, or another major mental health disorder. Biofeedback can potentially interfere with some medications, such as insulin, so patients with diabetes should exercise extra caution. Talk to your doctor to see whether biofeedback therapy is an appropriate treatment for you.

 What you can expect

You can receive biofeedback training in physical therapy clinics, medical centers and hospitals. A growing number of feedback devices and programs are being marketed for home use as well. But working with a therapist, initially, may provide the best long-term results.

Preparation depends on the type of biofeedback therapy used. A typical biofeedback session lasts 30 to 60 minutes. The length and number of sessions will be determined by your condition and how quickly you learn to control your physical responses.

During a biofeedback session, a therapist will apply electrical sensors to different parts of your body. These sensors will monitor your body’s physiological response to stress — for instance, your muscle contraction during a tension headache — then feed the information back to you via cues such as a beeping sound or a flashing light. The feedback will allow you to begin to associate your body’s response — in this case, headache pain — with certain physical functions, such as your muscles tensing.

Once you begin to recognize that your headache is a result of tense muscles, the next step is to learn how to invoke positive physical changes in your body, such as relaxing those specific muscles, when your body is physically or mentally stressed. Your eventual goal will be to produce these responses on your own, outside the therapist’s office and without the help of technology.

rain activity

Blood pressure
Muscle tension
Heart rate
Skin temperature
Sweat gland activity

You can use biofeedback to help treat many physical and mental health problems when you’ve learned to recognize and control these functions and responses.

Types of biofeedback

Your therapist may use several different techniques to gather information about your body’s responses. Determining the one that’s right for you will depend on your particular health problems and objectives. Machines and techniques include:

Electromyogram (EMG). An EMG uses electrodes or other types of sensors to measure muscle tension. By the EMG alerting you to muscle tension, you can learn to recognize the feeling early on and try to control the tension right away. EMG is mainly used to promote the relaxation of those muscles involved in backaches, headaches, neck pain and grinding your teeth (bruxism). An EMG may be used to treat some illnesses in which the symptoms tend to worsen under stress, such as asthma and ulcers.
Temperature biofeedback. Sensors attached to your fingers or feet measure your skin temperature. Because your temperature often drops when you’re under stress, a low reading can prompt you to begin relaxation techniques. Temperature biofeedback can help treat certain circulatory disorders, such as Raynaud’s disease, or reduce the frequency of headaches.
Galvanic skin response training. Sensors measure the activity of your sweat glands and the amount of perspiration on your skin, alerting you to anxiety. This information can be useful in treating emotional disorders such as phobias, anxiety and stuttering.
Electroencephalogram (EEG). An EEG monitors the activity of brain waves linked to different mental states, such as wakefulness, relaxation, calmness, light sleep and deep sleep. EEG may be used to treat insomnia, epilepsy and other neurological disorders.

Finding a biofeedback therapist

Look for a qualified therapist if you decide to try biofeedback. Many biofeedback therapists are licensed in another area of health care — for instance, as a registered nurse or physical therapist — and may work under the guidance of a doctor. Some biofeedback therapists attain certification from the Biofeedback Certification Institute of America (BCIA). You may obtain a list of names of people in your area who have been certified by the BCIA by contacting the organization.

Gather information about each of the potential therapists you identify prior to making an appointment. Ask the therapists to provide references, whether they are licensed in biofeedback or another health care field, and what experience they have treating your specific condition and symptoms. If you can’t find a BCIA-certified therapist in your area, ask your doctor or another health professional with knowledge of biofeedback therapy to recommend someone who has experience treating your condition. Check, too, on whether your health insurer will cover the cost of treatment.

Results of biofeedback

Experts aren’t entirely sure how the biofeedback therapy works. Many people who’ve tried it can’t explain how they’re able to control their bodies, yet experience improvement in their symptoms. Biofeedback may enable you to reduce the amount of medication you take, or even help a condition that hasn’t responded well to medication.

Considering an Alternative Therapy?

Every medication or healing procedure that does not, strictly speaking, fall under the category of conventional medicine is normally referred to as alternative medicine, or alternative therapy. Alternative therapy varies from conventional therapies not only in origin, but also in practice. This form of therapy possibly based on spiritual beliefs and folk traditions. Mainstream medical practitioners are still hesitant to recognize alternative health therapies merely because most of these techniques are yet to be methodically tested in order to assurance their safety and efficiency. Due to the lack of evidence regarding the effectiveness of alternative therapy, several physicians rather to call it non-evidence based medicine; or some decline to recognize these alternative forms of medicine or therapy, as medical therapies at all. Medical professionals may take up this form of therapy only if their safety and effectiveness is scientifically proven.

Tai chi for example, is a martial art, regularly resorted to as a form of alternative therapy in order to reduce high stress levels. Other forms of alternative therapy include reflexology, yoga, aromatherapy, naturopathy, Unani, Ayurveda, Chinese medicine, Homoeopathy and acupuncture, among a wide range of other treatments. Magnetic therapy is also a form of alternative therapy that uses static magnetic fields. A lot of medical practitioners are of the opinion that exposing certain parts of the body to such static magnetic fields helps in the improvement o adverse medical conditions. It is significant to remember that the magnets used during magnetic therapy are of right magnitude in order to ensure that the do not affect the blood circulation in any way.

It is difficult to test the efficiency of the magnetic therapy simply because the magnetisms of an object can only be tested against iron. Consequently it is hard to explicitly describe the exact method in which the static magnetic field believed to be present, acts upon the area to be healed. The concept of magnetic therapy dates back to several centuries earlier. It is believed that Cleopatra wore magnetic jewelry because of its healing energies. This type of therapy has rapidly gained popularity in the last decade or so, and now it has become a thriving 100-dollar industry. Alternative therapists presently use magnets of standardized size and strength. One of the most commonly used magnetic therapy products is the magnetic mattress pad, which is generally used to treat ailments like insomnia, joint pain, muscle spasm, etc.

It isn’t easy to trust alternative therapy because of the absence of a reassuring scientific base. Though, because of the growing popularity of methods like yoga, meditation, tai chi, etc., it can be assumed that such alternative methods of healing are greatly effective. Most of these alternative therapies are used in conjunction with conventional medication, and are often referred to as complementary and alternative medicine (CAM). Alternative therapy, mainly like magnetic therapy is naturally used to treat chronic ailments. While therapies like yoga, magnetic therapy and aromatherapy are considerably safe as they do not involve intake of medicine or any other substance, alternative forms of medicine like Ayurveda and Chinese medicine should preferably be taken along with mainstream medication only after consulting a qualified physician, in order to avoid possible side effects.

Complementary therapies for migraine pain. Watch this and more health videos at: www.answerstv.com

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Dyadic Developmental Psychotherapy: an Evidence-based and Effective Treatment for Children With Complex Trauma and Disorders of Attachment

Reactive Attachment Disorder is a severe developmental disorder caused by a chronic history of maltreatment during the first couple of years of life. Reactive Attachment Disorder is frequently misdiagnosed by mental health professionals who do not have the appropriate training and experience evaluating and treating such children and adults. Often, children in the child welfare system have a variety of previous diagnoses. The behaviors and symptoms that are the basis for these previous diagnoses are better conceptualized as resulting from disordered attachment. Oppositional Defiant Disorder behaviors are subsumed under Reactive Attachment Disorder. Post Traumatic Stress Disorder symptoms are the result of a significant history of abuse and neglect and are another dimension of attachment disorder. Attention problems, and even Psychotic Disorder symptoms are often seen in children with disorganized attachment (1)

Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms (2). Many of these children are violent (3) and aggressive (4), and as adults are at risk of developing a variety of psychological problems(5) and personality disorders, including antisocial personality disorder (6), narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder (7). Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence (8). Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults (9). Children who have been sexually abused are at significant risk of developing anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial behavior (4.3 times average) (10). The effective treatment of such children is a public health concern (11).

Left untreated, children who have been abused and neglected and who have an attachment disorder become adults whose ability to develop and maintain healthy relationships is deeply damaged. Without placement in an appropriate permanent home and effective treatment, the condition will worsen. Many children with attachment disorders develop borderline personality disorder or anti-social personality disorder as adults (11).

So, what is a person to do? Is there effective treatment for disorders of attachment? The answer is yes; there is an effective treatment for disorders of attachment. Dyadic Developmental Psychotherapy (12). Family therapy, individual therapy, play therapy, residential placements, and intensive outpatient treatment, among other treatments, are often used to treat attachment disorders. However, when compared with Dyadic Developmental Psychotherapy, these treatments proved to be ineffective. A follow-up study compared the effectiveness of Dyadic Developmental Psychotherapy and “usual care,” and found that Dyadic Developmental Psychotherapy produced clinically and statistically significant improvements one year after treatment ended. The study was composed of 34 families receiving Dyadic Developmental Psychotherapy and 30 families receiving “usual care.”

Before treatment/evaluation in both the treatment and control groups, Randolph Attachment Disorder Questionnaire scores and Child Behavior Checklist scale scores were elevated and in clinically significant ranges (more than two standard deviations above the mean for the CBCL). The extent and severity of these children’s disorder is underscored by the fact that 82% of the treatment group and 83% of the control-group subjects had received prior treatment using other methods. The average number of previous treatment episodes was 3.2 for the treatment group and 2.7 for the control group.

The results for the treatment-group were achieved among children aged six to fifteen years, averaging 9.4 years, who received an average of twenty-three sessions over eleven months. The study found clinically and statistically significant reductions in scores for the treatment group and no change for the control group.

Dyadic Developmental Psychotherapy is effective because of its reliance on and development of concordant intersubjectivity and affective attunement between therapist and child, caregiver and child, and therapist and caregiver. The process of maintaining affective attunement allows for dyadic regulation of affect between child and therapist so that the child feels a sense of safety and security and can experience the affect associated with past traumas, allowing for integration of these experiences rather than dissociation of the affect and memory. Furthermore, Dyadic Developmental Psychotherapy’s significant involvement of caregivers in treatment facilitates the development of an affectively attuned relationship between the child and caregiver. An affectively attuned relationship may be described as a relationship in which the two persons are experiencing the same affect and that their affect co-varies. Within the safety of the attuned relationship the shame of past trauma and current misbehaviors are explored, experienced, and integrated. The caregiver-child interactions build on a dyadic affect regulation process that normally occurs during infancy and the toddler years. The child’s past traumatic history of abuse and neglect strongly suggests that such interaction, which facilitates a health attachment and a trusting and safe relationship, did not occur or occurred in an inadequate manner. Dyadic Developmental Psychotherapy facilitates the development of a healthy attachment between child and caregiver, enables the child to affectively trust the caregiver, and allows the child to secure comfort and safety from the caregiver.

This study examined the effects of Dyadic Developmental Psychotherapy on children with trauma-attachment disorders who meet the DSM IV criteria for Reactive Attachment Disorder, all of whom were either adopted or in foster care. A treatment group composed of thirty-four subjects and a usual care group composed of thirty subjects was compared. All children were between the ages of five and sixteen when the study began. Seven hypotheses were explored. It was hypothesized that Dyadic Developmental Psychotherapy would reduce the symptoms of attachment disorder, aggressive and delinquent behaviors, social problems and withdrawal, anxiety and depressive problems, thought problems, and attention problems among children who received Dyadic Developmental Psychotherapy. Significant reductions were achieved in all measures studied. The results were achieved in an average of twenty-three sessions over eleven months. These findings continued for an average of 1.1 years after treatment ended for children between the ages of six and fifteen years. There were no changes in the usual care-group subjects, who were re-tested an average of 1.3 years after the evaluation was completed. The results are particularly salient since 82% of the treatment-group subjects and 83% of the usual care-group subjects had previously received treatment with an average of 3.2 prior treatment episodes. This past history of unsuccessful treatment further underscores the importance of these results in demonstrating the effectiveness and efficacy of Dyadic Developmental Psychotherapy as a treatment for children with trauma-attachment problems. In addition, 53% of the usual care-group subjects received “usual care” but without any measurable change in the outcome variables measured. Children with trauma-attachment problems are at significant risk of developing severe disorders in adulthood such as Post Traumatic Stress Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and other personality disorders.

A second study followed these children out to four years after treatment ended and found that the children in the treatment group continued to have scores in the normal range on the Child Behavior Checklist. (13).

The children in the usual care or control group continued to have scores on the Child Behavior Checklist that were unchanged prior to treatment and remained in the clinical range, and that actually got statistically significantly worse on several of the scales of the Child Behavior Checklist; despite the fact that all these children received treatment (but not Dyadic Developmental Psychotherapy) from other providers at other clinics.(14)

This study supports several of O’Connor & Zeanah’s (15) conclusions and recommendations concerning treatment. They state (p. 241), “treatments for children with attachment disorders should be promoted only when they are evidence-based.” The results of this study are a beginning toward that end. Dyadic Developmental Psychotherapy provides caregiver support as an integral part of its treatment methodologies. Finally, Dyadic Developmental Psychotherapy uses a multimodal approach built around the concordant intersubjective sharing of experience.

Arthur Becker-Weidman, Ph.D.

Director

Center For Family Development

5820 Main Street, suite 406

Williamsville, NY 14221

716-810-0790

REFERENCES

[1] Lyons-Ruth, K., & Jacobvitz, D., Attachment disorganization: unresolved loss, relational violence and lapses in behavioral and attentional strategies. In Cassidy, J. & Shaver, P., (Eds.) Handbook of Attachment. pp 520-554, NY: Guilford Press, 1999.

Solomon, J. & George, C. (Eds.). Attachment Disorganization. NY: Guilford Press, 1999.

Main, M. & Hesse, E. Parents’ Unresolved Traumatic Experiences are related to infant disorganized attachment status. In Greenberg, M.T., Ciccehetti, D., & Cummings, E.M. (Eds.) Attachment in the Preschool Years: Theory, Research, and Intervention, pp.161-182, Chicago: University of Chicago Press, 1990.

Carlson, E.A. (1988). A prospective longitudinal study of disorganized/disoriented attachment. Child Development 69, 1107-1128.

[2] Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1995). Finding order in disorganization: Lessons from research on maltreated infants’ attachments to their caregivers. In D. Cicchetti & V. Carlson (Eds), Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 135-157). NY: Cambridge University Press.

Cicchetti, D., Cummings, E.M., Greenberg, M.T., & Marvin, R.S. (1990). An organizational perspective on attachment beyond infancy. In M. Greenberg, D. Cicchetti, & M. Cummings (Eds), Attachment in the Preschool Years (pp. 3-50). Chicago: University of Chicago Press.

[3] Robins, L.N. (1978) Longitudinal studies: Sturdy childhood predictors of adult antisocial behavior. Psychological Medicine,. 8, 611-622.

[4] Prino, C.T. & Peyrot, M. (1994) The effect of child physical abuse and neglect on aggressive withdrawn, and prosocial behavior. Child Abuse and Neglect, 18, 871-884.

[5] Schreiber, R. & Lyddon, W. J. (1998) Parental bonding and Current Psychological Functioning Among Childhood Sexual Abuse Survivors. Journal of Counseling Psychology, 45, 358-362.

[6] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment Styles in Maltreated Children: A Comparative Study. Child Development and Human Development, 31, 113-128.

[7] Dozier, M., Stovall, K.C., & Albus, K. (1999) Attachment and Psychopathology in Adulthood. In J. Cassidy & P. Shaver (Eds.). Handbook of Attachment (pp. 497-519). NY: Guilford Press.

[8] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment Styles in Maltreated Children: A Comparative Study. Child Development and Human Development, 31, 113-128.

[9] Allan, J. (2001). Traumatic Relationships and Serious Mental Disorders. NY: John Wiley.

Andrews, B., Varewin, C.R., Rose, S., & Kirk (2000). Predicting PTSD symptoms in Victims of Violent Crime. Journal of Abnormal Psychology, 109, 69-73.

[10] MacMillian, H.L. (2001). Childhood Abuse and Lifetime Psychopathology in a Community Sample. American Journal of Psychiatry, 158, 1878-1883.

[11] Allan, J. Traumatic Relationships and Serious Mental Disorders, NY: Wiley, 2001.

Andrews, B., Varewin, C.R., Rose, S. & Kirk. Predicting PTSD symptoms in Victims of Violent Crime. Journal of Abnormal Psychology, vol. 109, 69-73, 2000.

[12] Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity for Attachment: Dyadic Developmental Psychotherapy in the Treatment of Trauma-Attachment Disorders. OK: Woods N Barnes publishing.

Becker-Weidman, A., (2006) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, pp. 147-171 April 2006.

Becker-Weidman, A., (2006) “Dyadic Developmental Psychotherapy: A multi-year Follow-up”, in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, 2006, pp. 43 – 60.

Becker-Weidman, A., (2007) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” http://www.center4familydevelop.com/research.pdf

Becker-Weidman, A., & Hughes, D., (2008)“Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment,” Child & Adolescent Social Work, 13, pp.329-337.

[13] Becker-Weidman, A., (2005) Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. Vol. 12 #6, December.

[14] Becker-Weidman, A., (2006) “Dyadic Developmental Psychotherapy: A multi-year Follow-up”, in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, 2006, pp. 43 – 60.

[15] O’Connor, T., & Zeanah, C., (2003) Attachment Disorders: Assessment strategies and treatment approaches. Attachment & Human Development, 5, 223-245.

Dangers Inherent in the Trivialization of Psychotherapy

DEFINITION OF PSYCHOTHERAPY

For the purposes of this essay, I will use the term “psychotherapy” to refer to a particular type of interpersonal process intended to facilitate conscious awareness of that which had previously been unconscious.  It is not meant to include the direct attempt to modify behavior, whether overt as action or covert as thoughts and feelings, through medication or manipulation of the external consequences of behavior.  Similarly, it does not include counseling, coaching, advising, or teaching as its primary goal.

THE RECENT HISTORY OF PSYCHOTHERAPY

In its current form psychotherapy has been popular for only about a century, although its roots are ancient.  Freud called attention to the importance of the personal unconscious, repository of those thoughts and feelings which are unique to a particular individual and presumed to be a result of his or her personal life experiences and genetically transmitted instincts.  Jung invited us to notice the collective unconscious, where we find ourselves connected to all of humanity through shared patterns of thoughts and feelings.  Each of them found the contents of a person’s dreams to be of particular value in accessing the unconscious, whether personal or collective.   Many followers of these two pioneers have refined the methodology for accessing these two types of unconscious material and integrating it into one’s conscious awareness, particularly with regard to the manifestation of unconscious material in the transference and countertransference.  However, Freud and Jung deserve most of the credit for making popular in modern culture the idea that the exploration and integration of unconscious material is a very important task, perhaps even the most important task any person can undertake. 

THE GOAL OF PSYCHOTHERAPY

Interestingly, both Freud and Jung became interested in the unconscious through their role as physicians, whose goals are healing and the alleviation of suffering.  Each of them realized that these goals could be served through greater conscious awareness of the unconscious, although Freud’s model implied somewhat more modest goals than Jung’s.  Freud held that greater awareness of the contents of the personal unconscious might help one to adjust more comfortably to the demands of civilization, but that a certain degree of discontent was unavoidable.  Jung believed that the exploration of the collective unconscious could reveal the purpose of one’s life and bring one closer to a state of union with God.  It is important to note that, in spite of a difference in the ultimate goal of psychotherapy, the exploration of unconscious process, particularly as manifested in the contents of dreams and fantasies, were considered to be central in its achievement.

THE LARGER IMPORTANCE OF PSYCHOTHERAPY

As noted above, psychotherapy is a new name for an ancient practice.  Introspection in the broadest sense has ancient roots in practices such as contemplation, meditation, dream incubation and interpretation, fasting and other ascetic practices, prayer, religious ritual, music, ingestion of psychedelic plants, vision questing, sleep deprivation and the like, to facilitate it.  The intentional use of any technique which facilitates introspection implies that introspection is in some way of value.  Whether one limits that value to the alleviation of some psychological suffering, as Freud would, or sees the value as ultimate spiritual realization, as Jung would, there is no disagreement that there is value in the facilitation or enhancement of introspection.

One way to examine the value of introspection is to think about one’s source of authority.  In particular, the external versus internal locus of the source of authority is important to consider.  If an external authority, such as parents, culture, or church, leads me to believe that I should feel guilty or fearful, then the alleviation of such guilt or fear may come about as a result of discovering a more powerful  internal source of authority which contradicts this belief.  Of course there can be no guarantee that one can contact a more powerful internal source of authority.  Similarly, there is not guarantee that, once contacted, it will indeed counteract a belief previously instilled from an external source of authority.  However, many examples of such a counteraction are part of the experience most psychotherapists.

Here is a personal example of the shift from an external to an internal source of authority.  I was born in Utah and raised a Mormon.   I left Utah in the first year of my life, and left the Mormon church in the second decade.  The final chapter took place in my fourth decade, after having cultivated my sense of inner authority in therapy for 8 or 10 years, when I managed to get myself officially excommunicated.  During the course of the trial which resulted in my excommunication, I was sternly admonished by some of the members of the jury that the price I was going to pay in the hereafter for having been cast out of the Mormon brotherhood would be high indeed.  This invocation of the external authority of the belief system of the church produced a brief surge of terror in me–what if they were right?  Realizing after a few moments that my great fear was the result of my having been abusively conditioned as a child by such frightening stories, my terror quickly converted to rage.   Now paying more attention to my inner authority, I managed to suppress expression of both of these strong emotions and to continue with a fairly interesting dialogue with my jurors, and even got invited to offer a closing prayer when the trial came to an end.  The most powerful experience of my inner authority came after I walked out of the church.  When I got to the parking lot, and was quite separate from those who represented external authority of the church, I spontaneous and exuberantly began to leap into the air and shout for joy.

A more interesting question about internal versus external authority comes up when there are major philosophical or moral questions in need of answers.  Questions about the purpose of one’s life, the ultimate nature of reality, or what is intrinsically moral in response to a given situation, are examples of such questions.  These are the types of questions that come up repeatedly during the course of one’s life, and one is therefore well advised to have some ongoing way of introspecting deeply enough to be able to find answers as they are needed.

As example of the need for such answers was presented a few years ago by the publication of the book, Hitler’s Willing Executioners (Goldhagen, 1996).  It told of the thousands of German citizens, seemingly normal and decent human beings, who willingly went along with one of the most ghastly examples of genocide the world has seen.  It is interesting to speculate about the response of a German bureaucrat to the news that he will no longer be managing the logistics of railroad cars filled with merchandise bound for market.  Starting tomorrow his job will be the same with the minor exception of the cargo, which will now be human beings bound for torture and death.  He goes home, has dinner with his family, helps his children with their homework, makes love with his wife, and goes back to work the next day to carry out his slightly revised duties.  What is missing from this picture?  I would suggest that introspection is missing.  If this man had a habit of introspection, whether through prayer, meditation, contemplation, or psychotherapy, it is hard to imagine that he would go to work the next morning believing that his participation in genocide would not be in violation of some intrinsic moral principle.  (For research supporting this rather broad generalization, see May, [1987].)  Without such introspection, he is at the mercy of external authority, in this case the German state, which clearly reports to him no moral conflict in his compliance.  In fact, quite the opposite is the case.

I am not suggested that a brief course of psychotherapy or meditation instruction would have stopped a German bureaucrat in his or her tracks in the weeks before genocide became the assignment of the day.  The development of moral awareness that I am suggesting such introspective practices might have fostered would have to begin much earlier.  The popular TV show, “The Sopranos,” makes an attempt to examine what might happen when a person whose moral development has arrested at an early age is exposed to psychotherapy as a adult.  The result is certainly not a rapid compensation for earlier deficiencies in such development.  What I am suggesting is that a habit of introspection over the course of one entire life, or at least one’s entire adult life, can make a difference.

At the most generic level it would seem that the capacity for introspection may be something like a muscle.  With regular use it becomes flexible and strong and can be very helpful to its owner.  Without regular use it atrophies and becomes useless.  In the most extreme case of neglect of the inner life, one not only loses the capacity to introspect deeply; one also can lose the awareness that there even exists any significant internal territory to explore through introspection.  Such a loss makes one extremely vulnerable to the Hitlers of the world, which in turn makes all of us vulnerable.  Just as there is increasing evidence that regular mental activity can counteract the loss of cognitive capacity that often accompanies aging, so regular introspective activity could be expected to sustain the capacity to introspect.

Although the Hitlers of the world give a dramatic lesson about our vulnerability as a species if we lose sight of our internal resources, more mundane examples abound.  The young retail clerk who cannot make the simplest of change without using the calculator built into the cash register has lost sight of an internal ability to calculate.  The weatherman who tells us that tomorrow will be a miserable day because rain is predicted invites us to forget that we can decide for ourselves whether we enjoy rainy weather.  The increasingly bizarre warning labels that come with electronic appliances, telling us to refrain from all sorts of things that would only be done by a person too handicapped to live outside an institution or a person committed to a painful suicide, invite us to ignore our common sense.

However, it is the ignoring of our internal resources regarding how to live a meaningful and a moral life that presents the greatest possibilities for individual and mass misery.  A life without a conscious sense of meaning or purpose will generate a certain desperation of its own, which is in some way the manifestation of the unconscious as it tries to get one’s attention regarding the failure to heed one’s calling.  However, if one’s habits and culture do not generally support introspection under such circumstances, one is likely to express one’s desperation in harmful ways.  The situation is made worse by the absence of internal awareness of morality, leaving even greater room for destructive acting out of such desperation.

The use of introspection to discern an inner moral awareness is particularly under assault in much of the world today.  Laws, regulations, ethics codes, religious creeds, mandatory sentencing, and other external constraints on behavior, are displacing our internal awareness of what is moral and what is not.  As such external rules proliferate, they invite us to forget that we ever had any internal way of knowing such things in the first place–like the  young clerk who scarcely is aware of having the capacity to make change without a cash register.  Psychotherapy is one way to facilitate a reconnection with our inner moral compass.

This is not to say that external constraints on behavior are always negative.  I am quite pleased to have external constraints when needed in the short to prevent injury and death to humans as well as other species.  They may also raise awareness by calling to the public’s attention certain problems that need to be addressed.  However, in the long run such external constraints run the risk of displacing and weakening our internal constraints.  These internal constraints seem to me to be our only long term hope.  If we rely on some of us to wield the power to constrain others of us, who will constrain the some of us who are constraining the others?  If power corrupts, where will those in power turn for the moral awareness that could prevent them from being corrupted?  If I take a maintenance antibiotic to combat any infection that I might get, having the antibiotic doing the work my immune system should and could, how can I expect my immune system to remain robust or even reasonable competent? 

ON THE TRIVIALIZATION OF PSYCHOTHERAPY

Given the significance noted above of reclaiming deep introspection through psychotherapy,  it is noteworthy that psychotherapy itself is in some ways under attack at the present time.  At the most superficial level this attack has to do with funding–i.e. payment for psychotherapy by private health insurance and public agencies.  Although a statistical case can be made for the proposition that good psychotherapy pays for itself in increased productivity and reduced utilization of other general medical resources, there seems to be a trend toward the restriction of third party funding for psychotherapy.  One theory frequently put forward to explain this strange trend is that it is simply a result of the greed and shortsightedness of the CEOs of managed care organizations.  No doubt these factors play a role.

At a deeper level a more pernicious trend is emerging–the trivialization of psychotherapy.  Those who find deep introspection to be personally threatening have always expressed their anxiety through deprecating references to psychotherapy as involving self-absorption, navel gazing, and mental masturbation.  More recently the ways in which psychotherapy is trivialized have become more subtle and perhaps even auto-immune in nature.   That is, even among those who describe themselves as psychotherapists there seem to be increasing numbers who see their work as little more than providing a mental tune-up so that the client can function more efficiently in his or her already prescribed role in society.   At the core those who dismiss all introspection as nonsense, and those who see psychotherapy as merely intended to relieve symptoms,  both seem to share a disregard for the importance of deep introspection and the human relationship in the conduct of psychotherapy.

If one assumes that the human relationship is important in psychotherapy, then the selection of a good psychotherapist for a particular person involves much more than finding one with certain academic or professional credentials.  It involves some exploration of the inherent compatibility, or fit, between the two persons involved before a prediction can be made of the probable outcome of the psychotherapy.  Such exploration is all but prohibited by most managed care arrangements.  First the psychotherapist is usually referred to as a “provider of services,” a term which seems to connote that the function is more important than the person.  That might be true for a person who delivers a pizza to one’s home, but it is most certainly not true for a person with whom one contemplates entering into a most intimate relationship.  After getting past the insult of thinking of one’s psychotherapist is a provider of services, one is told that it is necessary to select a psychotherapist from a preselected panel of candidates, a very small fraction of those who might otherwise be available.  The members of this panel have usually been chosen on the basis of some minimal academic requirements and the willingness to work under adverse conditions.  These adverse conditions include low pay and frequent violation of the privacy necessary for effective psychotherapy.

The trivialization of psychotherapy as a result of the conditions imposed by managed care is increasingly being matched by conditions imposed by the professional disciplines which provide formal training and credentials for most psychotherapists.  Psychology is probably the discipline with the most noteworthy case of identification with the aggressor.  It has actively promoted the “manualization” of psychotherapy.  This term does not refer to conducting psychotherapy without the use of machinery; it refers to the notion that for any given condition, like depression, there is a single correct therapeutic approach to be taken.  This approach can be described in a manual, and then any person who can read the manual and follow its instructions can perform the psychotherapy.  While it may be true that anyone who can read a map and drive a car can deliver a pizza, it is certainly not that simple with psychotherapy.  For psychology as a profession to pretend otherwise trivializes and demeans psychotherapy.  

I was recently involved in an informal supervision session, in which a very mature and sophisticated psychotherapist presented a complicated clinical dilemma which had arisen in one of her psychotherapy groups.  Several respected colleagues, all working within essentially the same theoretical framework, offered feedback.  Although the underlying premises about the importance of such things as authenticity, integrity, and respect were the shared by all, the actual recommended actions to be taken diverged greatly. The woman presenting the case thoughtfully took in all these recommendations, asked for clarification or elaboration regarding some of them, and then formulated her next intervention for her group.  She also commented that the diversity of opinion from highly respected colleagues was both disturbing and relieving, since it made clear that there is no single correct approach to any given clinical situation.  Clearly this woman is not a candidate for getting involved in anything the looks like “manualization.”  On the other hand, she is someone to whom I would refer, without hesitation, a person I love. 

The most recent example of the trivialization of psychotherapy in our culture has come in the form of legislatively mandated keeping of “Medical Records.”  In some instances legislation has been written in such a way as to include psychotherapists in general, and psychologists in particular, within its requirements.  For psychotherapists to keep such records has at least two trivializing implications for psychotherapy.  First is the implication that there would be some genuine utility in the keeping of such records.  This assumes that a person could move from one psychotherapist to another, have his or her “Medical Records” transferred to the new psychotherapist, and pick up where he or she left off with the previous psychotherapist.  This is a preposterous assumption when applied to as personal a relationship as is involved in psychotherapy.  The second, and perhaps more chilling, implication of such record keeping is contained in the actual act of writing down for possible future disclosure to others, as yet unnamed, any meaningful part of what transpires in psychotherapy.   It would be hard to imagine a mechanism more antithetical to the creation of the kind of trust and safety required for meaningful psychotherapy to take place.

WHAT IS TO BE DONE?

The problems arising from the trivialization of psychotherapy are the tip of the iceberg.  The trivialization of introspection lies below it, with grave consequences for the Titanic of humanity if ignored.  No amount of enforcement of current or future environmental laws have a chance of saving the earth in the long run unless a significant percentage of humans have a more immediate and personal experience of a deep connection to other humans in particular and to All Things in general.  A similar statement could be made about the possibility that international treaties, tribunals, and organizations will save us from future wars or nuclear holocaust through their ability to impose external constraints on our behavior.  As mentioned above, they may heighten our awareness of the problems we face, and they may helpful by starting meaningful dialogue between people who would otherwise be killing each other.  However, if such dialogue does not ultimately lead to a greater appreciation of The Other, genocide will merely be postponed.  Dialogue combined with introspection can provide the opportunity to genuinely experience “walking a mile in your enemy’s moccasins,” and this experience can in turn open us up to non-violent options for dealing with old hatreds and fears.  Anything that facilitates the kind of introspection which can lead to such deeply meaningful experiences increases our chances of survival, not to mention peace of mind.  Anything one can do to support the profound significance, as opposed to trivialization, of such a process should help.  The first step probably has to be a reaffirmation of the importance of deep introspection in one’s own life.  Clearly psychotherapy is not the only way to do this, but it is a very good place to start.  

References
Goldhagen, Daniel Jonah, Hitler’s Willing Executioners: Ordinary Germans and The Holocaust, 1996, Alfred A. Knopf, New York, 640 pages.

May, Gerald G. Will and Spirit, 1987, Harper, San Francisco, 368 pages.

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ADDENDUM
Since this paper was originally drafted, two things have occurred which call for additional comments.  The first of these is the series of tragic events which took place on 9-11-01.  The second is the response of the editor to the first draft.  Among other things she notes that deep introspection might lead to the desire for violence, rather than the opposite, and that many good and moral people do not introspect and have never experienced psychotherapy.

In the weeks after September 11, like many others, I found myself very curious about the motivational dynamics of those who had been willing to kill so many others.   What began to emerge for me was a picture of young men who had been completely cut off from meaningful interpersonal support for introspection since they were very young.   This means not only the deprivation of anything as structured and formal as psychotherapy, but also the absence of any opportunity for more informal interpersonal exchanges having to do with introspection or subjective experiences other than those prescribed by family, friends, religion, and one’s entire social milieu.  In the extreme I imagined what it would have been like for one of those young men, in the months before September 11, to have raised doubts or misgivings about the plans they were making.  A dream, a fantasy, or an emotion that had such implications would have to have been suppressed or repressed almost immediately.  Certainly to allow oneself such experiences, and to open discussion about them with one’s fellows, would have been to risk complete rejection as a minimum, and immediate death as a high probability.

At the opposite extreme would be the ancient mystical and meditative traditions of the world.  What little I know of Buddhist and other such practices is that an enormous variety of powerful subjective experiences are expected when the seeker enters into the particular form of deep introspection associated with a given tradition.  Vivid fantasies of unbridled sexuality and violence are common, but in the end give way to–or perhaps are part of– experiences which ultimately develop deep compassion and equanimity in the seeker.  Psychologically this process may be seen at least in part as a withdrawal of the projection of evil which, when projected, leads to the perception of “evil-doers” in external reality and the conviction that one’s holy task is to slay them.  The Vietnamese Buddhist monk Thich Nhat Hanh reports having been able to view the corpses of six young men he regarded as his sons, brutally murdered because of their opposition to the war in Vietnam, and still feel compassion for their killers.

Perhaps most people navigate a middle course, being somewhat introspective in a random or unconscious sort of way.  Thanks to sleep researchers we know that everyone dreams, whether or not the dreams are available for conscious recall upon awakening.  Similarly, everyone daydreams, although there appear to be enormous differences in the degree to which this experience is invited or suppressed.  In any case, a certain degree of introspection seems to be inherent in the human condition.   It is up to us to decide how much to nurture this tendency, as individuals and as a culture or society.

Strategies for Understanding and Assessing Suicide Risk in Psychotherapy

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Suicide is one of the few topics that almost uniformly triggers anxiety and apprehension in clinicians, both novice students and seasoned practitioners (Rudd, 2006). Moreover, the actual assessment and subsequent treatment plans for suicidal clients are perhaps the most challenging clinical endeavors mental health practitioners may face during their careers. Literature shows that this is often the case because one concrete outcome of negligence in this area is a client fatality and resultant liability for the clinician (Jobes, 2006; Jobes & Drozd, 2004; Packman, Marlitt, Bongar, & O’Connor-Pennuto, 2004; Peruzzi & Bongar, 1994). Perhaps this explains one reason why psychotherapists seem to focus on collecting data surrounding lethality and risk factors instead of exploring the narrative story of the suicidal client (Rogers & Soyka, 2004). As Schwartz and Rogers (2004) explain, psychotherapists should realize that although they will be unable to successfully prevent all instances of suicide due to the unpredictability of human nature, clinicians can lessen the number of completed suicides by being able to better identify at-risk populations and common themes of suicidality. However, clinicians should also remember not to omit a thorough exploration of the individual meanings of suicidality for a particular client.

Approximately 71% of psychotherapists report managing at least one client who has attempted suicide, with 28% reporting having had at least one client die by suicide (Rogers, Gueulette, Abbey-Hines, Carney, & Werth, 2001). For psychotherapists, the psychological impact of losing a client by suicide is similar to the stress and trauma that would be experienced in the death of a loved one (Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988). Therefore, updated information surrounding suicide risk factors, myths, assessment strategies, treatment options, and additional resources are crucial when working with this particularly challenging population.

Information on Suicide Risk Factors

Suicide takes the lives of over 30,000 Americans every year according to the Centers for Disease Control and Prevention’s (CDC) Fatal Injury Report, making it the eighth leading cause of death for males and the 19th leading cause of death for females (Centers for Disease Control [CDC], 2006). Overall, in the United States, suicides outnumber homicides 3:2 and take the lives of twice as many persons as HIV/AIDS (CDC, 2006). Over the last century, researchers have tried to produce a set of “risk factors,” which, when identified, would label a client as someone who might take his or her own life (Maris, Berman, & Silverman, 2000). The underlying premise is that if there were a way to predict suicidal behavior, lives would be saved (Maris et al., 2000). Unfortunately, research has not yielded a specific flow chart that all clinicians can follow when working with a suicidal individual. In fact, according to research by Plutchik (1995), 41 factors correlate with the risk of completed suicide. Although no one person could either remember or assess all potential risk factors, below are some of the most common ones discussed in the literature.

First, suicide among young people between the ages of 15 and 24 ranks as the third leading cause of death (National Center for Health Statistics, 2002). This represents 7.9 deaths per 100,000 persons, with a male-to-female ratio of 3:1. Between the ages of 20–24, suicide claims the lives of 12 persons per 100,000, with a male-to-female ratio of 7:1 (National Institute of Mental Health, 2001). Within the last few decades, teen suicides have steadily been on the rise. In fact, in a study conducted of high school age students, as many as 15% have made at least one suicide attempt (King, 1997), with teen girls being particularly vulnerable (Lewinsohn, Rohde, Seeley, & Baldwin, 2001). Teens who suffer from depression and substance abuse are at a higher risk, and both of these factors are on the rise (Gould & Kramer, 2001). Perhaps teens are more at risk due to their lack of financial and social resources, lack of emotional self-control, poorer problem-solving capacity, and lack of mobility (Reynolds & Mazza, 1994).

Currently, the age group considered most at risk contains white males who are over the age of 65 (CDC, 2006). Suicide among the elderly represents 14.6 deaths per 100,000 persons, a highly at-risk age group that is often under-assessed by mental health professionals. Particularly distressing is that 75% of the elderly use a gun of some sort, leaving a significantly reduced margin for failed attempts (Frierson & Melikian, 2002). It has been speculated that at this age, the elderly are struggling with physical and mental depreciation, as well as with the loss of friends and family members, leading to a mild or moderate depression that they may never have experienced before. Therefore, their coping strategies may be inadequate (CDC, 2006; Maris et al., 2000).

Although age is considered one important risk factor to evaluate, gender also provides information regarding the plausibility of a client attempting and/or completing suicide. As stated above, suicide is the eighth leading cause of death for males and the 19th leading cause of death for females (CDC, 2006). Subsequently, there are four male-completed suicides for every one female-completed suicide, but there are three female-attempted suicides for every one male attempt (CDC, 2006). Simply stated, more men complete suicide, while more women attempt it.

In addition to age and gender, people suffering from a mental illness (e.g., DSM diagnosis) are another at-risk group, accounting for an estimated 95% of all completed suicides (Shea, 2002). One of the most reliable predictors of suicidality is current, severe, depressive symptoms. In fact, the risk of suicide in clients with Major Depressive Disorder is approximately 20 times that of the general population (American Association of Suicidality [AAS], 2005). Research shows that seven out of every 100 men and one out of every 100 women who have had clinical depression at some point in their lifetime will go on to complete suicide (AAS, 2005). Although depression is a primary risk factor, a diagnosis of schizophrenia, bipolar disorder, and severe borderline personality disorder are also considered to put an individual at risk for completing suicide (Maris et al., 2000; Schwartz & Rogers, 2004; Shea, 2002).

It is important to monitor clients with mental illness under a psychiatrist’s care, as well as those currently in psychotherapy. Between 50% to 67% of individuals completing suicide had seen a doctor less than one month prior, between 10%–40% saw a doctor in the week preceding death, and in over half of suicides via overdose, the prescription had been either written, or refilled a week prior to the overdose (U.S. Preventive Services Task Force, 1996). Therefore, clients taking psychotropic medications should be monitored closely. Also, clients who are actively engaging in substance use and abuse are more likely to complete suicide due to the exacerbation of other environmental problems, as well as lowered inhibition when making a suicide attempt (Maris et al., 2000; Westefeld et al., 2000). Moreover, clients who are dependent on substances often have a number of supplementary risk factors for suicide (i.e., depression, engagement in high risk/self-injurious behaviors, or financial problems), which should be assessed by psychotherapists (Jobes, 2006; Shea, 2002).

Clients who are coping with chronic illness or chronic pain may be unable to imagine the possibility of change or progress in their struggle and may look to suicide as a way of absolving themselves of being “stuck” (Reeves, Bowl, Wheeler, & Guthrie, 2004). Moreover, these clients may be psychologically overwhelmed to the point that they can no longer cope with their current suffering, nor find a means of relief from it (Jobes, 2006; Shneidman, 1993; Schwartz & Rogers, 2004). Finally, the three most critical at-risk factors for suicide assessment are the number and severity of previous attempts, a family history of suicide, and current suicidal ideation (Jobes, 2006; Maris et al., 2000; Peruzzi & Bongar, 1994; Rogers & Soyka, 2004). Consequently, research by Packman, Marlitt, Bongar, and O’Connor-Pennuto (2004) found that multiple attempters possessed a greater overall baseline risk, indicating that suicide attempts increase the overall vulnerability for future suicide completion. Moreover, a familial pattern of suicidal behavior is considered an amplifier of risk through genetic and temperament influences and possible behavioral modeling (Packman et al., 2004).

Myths About Suicide and the Psychotherapy Relationship

There are several myths surrounding suicide that may inadvertently influence a clinician’s ability to accurately assess a client’s lethality. Most importantly, individuals in general (and some clinicians, as well) often believe that discussing suicide may directly lead to increased suicide risk. As Schwartz and Singer (2005) point out, clients kill themselves because they decide to, not because it was discussed in a psychotherapy session. In fact, there are data suggesting that psychotherapists rarely explore with their clients past experiences with suicidal thoughts or attempts (Rogers & Soyka, 2004). This clinical pattern may serve the purpose of helping clinicians to “feel better” while unwittingly contaminating the suicide assessment process (Schwartz & Singer, 2005).

Other common misperceptions about suicide are that suicide is an “irrational” act, or that suicidal behaviors are always “impulsive” acts, that children and elderly may be at risk but do not actually complete suicide, and that people who commit suicide usually do not actively seek help beforehand (Peruzzi & Bongar, 1994; Schwartz & Rogers, 2004; Schwartz & Singer, 2005; Wingate, Joiner, Walker, Rudd, & Jobes, 2004). However, a review of 71 completed suicides showed that more than half of the victims communicated their suicidal ideation within 3 months before the fatal attempt (Isometas et al., 1994). A final myth that should be noted is that people whose suicide attempts have failed really were not seriously contemplating suicide. That is, these clients were only looking for sympathy or attention (Segal, 2000). Unfortunately, research has shown that 40% of all suicide victims (i.e., those who completed suicide) made previous attempts or threats, and as the number of attempts increases, so does the likelihood that a future attempt will be fatal (Goldstein, Black, Nasrallah, & Winokur, 1991). In fact, all of the myths described above have been disputed both by clinical reports, as well as empirical research findings. Even though these suicide-related myths abound in American popular culture, it is crucial that clinicians do not succumb to their damaging influence. For various reasons—discomfort with the suicide assessment process, fears of client vulnerability and suicidality, clinician countertransference (perhaps one’s friend or relative attempted or completed suicide)—psychotherapists are at risk of not hearing clients’ calls for help. Clinicians should be aware of the myths outlined above because by increasing their understanding of what is, and is not, linked to suicidality, psychotherapists can remain open and objective during the assessment process (Schwartz & Rogers, 2004).

It is vital that psychotherapists listen intently to what clients mean behind what they say, objectively and empathically, in order to fully engage clients in a thorough suicide assessment (Schwartz & Singer, 2005). Jobes (2006, p. 7) observes that given what we currently know about people who commit suicide, there are “three essential truisms” for clinicians to note:

1) Most suicidal people do not want to end to their biological existence; rather, they want an end to their psychological pain and suffering.

2) Most suicidal people tell others (including mental health professionals) that they are thinking about suicide as a compelling option for coping with their pain.

3) Most suicidal people have psychological problems, social problems, and poor methods for coping with pain—all things that mental health professionals are usually well trained to tackle.

Strategies for Suicide Assessment

Despite the fact that several useful surveys and questionnaires are available to help clinicians evaluate suicide risk, a face-to-face clinician/client interview is thought to be both preferential and necessary to the assessment process (Reeves, Bowl, Wheeler, & Guthrie, 2004). Whether this interview is done from a crisis intervention framework, a cognitive framework, an existential-constructionist framework, or a collaborative framework, a face-to-face thorough assessment remains the only valid method for determining risk (O’Connor, Warby, Raphael, and Vassallo, 2004). The psychotherapy relationship therefore becomes the pivotal pathway for clinicians to access clients’ lethality. In order to accomplish this task, it is the responsibility of the psychotherapist to maintain an awareness of current information on suicide risk assessment practices (Westfeld et al., 2000). In this regard, the crisis interview method utilizing Shea’s validity techniques (2002), the Collaborative Assessment and Management of Suicidality (CAMS) model (Jobes, 2006), and the Aeschi Group’s Guidelines for Clinicians will be examined below.

One of the first things a clinician must be willing to participate in is a self-inventory for the identification of biases regarding suicide as an act. This self-reflection can determine whether an intervention will be a success or a failure (Shea, 2002). Self-exploration is not a static awareness, but on ongoing process (Shea, 2002). Attitudes can range vastly from “suicide is wrong” to “suicide has intrinsic positive worth” (Shea, 2002). Suicide is a difficult topic for discussion, even for the experienced therapist. It is for this reason that the therapist should be aware and keep track of his or her values and ongoing emotional experiences. Counter-transference is one phenomenon the psychotherapist should be continually checking in with, as this can create a power struggle between client and therapist. For example, Maris, Berman, and Silverman posit that suicidal clients can actually be “help-rejecting” as well as engaging in a wide variety of “interpersonally alienating behaviors” (p. 513), which may create negative counter-transference.

There are many schools of thought on how to assess a suicidal individual. One such assessment is the crisis interview wherein the psychotherapist directly asks questions regarding suicidality (e.g., ideation, intent, plan, means of completion). During this process, a helpful hint is to use very specific and concrete wording such as “kill yourself” or “commit suicide” versus general “softer” words such as “stop the pain” (Shea, 2002). The client needs to know that the psychotherapist can handle their thoughts surrounding taking their own life, as many clients do not have anyone else with whom to discuss these confusing thoughts.

Shea (2002) offers several other points to keep in mind when assessing a client’s lethality. First, the slightest hesitancy in a client’s response may suggest that he or she has thought about suicidal ideation (even if they deny it). Next, answers such as “no, not really” when clients are questioned about suicidal ideation usually means there have been at least some suicidal thinking. Clinicians should also try to be as present with the client as possible to pick up on any non-verbal cues he or she may be sending. For this reason, it may be beneficial for clinicians not to take notes (or to do so sparingly) during the suicide assessment, so they may be 100% available to the client during the process. Clinicians should routinely check themselves during the interview, asking “What am I feeling right now?” and “Is there any part of me that doesn’t want to hear the truth right now?” These simple preparations can help guide the techniques the clinician will use when eliciting suicidal intent.

In The Practical Art of Suicide Assessment, Shea (2002) discusses six validity techniques that clinicians can utilize to explore sensitive material with a client. These can be used with a variety of sensitive topics, such as domestic violence, substance abuse, antisocial behavior, sexual abuse, and suicide. The first validity technique, the behavioral incident, is when the clinician asks about concrete behavioral facts. Questions like, “Exactly how many pills did you take?” provide the facts of the incident. The next technique is shame attenuation, which relates to the therapists’ ability to inquire about information without making the client feel shame or guilt. Instead of asking the client, “Do you have a bad temper and tend to pick fights?” the clinician could ask, “Do you find people tend to pick fights with you when you are out trying to have a good time?” Or, “Some people have told me that when they get angry they tend to pick fights, has that happened with you?”

The next technique is designed to help increase the chances the client will be open with sensitive information. Gentle assumption is a technique that proposes that the behavior is already happening. Instead of asking, “Do you drink?” The therapist can ask, “How much do you drink?” In the case of potential suicidality, if the client is severely depressed the clinician may ask, “During the past two weeks how difficult has it been to not think about taking your own life?” This technique helps clients bypass the psychological hurdle of admitting to problem behaviors in the first place.

The technique symptom amplification uses the client’s natural tendency to minimize or downplay quantitative information about problem behaviors. By setting the upper limits of the quantity higher than average during questioning, the client has “room to move” while being more truthful about the actual number. For example, rather than asking, “Have you had thoughts of suicide during the past week?” the therapist could ask, “How many times has the thought of suicide entered your mind during the past week, fifteen or twenty?” This allows the client to ease his or her natural defense mechanisms and avoid confrontation. The question may be particularly effective after a gentle assumption (see above) has already exposed suicidality.

The technique denial of the specific involves asking the client specific questions versus generic or global questions. The rationale is that it is easier to deny a generic question than a specific one. If trying to assess the use of drugs a clinician might ask, “Have you ever tried cocaine?” or, “Have you ever smoked crack?” or, “Have you ever used crystal meth?” or, “Have you ever dropped acid?” rather than, “Do you use illegal drugs?” Regarding suicidality, when assessing a plan after suicidal ideation and/or intent has been revealed, the clinician may ask, “Have you thought about overdosing on your medication?” and, “Have you thought about taking your life by hanging?” and, “Have you considered using a gun to take your life?”

The last validity technique Shea (2002) offers is normalization. By normalizing their problem behavior, the client may not feel as embarrassed or anxious when discussing it. For example, regarding depressive symptoms, the therapist may ask, “Sometimes when people are depressed they will have a decrease in their sex drive . . . has this happened to you?” When assessing suicidality, a therapist might ask, “Many times when people are sad and ‘in the dumps’ as you have described yourself, they say the thought of wanting to die comes into their minds . . . has this thought surfaced for you?” Letting people know they aren’t the only ones to experience the behavior allows them to feel less anxious about it and free to share it with the interviewer.

When completing an assessment of a potentially suicidal client, the clinician must be aware of the most important information needed from the client: mainly, the client’s current level of suicidal ideation, suicidal intentions, whether a plan for action has been considered, and what access the client has for the means of completion (O’Connor et al., 2004; Packman et al., 2004; Schwartz & Rogers, 2004; Shea, 2002; Wingate et al., 2004). As the amount of information from these four areas increases, so does the probability that the client may be truly at risk. For example, if suicidal ideation is present, the clinician should evaluate how often these thoughts are occurring, how long the thoughts have been present, whether or not the thoughts have become more intense over time, and how difficult is it for the client to keep from acting upon these thoughts (Schwartz & Rogers, 2004). Another clinically important area would be to determine whether or not the client has a specific plan to harm him or herself. If a plan exists, the clinician would need to determine how well developed the plan is and whether the client has the means accessible to complete the plan. Not only will this exploration of ideation help to determine the lethality of the client, but it will also provide direct suggestions for setting up a safety plan.

Lethality is a function not only of risk factors, but also of whether or not protective factors are present (Maris et al., 2000). Below are some general guidelines provided by Schwartz and Rogers (2004) that may be helpful in determining the lethality of a client who acknowledges suicidal ideation:

* Low lethality—suicidal ideation is present but intent is denied, client does not have a concrete plan, and has never attempted suicide in the past.

* Moderate lethality—more than one general risk factor for suicide is present, suicidal ideation and intent are present but a clear plan is denied, and the client is motivated to improve his/her psychological state if possible.

* High lethality—several general risk factors for suicide are present, client has verbalized suicidal ideation and intent, has a coherent plan to harm him or herself, and reports access to resources needed to complete the plan.

* Very high lethality—client verbalizes suicidal ideation and intent, he or she has communicated a well thought out plan with immediate access to resources needed to complete the plan, demonstrates cognitive rigidity and hopelessness for the future, denies any available social support, and has made previous suicide attempts in the past.

Although suicide involves a complex range of behaviors, thoughts, and affective states, the evaluation of concrete suicide markers (i.e., ideation, intent, planning, and means) may increase a clinician’s success in predicting a client’s overall lethality (Schwartz & Rogers, 2004; Shea, 2002). However, as O’Connor et al. (2004) state, it is important to realize that “every clinician lives with the knowledge that even with our best efforts and exemplary care, there will still be some suicide deaths” (p. 359).

Another assessment approach that has been gaining popularity is an inclusive or “team-building” approach called the Collaborative Assessment and Management of Suicidality (CAMS), created from the research of David Jobes and associates. The main focus and uniqueness of this assessment model is that it targets the client’s subjective suicidality as the central clinical problem, independent of objective diagnosis (Jobes, 2006). In addition, by utilizing the Suicide Status Form (SSF), both the clinician and client develop a shared understanding of the client’s suicidality by rating the client’s current psychological pain, press (stress), perturbation (agitation), hopelessness, and poor self-regard (self-hate) (Jobes, 2006; Jobes & Drozd, 2004). With the CAMS model, even the traditional face-to-face seating is changed once suicide is mentioned. The clinician asks for permission to sit side-by-side the client while filling out the SSF in order to facilitate a more collaborative feeling (Jobes, 2006; Jobes & Drozd, 2004).

In addition to ranking risk-related characteristics, the CAMS model also helps the client to identify reasons for living as well as reasons for dying. In doing this, the clinician receives a glimpse at some of the protective factors that have kept the client from taking his or her life up to this point. As Jobes & Drozd (2004) profess, it is our job as clinicians to help suicidal individuals find alternative ways of coping with the unbearable pain and stress in their lives in order to alleviate suicide as a viable option. Finding a common ground and being able to agree on mutual goals increases collaboration immensely (Ellis, 2004).

The CAMS model incorporates its own documentation throughout each of the stages. In this model, the SSF has 4 sections:

Section A: This initial section is completed collaboratively in order to extract a true understanding of the meaning the world has for the client currently.

Section B: This section is completed by the clinician who asks specific questions regarding plan, preparation, rehearsal, history of suicidality, and so on.

Section C: This section is completed collaboratively and explicitly states what the outpatient treatment plan will be.

Section D: This section is completed by the clinician post-session and includes a mental status exam, preliminary diagnosis, and the client’s overall suicide risk level. Also, this section provides a place for the clinicians to jot down any additional information not otherwise covered in sections A-D.

There is a place at the bottom of each section for the client and clinician’s signature and date. This aspect of the model also reinforces collaboration during the assessment process, because the information collected is reviewed and agreed to by both clinician and client. This same process would be completed each session until there were three consecutive sessions without suicidal ideations (Jobes, 2006). As Jobes (2006) states, “I truly believe that through collaboration all things are possible, not the least of which is coaxing a life to be meaningfully lived back from the jaws of suicidal death” (p. 137)

By Michelle E. Toth, MA; Robert C. Schwartz, PhD; and Sandy T. Kurka, MA

In this Gestalt Therapy video clip, renowned therapist and teacher Erving Polster artfully and adeptly works with Gerald: bright, cynical, emotionally detached, overly-intellectual, and determined to defeat this therapist as he has previous ones. We watch Polster engage him in here-and-now interactions, matching wits, and challenging his defenses with a delicate balance of confrontation and empathy.
Video Rating: 5 / 5

How to Become a Marriage and Family Therapy Counselor

Many prospective students are learning more about how to become a marriage and family therapy counselor these days because there is an increasing demand for this job, and there are many rewards to choosing this career. Families and couples have many problems facing them, including emotional difficulties, problems with children’s behavior and the unhealthy, difficult-to-break family patterns. This is where the marriage and family therapy counselor fits in. With sufficient career information, you should be able to learn how to become a marriage and family therapy counselor and decide whether this job is right for you.

The first step in how to become a marriage and family therapy counselor is to get the degrees needed to move to the next level of certification. You will need to begin with a bachelor’s degree in a psychology-related field, and then complete a master’s degree in marriage and family counseling. The whole process will take at least six or seven years, but once you are done, you will be an expert in areas such as adolescent psychology, development, group therapy, human growth, marriage and family systems, psychotherapy, principles of counseling, theories of counseling, sexuality and substance abuse.

After you have the degrees needed to become a marriage and family therapy counselor and have satisfied all the state licensing requirements, then you can focus on completing a supervised practical internship that includes hands-on experience as a marriage and family counselor. This typically takes about a semester, or approximately four to six months. Once you begin working in the field, you can expect to earn close to the average salary of ,310, and with additional experience you should be able to earn the higher average salary percentiles of ,050 to ,240.

As a marriage and family therapy counselor you will deal with problems such as adolescent behavior, depression, divorce and other marital problems, domestic violence, grief, infertility, infidelity and substance abuse. It is an important job that will continue to be in demand as long as there are marriages and families. If you really want to learn more about how to become a marriage and family therapy counselor, local colleges and universities should be able to provide additional information.

Institutions offering quality Marriage and Family Therapy Programs include University of Phoenix, University of the Rockies, Friends University and Argosy University.

Relaxation and stress reduction – A vital key for IT professionals seeking work

Due to the current global downturn, never before have we seen so many applicants applying for the same job. Certain industries are worse than others, if you are currently seeking your dream job in I.T then for sure you will be going up against some of the very best in the business. Stress itself long term can literally kill, but short term it is imperative you learn to manage and reduce yours in order to place yourself amongst the elite if you are to win that new role. Relaxation and stress reduction needs to be considered a priority if you are to perform and communicate effectively.

If you are currently seeking work in the field of I.T, you are more than likely a well educated and certified, professional and a hard working individual. So right now if you are out of work it is certainly not your fault, and you are not alone. It is imperative however that you raise your game and separate yourself from all those competing for the same job!

Have you ever considered if you are affected in any way by stress?

Recent figures suggested that somewhere in the region of one third of all Americans are suffering with too much stress. So if you have never considered your stress level, you have a one in three chance it is too raised!

There are many reasons and permutations as to ‘why’ you may have high stress levels, but for now take a look at this list to see if you can relate to any of the following which more importantly may identify whether you are more stressed than you thought:

* Feeling low or anxious?

* Headaches?

* Having trouble sleeping? * Heart palpitations?

* Stomach upsets such as diarrhoea or constipation?

* Increased aggression or mood swings?

* Feelings of overwhelm or a lack in motivation?

Why should you consider if you are suffering from stress – after all what damage can it do?

Understanding the consequences of unmanaged stress is more vital to your very existence than you might first think. Some of the more serious ill effects of too much stress are potentially fatal. Living a life with too much stress means that you are more likely to suffer from cancer. Alzheimer’s disease is thought also to be directly linked to stress, and heart failure another condition of this most silent of killers! It is time to understand why relaxation and stress reduction must be considered a higher priority than most currently may!

How does all of this relate to seeking a new career in I.T?

The above conditions are extreme and relate to long term stress mismanagement. In the short term however, it is surprising to think that stress has a direct effect on how well we communicate with those around us, and the quality of the work and it’s value that we are able to ‘bring to the table’. Modern interview techniques have come of age and some are designed to diagnose how well any individual may react in a particular situation. Therefore if you are able to sharpen your awarenesses and improve how you react to pressurised situations it would stand to reason that you will of improved your chances of landing the dream job?

What therefore should you consider to effectively implement stress management?

* Consume less alcohol and caffeine – both disturb sleep patterns.

* Take regular exercise – releasing feel good hormones through your system.

* Create ‘you’ time – away from computers that strain your eyes and mind.

* Eat a well balanced diet – some minerals and vitamins are thought to help calm your mind.

All, in fairness would be easy and cost effective enough to implement if you really are motivated to your cause. One last string to the success of your relaxation and stress reduction program would be the study of a home based relaxation and stress reduction program. Designed using the most cutting edge stress managing techniques, you can now download such programs from the internet at very little cost. These programs will help you to:

* Stop stress from building up

* Learn PROVEN tools for Destroying undue stress

* Understand others and communicate effectively.

* Master to retain calm whilst those around you lose theirs!

* STOP other people pushing you around and learn how you can get others to do what you wish.

* Increase your metabolic rate causing you to lose that unwanted weight and increase your energy levels.

* Sharpen your mind and access heightened levels of creativity….. and much much more.

Should you implement a relaxation and stress reduction program thoroughly, you will be put yourself in to a position that many of your peers are not. One of increased self awareness, being able to call on increased creativity and utilize better communication skills. These skill sets alone will stand you above others and help you to calmly find the job that you so desire.

It may take you a little time researching the best relaxation and stress reduction program for your needs, but they are now readily available on-line for very little cost. Any money spent learning these crucial life skills will be repaid back tens of times for the rest of your life. Take action now, reduce the risk of long term harm caused by too much stress and help yourself to find the job of your dreams by using a relaxation and stress reduction program.

Severe Depression

There are three main categories of depression disorder. They are known as Bipolar Disorder, Chronic Depression Disorder and Major Depression Disorder. Of the three mood disorders Major Depression Disorder is the most severe. This disorder may also be called Severe Depression.

In Severe Depression the cause can be a single traumatic event in your life. It could even be the result of many personal disappointments and problems in your life. Sometimes it is possible to develop Severe Depression without any traumatic events or life problems. Still other times people who suffer from Chronic Depression can go into Severe Depression as a result of a traumatic event.

The symptoms of depression are also present in Severe Depression. They are however more intense than normal depression symptoms. For most people who suffer from Severe Depression, they can either have a recurring Severe Depression episode or their Severe Depression may occur only once in their lifetime and never reoccur again.

Recurring Severe Depression is where the individual will have periods of Severe Depression that are followed by periods of depression. After these bouts of depression are finished, they will be able to live at least several years without any episodes of depression. They may have another episode of Severe Depression which can arise due to some traumatic event. In a single episode of Severe Depression the symptoms occur due to a major traumatic event in the individual’s life. Once medical treatment has taken effect, the Severe Depression will not occur again in their lifetime.

In general the medication that is prescribed for Severe Depression is anti-depressants. There are several types of depression medications that are used for Severe Depression. These medications include Tricyclics, Selective Serotonin Reuptake Inhibitors, Serotonin Noradrenaline Reuptake Inhibitors, Noradrenergic and Serotonergic anti-depressants, Serotonin 5-HT (2) Receptor Antagonists, Monoamine Oxidase Inhibitors and Bupropion.

The other type of treatment that works for Severe Depression is that of cognitive-behavioral therapy. The best method of treatment is that of medication combined with cognitive therapy. The therapy is used to treat the psychological aspects of Severe Depression while the medication will treat the symptoms of Severe Depression.

The intensified symptoms of Severe Depression include restlessness, irritability, insomnia, oversleeping, fatigue, thoughts of death, suicide, early morning waking, pessimism, hopelessness, weight loss or gain, and a change in appetite

These symptoms coupled with any traumatic incident or an accumulation of life problems can trigger either recurring Severe Depression or episodic Severe Depression. Both types of Severe Depression need to be treated as the consequences can be life threatening. Should you suspect that you may be having Severe Depression then you should get immediate medical help.

How Depression Affect our Lives: Why Women are More Vulnerable to Depression

Researchers claim that women are four times more vulnerable to depression than men. I am not implying in any way that women are weaker than men. It’s that their biology is so much different from men’s. They can be so sensitive and more susceptible to depression, anxiety attacks and stress. Let’s point out some of the differences between men and women and how both respond to depression and the symptoms of depression.

Differences Between Men and Women:

* Different levels of hormones like serotonin, estrogen etc. Women’s hormone levels are fluctuating, thus women are by nature more stressful and physically sensitive than men, that’s why they are more likely to suffer from depressive symptoms. Hormones are really important for women. For example estrogen is responsible for more than 250 functions in a woman’s body.

* Women are more vulnerable against special types of depressive states. These are types of depression unique to women. Women become more vulnerable to these depression threats during pregnancy periods or during menopause. Men on the other hand suffer from standard depression forms.

* Women may develop different depression symptoms like anxiety/panic attacks or eating disorders while men develop symptoms like alcohol or drug abuse. So say the analysts.

* There are women who have suffered from severe sexual traumas like a rape or other abuse. These traumas may cause depression at any point during a woman’s life. It’s these special situations that cause unique female types of depression to appear.

* A woman’s menstrual cycle is a really important factor that makes women more vulnerable to stress and depression. During menstrual cycles virtually anything could impact a woman’s mood and trigger depressive episodes.

Conclusion: Women should be respected for the struggle they have to suffer in order to survive against depression. There are special female types of depression and women are often being blamed on “..being moody..” etc. and go untreated. It’s time to open our minds and go beyond that.

More Types Of Depression Articles

What is the drug to treat depression?

An antidepressant by nature Fluoxetine is quite helpful in treating patients suffering from depression, panic disorder, obsessive-compulsive disorder (OCD), and bulimia. While the therapy is not licensed to cure small kids and adloscence with bulimia or panic disorder, it has been approved for treating OCD and depression in children. fluoxetine are also used to cure conditions such as personality disorders, obesity, and social anxiety disorder which are not mentioned in the label.

(Prozac®) has been certified to treat many medical conditions.These fluoxetine uses include treatment for:

Depression (also referred as major depression or clinical depression)
Obsessive-compulsive disorder (OCD)
Bulimia
Panic disorder.

The drug is sometimes used along with Zyprexa® (olanzapine), to cure many conditions such as

Depression induced by bipolar disorder
Treatment-resistant depression (depression that is not affected by number of antidepressants ).

Sarafem is identical to fluoxetine and its use for premenstrual dysphoric disorder (PMDD) has been approved while the Prozac and its generic forms cannot be used even though the medications are similar.} .

When a person is diagnosed with depression it doesn’t mean that their only problem is being sad all the time. Usual signs of depression can consists of :

Changes in sleep (sleeping too much or not enough)
Eating too much or too little (and weight gain or weight loss)
Having little interest in things that you used to enjoy
Physical pain
Feeling hopeless or worthless
Suicidal thoughts.

It has been found through clinical trials that Fluoxetine is extremely effective in curing patients of all ages suffering from depression . Patience is important in this treatment and one must not get alarmed if they do not experience relief immediately as it take a number of weeks for the drug to create impact. At times, people around you will detect the changes in your signs of depression before you do.Often, the physical symptoms of depression (such as pain or changes in sleep) will improve first, sometimes within the first few weeks of treatment.However it takes as long as 4 to 6 weeks to develop changes in the mood.As the drug takes a long time to show improvement one must be patient and must not discontinue it.

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