It is widely believed that the Beats led to the hippies of the 60s and contributed to changing societal views towards drugs, sex, the arts, and more. When people debate about legalizing marijuana or same-sex marriage today, they can trace such ideas back to the Beats. In their book Mania, authors Ronald K.L. Collins and David M. Skover examine the lives of those men referred to as the Beats and how these fascinating individuals left an indelible mark on our culture.

Collins and Skover explicitly state that in this work they “seek neither to demonize nor apologize for Ginsberg and his cohorts.” That is, the authors aim to present the Beats in an honest way, without necessarily glorifying some of the more contentious aspects of the group members’ lives. In certain ways, the book emulates the writing of the Beats themselves; the stories are raw, without any sugarcoating of the alcohol, drugs, or sex that permeated the scene of these counter-cultural icons.

By the end, the reader feels that they have journeyed across the country with Kerouac, Ginsberg, and the entire cast of “angelheaded hipsters.”

While the Beat Generation was undoubtedly an influential movement in our history, one might wonder why a book about this group is being featured on a mental health website. In fact, the field of psychiatry and mental health were prominent themes in the lives and writing of many members of the Beats.

Allen Ginsberg was once a patient at the Columbia Presbyterian Psychiatric Institute and much is told in Mania about the relationship he formed with writer Carl Solomon while they were both there receiving psychiatric care. Jack Kerouac as well was sent to a psychiatric ward while he served in the Navy. One of Kerouac’s more famous quotes is the line from On the Road that begins “The only people for me are the mad ones…”

In these stories of what authorities in the 40s and 50s deemed “madness,” we can catch a glimpse of the history of psychiatric treatment. While it is hard and perhaps inappropriate to speculate as to whether or not these famous men suffered from mental illnesses, it seems that their nonconformity to society’s norms certainly played a role in their hospitalization. For instance, Ginsberg’s homosexual behavior was cited as one of the reasons for his need of care, whereas nowadays this would not be the case. Much of what may have seemed shocking in their day would seem to be to be normal or commonplace to most people today.

The authors utilize Ginsberg’s famous poem “Howl” as a focal point of the book. Perhaps the most well-known work of the Beats (it shares its title with a 2010 film about Ginsberg starring James Franco), its opening lines echo its writer’s experience with emotional distress: I saw the best minds of my generation destroyed by madness.

With graphic imagery and stark language, the poem typifies the Beat ethos of presenting life exactly as one sees it, with no holding back. As Collins and Skover put it, this poem represents when Ginsberg “turned his inner madness outward.” The book also goes into detail regarding the famous obscenity trial over the poem. Through this legal battle, the reader sees how the Beats influenced the very definition of art in modern times.

Whatever one thinks of the Beats and their writing, there is no denying that they had a major influence on our society: Artists from Bob Dylan to the Beatles have commented on the inspiration they drew from this group. Mania offers an intriguing look at the Beat Generation, even for readers who may be unfamiliar with these compelling icons. Meanwhile, for those who may be well versed in the history of the counter-cultural movement, the book provides a great deal of new insight. And although the book is not meant as a history of mental health care, it serves as a fascinating look at what was considered psychologically “abnormal” just half a century ago.

Mania
Top Five Books, March, 2013
Hardcover, 464 pages
$26.00 

Goldstein describes mindfulness as “paying attention to something on purpose and with fresh eyes.” This is why mindfulness is so helpful. Instead of focusing on how badly we want the pain to stop, we pay attention to our pain with curiosity and without judgment.

This approach is very different from what our brains naturally do when we experience the physiological sensation of pain. Our minds typically launch into a litany of judgments and negative thoughts. According to Goldstein, we start ruminating about how much we hate the pain and want to wish it away. “We judge the pain, and that only makes it worse.” In fact, our negative thoughts and judgments not only exacerbate the pain, they also fuel anxiety and depression, he said.

What also makes matters worse is that our minds start brainstorming ways to soothe the pain. Goldstein likens this to the Roomba, a robot vacuum. If you trap the Roomba, it just keeps bouncing off the edges. Our brains do the same with scouring for solutions. This “creates a lot of frustration, stress and feeling trapped.”

Mindfulness teaches people with chronic pain to be curious about the intensity of their pain, instead of letting their minds jump into thoughts like “This is awful,” said Goldstein, also author of The Now Effect: How This Moment Can Change The Rest of Your Life and co-author of A Mindfulness-Based Stress Reduction Workbook.

It also teaches individuals to let go of goals and expectations. When you expect something will ease your pain, and it doesn’t or not as much as you’d like, your mind goes into alarm- or solution-mode, he said. You start thinking thoughts like “nothing ever works.”

“What we want to do as best as we can is to engage with the pain just as it is.” It’s not about achieving a certain goal – like minimizing pain – but learning to relate to your pain differently, he said.

Goldstein called it a learning mindset, as opposed to an achievement-oriented mindset. In other words, as you’re applying mindfulness to your pain, you might consider your experience, and ask yourself: “What can I learn about this pain? What do I notice?”

As Jon Kabat-Zinn, Ph.D, writes in the introduction of The Mindfulness Solution to Pain, “From the perspective of mindfulness, nothing needs fixing. Nothing needs to be forced to stop, or change, or go away.”

Kabat-Zinn actually founded an effective program called mindfulness-based stress reduction (MBSR) in 1979. While today it helps individuals with all sorts of concerns, such as stress, sleep problems, anxiety and high blood pressure, it was originally created to help chronic pain patients.

“In MBSR, we emphasize that awareness and thinking are very different capacities. Both, of course, are extremely potent and valuable, but from the perspective of mindfulness, it is awareness that is healing, rather than mere thinking…Also, it is only awareness itself that can balance out all of our various inflammations of thought and the emotional agitations and distortions that accompany the frequent storms that blow through the mind, especially in the face of a chronic pain condition,” Kabat-Zinn writes in the book.

Mindfulness provides a more accurate perception of pain, according to Goldstein. For instance, you might think that you’re in pain all day. But bringing awareness to your pain might reveal that it actually peaks, valleys and completely subsides. One of Goldstein’s clients believed that his pain was constant throughout the day. But when he examined his pain, he realized it hits him about six times a day. This helped to lift his frustration and anxiety.

If you’re struggling with chronic pain, Goldstein suggested these mindfulness-based strategies. He also stressed the importance of paying attention to what works for you and what doesn’t.

Body Scan

A body scan, which also is included in MBSR, involves bringing awareness to each body part. “You’re bringing attention to what the brain wants to move away from,” Goldstein said. However, instead of immediately reacting to your pain, the body scan teaches “your brain the experience that it can actually be with what’s there.”

You’ll find helpful videos with a three-, five- and 10-minute body scan on Goldstein’s website.

Breathing

When “pain arises, the brain reacts automatically,” with thoughts, such as “I hate this, what am I going to do?” Goldstein said. Though you can’t stop these first few negative thoughts, you can calm your mind and “ground your breath.”

Goldstein suggested simply breathing in slowly and saying to yourself “In,” and breathing out slowly and saying “Out.” Then you also might ask yourself, “What’s most important for me to pay attention to now?”

Distractions

A distraction can be a helpful tool when your pain is high (such as anything above an 8 on a 10-point scale), Goldstein said. The key is to pick a healthy distraction. For instance, it could be anything from playing a game on your iPad to focusing on a conversation with a friend to getting lost in a book, he said.

Mindfulness is an effective practice for approaching chronic pain. It teaches individuals to observe their pain, and be curious about it. And, while counterintuitive, it’s this very act of paying attention that can help your pain.

Yet cognitive symptoms are quite common. “[They] are actually significantly prominent in depression,” said Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression.

And these symptoms are incredibly debilitating. “In my opinion, when cognitive symptoms of depression hit, they are more of a pressing concern than physical symptoms.”

Cognitive symptoms can interfere with all areas of a person’s life, including work, school and their relationships. Problem-solving and higher thinking, according to Serani, are greatly diminished. “This can leave a person feeling helpless and without a plan of action to defeat depression.”

Poor concentration can cause problems with communication, and indecisiveness may strain relationships, according to William Marchand, M.D., a clinical associate professor of psychiatry at the University of Utah School of Medicine and author of the book Depression and Bipolar Disorder: Your Guide to Recovery.

The cognitive symptoms of depression also may get confused with other conditions, complicating diagnosis. Here’s a specific list of symptoms along with similar disorders.

Cognitive Symptoms of Depression

“Cognitive symptoms can be subtle and often go unrecognized,” according to Dr. Marchand. Fortunately, psychotherapy can help individuals become more aware of these symptoms, such as distorted thinking, he said.

Marchand and Serani shared these cognitive symptoms of depression:

• Negative or distorted thinking
• Difficulty concentrating
• Distractibility
• Forgetfulness
• Reduced reaction time
• Memory loss
• Indecisiveness

Disorders That Mimic Depression

“The cognitive aspects of depression usually involve a person’s thinking being sluggish, negative or distorted in quality,” Serani said. However, there are many other disorders that share these similar symptoms, because they, too, inhibit cognitive function. Unfortunately, this means that the “risk for misdiagnosis is high,” she said.

For instance, Serani mentioned attention deficit hyperactivity disorder (the inattentive type), post-traumatic stress disorder and substance abuse.

Co-occurring disorders can add to the confusion. “In many cases there are comorbid conditions such as dementia (in elderly individuals), adult ADHD and generalized anxiety disorder, and it can be difficult to sort out which condition is causing the cognitive symptoms,” Marchand said.

It’s critical to receive a proper and comprehensive evaluation to make sure that you have depression or another condition. Again, psychotherapy and medication can improve cognitive symptoms along with other symptoms of depression. Also, there are many strategies you can try on your own to reduce symptoms and feel better (which are explored in another article).

1. Everyone has challenges.

Clinical psychologist Christina G. Hibbert, PsyD, wants readers to know that they’re not alone in their struggles. “We all have challenges. Even as I sit in my chair helping [a client], I have challenges too. It hurts me to see clients feeling like they’re the only ones on earth who ‘need therapy.’”

Therapist Joyce Marter, LCPC, agreed. She believes that our struggles are simply “part of the human condition…[E]verybody struggles with issues related to self-esteem, identity, navigating relationships, coping with various life traumas, managing stress or challenges in creating the life we want, personally and professionally.”

2. Everyone can benefit from therapy.

Therapy is a healthy and proactive approach to dealing with challenges, Marter said. “A therapist is like a personal trainer for your mind. I believe we can all benefit from therapy at various points in our lives and see it as a preventive and routine form of health care.”

3. Seeking therapy is courageous.

It’s a common myth that therapy is for weak people who can’t fix problems on their own. “I think of therapy as making use of all the tools at one’s disposal to manage negative emotional symptoms and maximize strengths and fulfillment,” said John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens. “People willing to delve into their own psyches are … actually quite courageous.”

4. Therapy helps you navigate life.

You can apply the skills you learn in therapy to any area of your life, according to Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression. “It really doesn’t matter if you go to therapy for anxiety, depression, to lessen obsessions, to quit smoking or to learn how to parent – whatever the reason – the techniques of self-reflection and thought-changing are involved in all.” In fact, she said, many people consider therapy to be the most meaningful and valuable experience of their lives.

5. Therapy is a process of self-discovery.

“To my thinking, therapy does not need to be an excruciating experience. Sometimes I think we do therapy itself a disservice when we call it ‘work.’ For my clients, I like to think of their therapy as a process of self-discovery, more joyous in the end than painful,” Duffy said.

6. Therapy isn’t about blaming others.

“Some people think therapy is about blaming their parents or their life histories for all of their woes,” said Marter, also owner of the counseling practice Urban Balance. Therapy is actually “about honoring those experiences and then taking full responsibility for your life from here forward.” She shared Wayne Dyer’s quote: “Everything you do is based on the choices you make. It’s not your parents, your past relationships, your job, the economy, the weather, an argument or your age that is to blame. You and only you are responsible for every decision and choice you make.”

7. Therapy is a place to say and ask anything.

“Therapy isn’t the place to put your best foot forward and try to convince the therapist that you have it all together,” according to Ryan Howes, Ph.D, a clinical psychologist and author of the blog “In Therapy.” Instead therapy is a space to be fully and authentically yourself. Bring everything from your daydreams and fantasies to your harsh opinions and random thoughts, he said. “A skilled therapist will work to understand these impulses and beliefs without judgment and help you make sense of them. Save the pleasantries for the outside world, and let your raw, real thoughts and feelings out here.”

The same is true for asking your therapist questions: If there’s a question you’d really like to ask about your treatment or therapy in general, ask away, Howes said. “If the therapist doesn’t want to answer, let them explain why and how not answering benefits you in the long run. If you’re not satisfied with the answer, let them know.” He noted that therapy is a relationship. “Therapists should be experts at setting boundaries and working through relational issues in a constructive way.”

8. Therapy doesn’t end as soon as you feel better.

Jeffrey Sumber, M.A., a psychotherapist, author and teacher, wishes that people knew that improvement doesn’t signal the end of therapy. “So often, folks begin to feel the shift within themselves, their patterns change, their mood improves, and they terminate treatment only to find themselves in a similar situation down the road.” That’s because those shifts are a mark of progress, not proof of a cure.

“The counseling process is multi-layered and the feelings of renewed purpose and lifeforce that accompany the internal shifts we make are actually there to help propel us forward so that we feel this way every day on our own. I wish people took the signs of improvement as a confirmation that treatment is helping, not over.”

9. Don’t compare your insides to others’ outsides.

“I often hear clients pathologize themselves and suggest that most other people are functioning at a higher level in various aspects of their lives,” Marter said. In reality, however, “we are all dealt a different hand of hardships and blessings. Therapy is a place to help you think through how you want to play your hand.” In fact, she’s seen “people overcome great adversity and others squander great blessings.”

10. Your thoughts dictate your feelings and behavior.

Marter cited Gandhi: “A man is but the product of his thoughts.” This is why it’s so helpful to pay attention to the things you say to yourself and shift your perspective to more realistic, empowering thoughts. “Through therapy, we can let go of negative or irrational thinking and promote positive thinking and a practice of gratitude that will attract more positivity into our lives,” Marter said.

11. Acceptance isn’t limiting; it’s liberating.

“Don’t get me wrong, there are times when we need to keep striving, pushing, and holding out hope for better health, better careers, or healthier relationships,” Howes said. However, many individuals end up wasting their time and energy wrestling limitations they can’t change, instead of focusing on the things they can alter. According to Howes:

We need to accept our age. We need to accept many physical and mental illnesses and addictions. We need to accept the past. We need to accept others as they are. This isn’t to say we need to like it, or that we can’t work to make the best of each of these entities, but we need to relinquish the idea that we have any power or responsibility to change them. Once people realize they can accept instead of fighting things beyond their control, they realize they have much more time and energy for things they can impact.

12. You are worthy. Whether her clients come in with depression, anxiety, relationship problems or parenting concerns, Hibbert believes that, at the core, they’re all struggling with the same thing: “an inability to comprehend and feel their worth.” She’s also seen this with friends and family and experienced it herself. “I’ve had to work very hard to discover my own self-worth.”

She wishes people truly understood that “they’re more than how they feel, what they do or say, and what they think. Deep down, we are each of infinite worth.” Connecting to our self-worth is “the key to living a life of meaning, abundance and joy,” said Hibbert, also a women’s mental health, postpartum and parenting expert. (She talks more about self-worth in this piece.)

13. Life requires balance.

Howes noted that while the idea of balance is cliché, he’s also seen the damage of living in extremes. “People who work too much, party too much, spend too much time online, exercise too much or let themselves become consumed by their relationships will face the consequences of a life out of balance.” The skills for achieving moderation are challenging yet critical to learn, he said.

14. Growth and progress are not linear.

“We all go through setbacks, relapses or regressions in life as a normal part of being human,” Marter said. Experiencing a setback doesn’t mean you’re back to square one. Instead, this is an “opportunity to learn, get back on the saddle, grow and move forward. Life is a process of ebbs and flows.”

15. Work on the inside.

According to Marter, “Some people are waiting for external factors such as a relationship, a job, a perfect body or a fat bank account to make them happy.” Instead, the key is to work from the inside out. She cited Eckhart Tolle: “If you get the inside right, the outside will fall into place.” Marter added: “Therapy is a place to explore your greatest gifts and align your life with those so that you will achieve all you desire personally and professionally.”

But it’s actually not uncommon for the first treatment to be unsuccessful. In fact, about 40 to 50 percent of people don’t respond to the first antidepressant they’re prescribed, according to Jonathan E. Alpert, M.D., Ph.D, the associate director of the Massachusetts General Hospital Depression Clinical and Research Program and co-founder and co-director of the Depression and Anxiety Group Practice.

Still, the people who stick with treatment do get better. So there is hope – real, tangible hope. Below, you’ll learn why treatment might not work, along with what you can do and how you can advocate for yourself.

Why the First Treatment Doesn’t Work

There are many reasons why the initial treatment doesn’t take. Here’s a selection.

Incorrect diagnosis. The treatment might be ineffective because the person doesn’t have depression in the first place. For instance, medical illnesses such as hypothyroidism can look like depression. Hypothyroidism produces significant fatigue, lack of motivation and difficulty concentrating, Dr. Alpert said.

A person might have another psychiatric disorder such as bipolar disorder. “On average bipolar disorder takes 7 years to diagnose,” said Kelli Hyland, M.D., a psychiatrist in outpatient private practice in Salt Lake City, Utah. Or an individual might have a personality disorder, which doesn’t respond to medication, she said. (In fact, “medication is often contraindicated.”)

Even if the diagnosis is correct, medical conditions can blunt the effect of antidepressants, Alpert said.

Stressors. Sometimes, the person is “living in an untenable situation,” Alpert said. So it doesn’t matter how well the antidepressant is working because the individual is still surrounded by stress – either at home or at work – that needs to be addressed, he said.

Adherence. Some people might stop taking their medication because they’re concerned that it’s habit-forming, addictive or a crutch, Alpert said. Other individuals might stop because they actually feel better. But, as he said, “Once someone responds, they need to stay on medication for a minimum of 6 to 9 months to ensure they don’t have a rapid relapse.”

Another reason people stop taking their medication is side effects, such as nausea, diarrhea, sexual dysfunction or weight gain, he said. (“Many of these side effects can be addressed by switching to a lower dosage or a different antidepressant or sometimes by prescribing a second medication that helps alleviate the side effect.”)

Alcohol or drug use. “Alcohol and drugs interfere with antidepressant response,” Alpert said. Even having a beer or glass of wine at night can mess with your medication, Hyland said.

Other medications. Hyland noted that other medications, such as steroids and hormones, can interfere with antidepressants. (Being perimenopausal or menopausal also can affect efficacy, she said.)

Sleep problems. “I tell my patients that if you’re not sleeping, we can take medication ‘til the cows come home,” Hyland said. “Insomnia exacerbates mood, anxiety and coping.” Treating an underlying sleep disorder or trauma is important, she said.

Severity of illness. With moderate to severe depression, people often do best with medication and therapy, Hyland said. And sometimes two or three medications aren’t enough, she said.

The Next Steps

If your first ineffective treatment was medication, there are several ways physicians proceed. Alpert begins by examining the reasons the medication didn’t work. If he can eliminate the above as culprits, he might increase the dose of the medication. He also might switch the patient to another antidepressant within the same class (such as switching from one selective serotonin reuptake inhibitor, or SSRI, to another). He then might choose a medication from another class.

Another technique is to add a medication to augment the effects of the initial antidepressant, “especially if there is some evidence of a partial response,” Alpert said. In other words, if a person thinks they’re about 20 percent better and they’re tolerating the medication well, the doctor may prescribe a second antidepressant that works on a different mechanism of the brain, he said. An example is combining an SSRI, which targets serotonin, with Wellbutrin, which works on dopamine and norepinephrine.

Physicians also might prescribe an atypical antipsychotic, such as Abilify or Seroquel, to bolster the effects of the original antidepressant, Alpert said.

Psychotherapy, including cognitive-behavioral therapy and interpersonal therapy, is highly effective for treating depression. Therapists help clients learn about their illness, cope with stressors in their lives, identify and change dysfunctional thinking, and take action to get better.

If you’re only taking medication, seeing a therapist can be tremendously helpful. (If you’re solely working with a therapist, it’s also possible that you might need medication.)

Somebody, somewhere, declared April to be Autism Awareness Month. I’m all for it. We need to be more aware of it so that children are diagnosed early and accurately to make sure that they get the treatment they need.

What is Autism?

Autism is a neurological disorder that usually becomes apparent by the age of 3 if people know what to look for. Part of the problem in diagnosing autism is the wide range of possible behaviors and abilities. However, there is usually a distinct pattern of significant impairment in three major areas:

• Impairment in reciprocal social interaction. Children who are on the autism spectrum don’t get the give and take of conversation and sharing of experience. Even when very little, neurotypical kids will point to things that interest them so that others will see it too. They will babble back and forth, imitating conversation. Autistic kids seem to be in their own world, uninterested in sharing it with others or unable to understand that other people aren’t as interested as they are in their obsession of the moment. Higher-functioning kids with autism may come off as rude, clueless, or self-centered because of their apparent inability to read what is socially appropriate at any given time.
• Impairment in communication skills. Their language may be unusual, stilted, or limited. High-functioning kids on the spectrum may have large vocabularies but may use words incorrectly or idiosyncratically. Lower-functioning kids may not speak at all.
• Presence of stereotyped behaviors, interests, and activities.Spinning, flapping, and finger-flicking are common in young kids and even in some autistic adults. Many rock to comfort themselves. Children may develop an intense obsessive interest in just about anything. I’ve known kids who are walking encyclopedias about pirates or fishing or who know every detail of every one of the Star Wars movies. They can talk for hours about their “thing” but are unable to have even a brief conversation about almost anything else.Some of the more disabled kids with autism I’ve known have been obsessed with things such as different kinds of tires, ceiling fans or string. They are happiest when they can watch or play with their particular interest. High-functioning autistic adults may become experts in arcane academic or technical areas, again to the exclusion of almost everything else.

  In addition, many of these children show sensory processing disorders. They can be intensely over- or under-sensitive to sensory stimulation (lights, sounds, smells, or touch). Some are unable to stand the buzz of fluorescent lights or the smell of certain foods, the sensation of certain fabrics or changes in temperature, to name only a few examples. Some have a very high tolerance for pain. (A school program called me recently because a teenaged girl seemed to feel no pain when she pulled off fingernails.) Some can’t manage any discomfort at all. I know one preschooler who walks on tip-toe whenever he is barefoot because he can’t tolerate how grit feels on his feet.

Autism is associated with a known medical condition in only 10 to 20 percent of cases. It is thought to be genetic since 60 to 90 percent of identical twins both have it while in fraternal twins it is less than 5 percent. As yet, there is no genetic test or brain scan or medical test to use for diagnosis. We rely on observation and the experience of professionals.

Why Does the Prevalence Rate Keep Growing?

In my professional lifetime, the odds of a child having autism have kept growing. In the 1970s, the statistic worldwide was 4 in 10,000. Between 1985-1995, the number tripled to 12 in 10,000. The rate was estimated to be 1 in 155 by 2002; 1 in 110 in 2006 and 1 in 88 in 2008. Some studies are now suggesting that it afflicts 1 in 50 kids in the U.S.

What happened? Partly it’s about a change in the acceptance of autism as a genuine, distinct disorder. Partly it’s due to a change over time in the description of criteria and the number of criteria that need to be met to make a diagnosis.

When I was in graduate school in the early 1970s, we were using the DSM-II. Autism isn’t mentioned except as a subset of childhood schizophrenia. Frankly, back then, I’d never heard of it. When DSM-III came along in 1980, a section on infantile autism was added and the first effort was made to delineate criteria. It took until the DSM-IIIR in 1987 for autism disorder to appear with a well-articulated set of 16 criteria, 8 of which had to be present to warrant a diagnosis. By the time the DSM-IV (1994) and DSM-IVR (2000) came out, the number of criteria had been reduced to 12, with 6 being needed for a diagnosis. With each succeeding edition, mental health professionals became more aware of autism as a possible diagnosis.

At least some of the increase in prevalence is due to that awareness on the part of professionals. Some of it is probably because kids who at one time might have been diagnosed with psychosis or retardation or hyperactivity are now being assigned the diagnosis of autism. And some of it is due to the fact that parents and teachers have become much more attuned to the possibility that a child is on the autism spectrum, so evaluations are occurring at a much earlier age. Finally, it’s possible that there is something going on in our environment or in genetics that is causing an increase in the disorder. That last one remains a mystery.

What if You Suspect Your Child Has Autism?

With the increase in autism prevalence and awareness has come an increased sophistication in screening. A diagnosis of autism is rarely assigned before 15 to 18 months of age. If by then you suspect that your child isn’t developing as he or she should, you can first go to one of the many websites that have quizzes and checklists for the symptoms of autism for the age of your child. But please don’t go on the results of those websites alone. There are many reasons why a child may not be keeping up with peers. It’s just a good, if crude, first effort.

The next step is to ask your pediatrician to take a look at your web-based checklists and to decide if a referral to an autism screening team is advisable. There are early childhood interventions (EI) teams all over the U.S. who can make a more refined diagnosis and who can offer treatment if it is needed. If there is no EI team nearby, there is probably a diagnostic team in a mental health clinic or children’s hospital near you. An accurate diagnosis is essential. Diagnosis is what determines what types of treat may be the most helpful for your child.

Early Intervention Matters

There is no cure for autism but when children get intense and appropriate treatment early on, preferably before age 3, many can and do learn compensatory skills. Excellent programs provide physical, occupational and speech therapy as well as coaching in social and language skills for the child. They also provide coaching and support for parents so they can reinforce and continue the treatment at home. If there is no comprehensive program nearby, there is often a resource center connected with a school or with a medical center that can help families get the services the child needs.

“I’m still surprised at the number of people who come to therapy to learn how to get someone else to change,” said Ryan Howes, Ph.D, a clinical psychologist and author of the popular blog “In Therapy.” “They want to know how to get their boss to talk to them differently, or want their wife to appreciate them more, or want their friends to be more considerate.”

Of course the only person you can change is yourself. That includes changing your beliefs, behaviors, reactions and patterns. As therapist Joyce Marter, LCPC, said, “In therapy, change may mean letting go of dysfunctional relationship patterns, irrational beliefs and self-sabotaging behaviors and then replacing them with a more positive, conscious and proactive mode of operation that leads to greater happiness, wellness and success.”

Why is Change so Hard?

According to clinical psychologist Christina G. Hibbert, PsyD, change is difficult because most people don’t know how to change, or we’re just not ready. She believes there are six stages of change, which are part of the “transtheoretical model of change.” This model demonstrates that change isn’t linear but a spiral. She said:

Most people spiral up and down the six stages of change several times before they actually make change that lasts. That’s just part of the nature of change.

As I always say, “As long as you’re in the spiral, you’re making progress. It doesn’t matter whether you’re spiraling up or down, what counts is that you keep on working.” Teaching this to my clients helps them see they’re actually doing better than they think.

(Hibbert explains the model in this post.)

Sometimes change isn’t really what you want. Howes gave an example of a husband who thought he wanted his wife to change.

I’ve worked with couples who claimed to want changes from their partner, but when change happens they want the old familiar dynamic back. A husband wants his wife to be more social, for example, but when she branches out he feels jealous and wants the homebody back. I encourage couples to be clear about the change they ask for, and prepared for that change to occur.

We also gravitate toward the familiar, and fear the unfamiliar, said Marter, owner of the counseling practice Urban Balance. “Change can be scary because people fear the unknown, perceived loss of relationships or the risk of failure.”

Howes quoted the common saying: “The devil we know is better than the devil we don’t.”

Some people hyperfocus on external changes. “I’d say that so many of us struggle with external change because we secretly hope we can bypass the true work which is changing how we feel inside,” said Jeffrey Sumber, M.A., a psychotherapist, author and teacher. Put another way, “when we place too much concern in things looking different then we tend to overlook the deeper need to shift our internal climate.”

Change is tough because it also takes time. According to Serani, “It takes time to discover patterns that create undesirable thoughts and behaviors. It also takes time to understand what issues get in the way of achieving your goals once you know what you need to change.”

Naturally, resisting change is normal, Marter said. “Breaking through defense mechanisms and developing the tools to think and operate differently is a process with ups and downs.”

While change is difficult, it’s to be expected. “I think we need to recognize the inevitability of change. We are all changing in some way or another, every day,” said clinical psychologist John Duffy, Ph.D, author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens.

How Therapists Facilitate Change

“I try to teach clients to be like a super-sleuthing detective. I want them not to just crave change, but to be immensely curious about it,” Serani said. In fact, she believes that “enthusiastic curiosity” helps us develop insight and replace old behaviors with new ones much faster.

Healthy change, she said, happens when we ask key questions, such as “Why isn’t this new technique working? What’s getting in the way? How can we make it work better?”

Hibbert, an expert in postpartum mental health, helps her clients learn how to change. “My job as a psychologist is to provide the ‘how’ so the client can get to work. I’ve seen many people make amazing changes, so I know it’s possible. You just have to believe it’s possible for you.”

Howes helps clients gain a clearer understanding of the trade-offs of change.

As pessimistic as it might sound, I try to help people know that change means trading in one set of problems for another. Sure, there may be some clear benefits to change, but there is always a different set of hardships to endure.

Just ask the people who win the lottery. Financial problems are solved, but a host of new problems emerge. If they’re informed and prepared for their new set of problems, change may be welcomed instead of dreaded.

Change is an inside job. Marter quoted Eckhart Tolle, author of The Power of Now, who said: “If we get the inside right, the outside will fall into place.” She explained:

Many people think if they have the perfect job, house, relationship, or body, they will finally be happy. Through therapy, I help clients make internal changes – such as detachment from ego, focus on essence, silencing the inner critic, practicing positive thinking and gratitude – that lead to positive change in life.

Marter teaches her clients to recognize that it’s “inner forces” that determine their lives, not external ones. This way “they feel empowerment to enact positive change in their lives, both personally and professionally.”

Plus, she teaches them to practice assertive communication, which includes “asking for what they need, setting healthy limits and boundaries and saying no to old patterns that are no longer serving them.”

Sumber also helps his clients transfer the focus from external change to internal transformation.

I work with clients to release their expectation of external manifestations and allow for a shift in their conscious awareness of who they are and why they are doing what they are doing. Most clients are surprised in the end to find that things have indeed shifted externally as a result.

Duffy helps clients foster self-awareness, which he views as a requisite “for satisfactory, proactive change. Otherwise, we are simply reacting to life, and often feel we are victim to it.”

Real change requires work and effort. As Serani said, “toxic tendencies or undesirable thoughts don’t happen overnight. They are created and cultivated over time. And the same goes for change. It doesn’t happen overnight either.”

Positive change is a process that ebbs and flows. But it’s worth it. Change is “an essential part of healing and development,” Marter said.

While the above questions are obvious appeals, they are not the only way that OCD sufferers seek reassurance. Indeed, the very nature of OCD centers around making certain that all is well. The disorder is characterized by unreasonable thoughts and fears (obsessions) that lead the sufferer to engage in repetitive thoughts or behaviors (compulsions). Obsessions are always unwanted and cause varying degrees of stress and anxiety, and compulsions temporarily alleviate these feelings. Compulsions are always, in some way, shape, or form, a quest for reassurance; a way to make everything okay.

A good example is the case of someone with OCD who is obsessed with a fire starting because he or she left the stove on. The compulsion of continually checking the stove is a recurring attempt to reassure oneself that the stove is indeed off and nobody will get hurt. Another OCD sufferer may fear germs (obsession) and wash his or her hands until they are raw (compulsion). The compulsion of hand-washing is an effort to make sure that his or her hands are clean enough so that there will be no germs.

My son Dan suffered from OCD for a few years before we even knew anything was really wrong. In retrospect, I realize he had a lot of reassurance-seeking behaviors. While he never asked the “Are you sure?” questions, he would often apologize for things that did not warrant an apology. If we went to the supermarket together he would say, “Sorry I spent so much money,” when, in fact, he had only picked out a few items. I, in turn, would reassure him that he hadn’t spent much at all. Dan would also thank me over and over again for things that most people might say “thank you” for only once, if that. Again, I would reassure him by saying, “You don’t have to thank me,” or “Stop thanking me already.” My responses to Dan in these cases gave him the reassurance he needed to feel certain that he hadn’t done anything wrong, had behaved appropriately, and all was well.

Of course hindsight is a wonderful thing and I now know that how I reacted to Dan at these times was actually classic enabling. I did him more harm than good. My reassuring Dan that all was well reinforced his misconception that he had to be certain, to have no doubt at all in his mind. While I helped reduce his anxiety at the moment, I was actually fueling the vicious cycle of OCD, because reassurance is addictive. Psychotherapist Jon Hershfield says:

If reassurance were a substance, it would be considered right up there with crack cocaine. One is never enough, a few makes you want more, tolerance is constantly on the rise, and withdrawal hurts. In other words, people with OCD and related conditions who compulsively seek reassurance get a quick fix, but actually worsen their discomfort in the long term.

So how can those with OCD “kick the habit?” It’s not easy, as sufferers continually wrestle with the feeling of incompleteness, never truly convinced that their task has been completed. There is always doubt.

But there is also always hope. Exposure Response Prevention (ERP) Therapy involves facing one’s fears and then avoiding engaging in compulsions. Using the stove example again, the sufferer would actually cook something on the stove and then shut the burner(s) off. He or she would then refrain from checking the stove to make sure it was off. No reassurance allowed. This is incredibly anxiety-provoking initially, but with time it gets easier. And while it is difficult to watch a loved one go through “withdrawal” it is imperative that family members and friends learn how not to accommodate or enable the sufferer.

Without reassurance, how will those with OCD achieve that need for certainty that they so desperately desire? Indeed, how can all of us make sure that nothing will ever go wrong? How can we control our lives, and the lives of those we love, so that nothing bad will ever happen?

The answer, of course, is that we can’t. Because as much as we’d all like to believe otherwise, much of what happens in our lives is beyond our control. Through ERP therapy, OCD sufferers will focus on the question “How can I live with uncertainty?” as opposed to “How can I be certain?” And instead of dwelling on the uncertainties of the past and the future, those with OCD can begin to live life to the fullest by concentrating on what matters most – the present.

“Whatever the reason, it’s vital to bring it into your sessions as soon as you feel it,” said Serani, author of the book Living With Depression. Howes agreed. Wanting to end therapy is a critical topic to explore, he said. And it could be as simple as telling your therapist, “I feel like it’s time to end therapy, I wonder what that’s all about?”

Therapy gives people the opportunity to have a positive ending, unlike most endings, which tend to be negative, such as death and divorce, Howes said. An end in therapy can be “more like a bittersweet graduation than a sad, abrupt, or complicated loss. Ideally, you can have a satisfying closure to therapy that will help you end relationships well in the future.”

That’s because our relationship with our therapist frequently mirrors our relationships outside their office. “We often unconsciously recreate dynamics from other relationships with our therapist,” said Joyce Marter, LCPC, a therapist and owner of the counseling practice Urban Balance. “Processing negative feelings can be a way to work through maladaptive patterns and make the therapeutic relationship a corrective experience. If you avoid this conversation by simply discontinuing therapy, you will miss this opportunity for a deeper level of healing resulting from your therapy.”

Tips on Ending Therapy

Below, clinicians share additional thoughts on the best ways to approach your therapist when you’d like to end therapy.

1. Figure out why you’d like to leave. According to Jeffrey Sumber, M.A., a psychotherapist, author and teacher, the best way to end therapy is to delve into why you’d like to leave. Ask yourself: Is it “because I feel disrespected, stuck or incompatible or [am I] actually feeling uncomfortable dealing with certain things that the counselor is pushing me on?” It’s common and part of the process of changing problematic patterns, he said, to feel triggered and even angry with your therapist.

2. Don’t stop therapy abruptly. Again, it’s important for clients to talk with their therapists, because they may realize that their desire to part ways is premature. Even if you decide to leave therapy, processing this is helpful. “A session or two to discuss how you feel and what kinds of post-treatment experiences you may go through will help ease guilt, regret or sadness that often arises when wanting to stop therapy,” Serani said.

Plus, “Honoring the relationship and the work you have done together with some sessions to achieve closure in a positive way can be a very powerful experience,” Marter said.

But there are exceptions. Howes suggested leaving abruptly if there are ethical violations. He reminded readers that you’re “the boss” in therapy:

If there have been significant ethical violations in therapy – sexual advances, breached confidentiality, boundary violations, etc. – it may be best to leave and seek treatment elsewhere. It’s important for clients to know they are the boss; it’s your time and your dime, and you can leave whenever you want. If the violations are serious enough, you may want to tell your therapist’s boss, your next therapist, or the licensing board about them.

3. Talk in person. Avoid ending therapy with a text, email or voicemail, Marter said. “Speaking directly is an opportunity to practice assertive communication and perhaps also conflict resolution, making it is an opportunity for learning and growth.”

4. Be honest. “If you feel comfortable and emotionally safe doing so, it is best to be direct and honest with your therapist about how you are feeling about him or her, the therapeutic relationship or the counseling process,” Marter said.

When offering feedback to your therapist, do so “without bitterness or judgment,” said John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens. “After all, this person will be working with others in the future, and your thoughts may change his or her style, and help them to better serve their clients in the future.”

“A good therapist will be open to feedback and will use it to continually improve,” added Christina G. Hibbert, Psy.D, a clinical psychologist and expert in postpartum mental health.

5. Communicate clearly. “Your best bet is to be as direct, open, and clear as possible,” Hibbert said. Articulate your exact reasons for wanting to end therapy. Hibbert gave the following examples: “’I didn’t agree with what you said last session and it makes me feel like this isn’t going to work,’ or ‘I’ve tried several sessions, but I just don’t feel like we’re a good match.’”

(“’Not being a “good match’ is a perfectly good reason to terminate therapy, since so much of it has to do with a good personality fit and a trusting relationship,” she added.)

6. Be ready for your therapist to disagree. According to Serani, “It is not unusual for a therapist to agree with ending therapy, especially if you’ve reached your goals and are doing well.” But they also might disagree with you, she said. Still, remember that this is “your therapy.” “Don’t agree to continue if you truly want to stop, or feel persuaded to keep coming for sessions because your therapist pressures you to stay.”

7. Plan for the end in the beginning. “Every therapy ends, there’s no reason to deny this fact,” Howes said. He suggested discussing termination at the start of treatment. “Early in therapy when you’re covering your treatment goals, why not talk about how and when you’d like therapy to end? Will you stop when you’ve achieved all your goals? When the insurance runs out? When and if you get bored in therapy?”

Again, therapy can teach you valuable skills to use for your other relationships. According to Marter, “Even if after expressing your negative feelings, you choose to end the therapeutic relationship, you can rest assured that you took good care of yourself by advocating for yourself in a way that was direct and honest. This is a skill you can bring with you to other relationships that are no longer working for you.”

How Therapists React to Termination

So how do clinicians take it when clients end therapy? All the therapists noted that having their clients share feedback on their experiences is incredibly valuable. In short, it helps them improve and grow as clinicians.

But, when there’s no official end to therapy, therapists are left with many unanswered questions. According to Howes:

When a client terminates via voicemail, fades away with a vague “I’ll call you for my next session,” or abruptly announces the end and leaves, I feel loss and am left with many questions.

What fell short in this therapy? What would have worked better? How could I have been a better therapist for you? What made you feel like you couldn’t discuss this with me? I’m left with no answers for these questions, and that’s difficult. I spend a lot of time reflecting on our work together, but I have no definite answers.

Serani and Marter echoed this sentiment. “Sometimes clients just ‘fizzle out’ without explanation, which has been one of the harder pieces of being a therapist for me because I am very invested in my work with my clients. It causes me to wonder if I did something that bothered them and wished that I knew,” Marter said.

Serani also talked about attempting to understand the client’s decision. “I always want to explore the reasons why. Was it something I said? Was it something I didn’t say? What has happened to make this decision so urgent? I often feel confused, and work hard to make sense of why this has happened.”

Hibbert tries not to take it personally. “Usually clients simply ‘stop coming,’ so it’s not easy to know if they’re just ‘done’ with therapy or if I’ve done something to make them want to leave. When this is the case, I just let it go. It’s their issue, not mine, and I don’t need to stress over it when I don’t know the reasons behind it.”

She takes a similar approach when a client wants to stop therapy because of personality differences. “Only a couple of times has a client verbalized a desire to leave because of ‘personality’ or ‘style’ differences. I can’t say it never stings, but I try not to take it personally. Like I said before, therapy, in large part, is a personality fit, and I can’t fit with every personality.”

When client and clinician are able to have a session (or two) for proper closure, it becomes a great opportunity to reflect on their work together. In fact, for Howes, these are often his most enjoyable sessions.

My goal is to help a client confront life head-on. If they have clear reasons to end therapy and we’ve had the time to talk about it and tie up the loose ends, ending therapy is a great time to reflect on our work, talk about the client’s future, and discuss what has been accomplished and what hasn’t. We can leave with a sense of closure, without lingering questions.

Some of my best sessions have been final appointments where we reminisce about our time together, talk about the client’s future, and I learn how to be a better clinician for others.

Serani described final sessions with mixed emotions. “This is usually an exciting but bittersweet time, where we both feel a loss about the goodbye, but know that leaving is part of the healing process. I’m always sad for me, but happy for my patient.”

Unless there are ethical violations, it’s important to discuss your desire to end therapy with your therapist, in person. As Duffy said, doing so with “respect and integrity will set the tone for other relationship issues you will encounter in life.” It also helps you process your emotions and figure out if you’re leaving too soon. And it gives your therapist valuable feedback that improves their work. In other words, with proper closure, everybody wins.

I’m just getting to know Michelle. She had her first baby 3 weeks ago and has been sad and irritable ever since. Her pediatrician was worried about her at the well-baby visit this week and sent her to me. She’d had a tough pregnancy (morning sickness that wouldn’t quit for what felt to her like forever), made tougher by the financial stress that came from her husband being out of work for several months. The doctor is worried that she and her baby aren’t getting off to a good start.

Sadly, moms like Michelle often feel alone and guilty. Not feeling what they think they are supposed to feel, they are embarrassed to admit to themselves and others that things aren’t going well. Just when they need help the most, many don’t reach out. Some start to resent their babies and begrudge them time and attention. They force themselves to do what needs to be done but don’t provide their newborns with the nurturing they need.

Still others give up on nursing, or holding their babies when bottle feeding, depriving themselves and their babies with the closeness that comes with the quiet feeding times. Propping a bottle is the best they can do. Overtired, irritable, and sinking into depression, life after birth isn’t at all what they expected.

As hormones shift and settle, it’s absolutely normal to feel what is commonly known as the baby blues in the weeks following birth. One of my clients described the first couple of weeks after her first child was born as PMS times ten. Others feel more emotionally fragile than usual and maybe a little weepy. Still others are surprised that they are on an emotional roller coaster, feeling great one minute and set off into tears by something that normally wouldn’t bother them the next. It’s all because the endorphins from delivery are leaving the new mother’s system and the body is resetting itself.

Different women react differently but normal baby blues are usually accompanied by moments of joy and wonder and happiness about the baby and motherhood. The emotions settle down after a couple of weeks and the routines and rhythms of new parenting get established.

But when those up and downs last more than a few weeks, and especially if they get worse, it may indicate that the new mom is developing postpartum depression (PPD). This happens to between 11 and 18 percent of new mothers, according to a 2010 survey by the Centers for Disease Control (CDC). Surprisingly, it can last anywhere from a couple of months to a couple of years.

Symptoms of Postpartum Depression

Postpartum depression looks like any major depression. Things that once gave the mother pleasure are no longer fun or interesting. She has trouble concentrating and making decisions. There are disturbances in sleep, appetite, and sexual interest. In some cases, there are thoughts of suicide. Many report feeling disconnected from their baby and some worry that they will hurt their baby. Feelings of hopelessness, helplessness and worthlessness immobilize them. Many feel guilty that they can’t love their child, which makes them feel even more inadequate.

In some cases, women develop psychotic delusions, thinking their baby is possessed or has special and frightening powers. Sadly, in some cases, the psychosis includes command hallucinations to kill the child.

Who Develops Postpartum Depression?

There are a number of issues that contribute to a woman’s risk of developing PPD:

• A prior diagnosis of major depression. Up to 30 percent of women who have had an episode of major depression also develop PPD.
• Having a relative who has ever had major depression or PDD seems to be a contributing factor.
• Lack of education about what to realistically expect of herself or the baby. Teen mothers who idealized what it would mean to have a baby to love with little appreciation for the work involved are especially vulnerable.
• Lack of an adequate support system. Unable to turn to someone for practical help or emotional support, a vulnerable new mom can become easily overwhelmed.
• A pregnancy or birth that had complications, especially if mother and baby had to be separated after the birth in order for one or the other to recover. This can get in the way of normal mother-child bonding.
• Being under unusual stress already. New mothers who are also dealing with financial stress, a shaky relationship with the baby’s dad, family problems, or isolation are more vulnerable.
• Multiple births. The demands of multiple babies are overwhelming even with substantial support.
• Having a miscarriage or stillbirth. The normal grieving of loss is made worse by the shifting hormones.

What to Do

In cases of the normal “baby blues,” often all a new mom needs is reassurance and some more practical help. Engaging the dad to be more helpful, joining a support group for new parents, or finding other sources of support so the mom can get some rest and develop more confidence in her mothering instincts and skills can put things back on track. As with any other stressful or demanding situation, new parenthood goes better when the parents are eating right, getting enough sleep, and getting some exercise. Friends and family can help by bringing some dinners, offering to take over with the baby for an hour or so so that the parents can get a nap, or by babysitting siblings to give the parents time to focus on the infant without feeling guilty or pulled in multiple directions.

Postpartum depression, however, is a serious condition that requires more than naps and caring attention. If the problem has persisted beyond a few weeks and has been unresponsive to support and help, the mother should first be evaluated for a medical condition. Sometimes a vitamin deficiency or another undiagnosed problem is a contributing factor.

If she is medically okay, those who care about her and her baby need to encourage her to get some counseling, both for the emotional support counseling offers and for some practical advice. Cognitive-behavioral treatment seems to be especially helpful. Since women who have experienced postpartum depression are vulnerable to having another episode of depression in their lives, it is wise to establish a relationship with a mental health counselor to make it easier to seek help if it is needed in the future. If the mom has had thoughts of suicide or infanticide, the therapist can help the family learn how to protect them both. If the birthing center or hospital offers a PPD support group, the new mom and dad should be encouraged to try it. Finally, sometimes psychotropic medications are indicated to alleviate the depression.

The baby blues are uncomfortable. Postpartum depression is serious. In either case, a new mom deserves to get practical help from family and friends. When that alone doesn’t help a new mom adjust, it’s time to seek out professional help as well.

Neurobiology of Breaking Habits

Self-destructive behavior patterns, such as addictions, are hard to break because they provide immediate relief. But their aftermath makes people defeated and ashamed, requiring more relief, and the cycle continues. These habitual, compulsive behavior patterns limit new learning and connections in the brain by obstructing opportunities to experience the positive rewards from sustainable, effective coping strategies.

Kaitlyn, 17, was bright, vibrant and charismatic. She was adopted at birth (and knew this all along), then struggled from early childhood with both epilepsy and an unbearable sense of psychological pain and inner isolation she could not articulate.

Kaitlyn’s shame and sense of herself as unlovable had its origins in feeling unwanted and abandoned. She was naturally outspoken, gregarious and likable, but developed an early pattern of self-consciousness and inhibition with peers, driven by fear of rejection. She learned to act according to what she thought friends and boys wanted – anxious to be liked and secure her relationships.

Shame, Rage and Self-Harm

Kaitlyn had a history of self-harm, typically provoked by real or imagined rejection. She harbored a secret fantasy of being hurt and then rescued, and impulses to make her pain visible and have it validated by others. This dynamic was an unconscious attempt to manage overpowering feelings. It brought others close enough so she wasn’t alone, while reassuring her she was still loved.

Shame is a terrible feeling of badness associated with wanting to hide one’s head and disappear. Kaitlyn’s feeling of shame and badness was fueled by episodes of rage at home, confirming her fear that she was a “monster” who drove people away and didn’t deserve love and happiness. Rage can be a defense against intolerable shame, when shame turns into blame and is projected onto others. In this way, the bad feeling is passed on like a hot potato, providing temporary respite from feeing terrible, but propelling the cycle of shame and self-destructive behavior.

Self-Fulfilling Prophecy and Self-Sabotage

Shame-based self-perceptions that are acted out through self-destructive fantasies and behavior create a self-fulfilling prophecy, providing rigged evidence of badness. Feelings such as worthlessness, badness, and inferiority have various origins in early experience when we are developing a sense of self. These feelings may later be experienced as factual — as if they represent the truth about who we are. When such compartmentalized experiences of oneself remain secret and unarticulated they can lead to unconscious pressure to make this inner “truth” a reality, leading to self-sabotage.

Dysfunctional behavior patterns are habits with psychological, often unconscious, motives. Breaking them requires insight into what function they serve and the discipline to stop them. It also requires courage and initiative to try out new behaviors and allow a different chain of events to occur. On a neurobehavioral level, new behaviors that generate positive feedback create new pathways in the brain, allowing momentum for psychological growth and change.

Kaitlyn had been caught in waves of powerful feelings and a difficult cycle of self-defeating patterns. But she wanted more than anything to be strong, self-respecting and independent and began to use her determination to work toward these positive goals, instead of hurting herself.

Kaitlyn’s first step was talking in family therapy about being secretly drawn to videos about suicide and self-harm on YouTube, especially when feeling sad or alone. She initially feared being judged and was scared that access to the videos would be taken away. However, as she trusted that it was safe to talk about these secrets without being judged and could make her own decision, Kaitlyn was able to evaluate what she wanted to do.

When taking a neutral step back to assess her thoughts and feelings, Kaitlyn recognized that exposing her mind to this content fed her fantasies, pulling her deeper into darkness, and created a cycle of regression which impeded independence and forward motion. Just as she could choose what food to put into her body based on its effect, she could decide whether she wanted to expose her mind to stories and images that made it harder to resist being self-destructive.

Trying Out New Behaviors

With encouragement, Kaitlyn became motivated to try out new ways to comfort herself. Learning better ways to regulate and take charge of her feelings gave Kaitlyn a jumpstart to taking healthy risks in the world.

Kaitlyn enrolled in a Saturday class in public speaking at a local college to develop her confidence. Having had a seizure at home after the first class, she missed the following class. She felt alienated and experienced a familiar sense of herself as defective, followed by the temptation to hide. In therapy she talked about the isolation and sadness she felt.

A week later, right after the next class, Kaitlyn burst with glee into the family therapy session, followed by her mom and dad. Grabbing the feelings list, she began the meeting as always — naming the feelings that fit her state at the moment: “Alive, amazed, confident, exuberant, happy, hopeful, proud,” she said. The excitement was contagious, but we glanced at each other curiously, waiting to find out what changed.

Kaitlyn went on to describe the class. The teacher asked for improvisational introductions by each student. Inspired by another student who made himself vulnerable, Kaitlyn bravely went up in front of the class and spontaneously spoke to her experience with epilepsy, telling her story in public for the first time. Looking around the classroom as she spoke authentically, Kaitlyn noticed people listening and completely engaged. Invigorated, she was fully present and one with herself. Everything felt natural. The class was mesmerized, responding with tears and applause.

Pride – the Antidote to Shame

Kaitlyn could barely contain the exhilaration brought on by this new feeling of pride (the antidote to shame) which emerged from a new experience of herself in relation to others. She took action that transformed her loneliness and alienation into a feeling of mastery and power. But the feeling of pride came not only from challenging herself with something meaningful to her and succeeding, but from something deeper.

Healthy Risk-Taking and Changing Behavior Patterns

Kaitlyn resisted the impulse to hide or pretend that typically escalated her feeling of being alone and ignited a self-destructive cycle. Instead, she took a healthy risk to let herself be seen, acting confidently from a position of strength and self-respect rather than a wish to be rescued.

Kaitlyn’s behavior created an opportunity for interpersonal feedback that challenged her sense of herself as defective and the belief that she could feel connected and affirmed only through pain. The key element here was that this challenge occurred experientially, not intellectually.

Healthy behaviors that foster connection and affirmation from a position of self-acceptance and self-respect offer the possibility of sustainable attachments. Here, Kaitlyn broke the cycle of feeling connected and affirmed only through darkness, potentially releasing herself from a treadmill of pain.

Choosing Happiness over Suffering: the Results

As she basked in the fact that people seemed to not only like her, but respect her and admire her courage, I said, “You see — you don’t have to hurt yourself to get people to see and care about you.” “ I like being happy!” Kaitlyn exclaimed, with a sense of wonder alongside awareness of the irony of this statement. She glance at her dad and they both smiled knowingly, “Who knew?!” her dad piped up in his good-humored way.

Disclaimer: The characters from these vignettes are fictitious. They were derived from a composite of people and events for the purpose of representing real-life situations and psychological dilemmas that occur in families.

Schizophrenia affects up to one in a hundred people at some point and can cause hallucinations, delusions, and loss of energy and motivation. Creative psychological interventions such as art therapy are widely used in combination with drugs. But the effectiveness of art therapy is unclear.

Professor Mike Crawford of Imperial College London, UK, and his team examined the benefits of group art therapy among 417 adults with a diagnosis of schizophrenia. The patients received group art therapy or non-art group activities each week for a year, or standard care.

The art therapy involved a range of art materials which the patients were encouraged to use “to express themselves freely.” Non-art group activities included board games, watching and discussing DVDs, and visiting local cafes.

This study differs from previous trials of art therapy by focusing on clinically important differences in outcomes. It also provides detailed information about attendance rates, and offers art therapy of a duration that is more like that in real-life clinical practice.

When patients were assessed after two years, overall functioning, social functioning, and mental health symptoms were similar between the groups. Levels of social functioning and satisfaction with care were also similar.

Patients offered a place in an art therapy group were more likely to attend sessions than those offered a place in an activity group. However, the levels of attendance at both types of group was low, with 39 percent of those referred to art therapy and 48 percent of those referred to activity groups not attending any sessions.

Writing in the British Medical Journal, the researchers state, “While we cannot rule out the possibility that group art therapy benefits a minority of people who are highly motivated to use this treatment, we did not find evidence that it leads to improved patient outcomes when offered to most people with schizophrenia.”

They conclude that art therapy, as delivered in this trial, “did not improve global functioning, mental health, or other health related outcomes.” They point out that “[T]hese findings challenge current national treatment guidelines that clinicians should consider referring all people with schizophrenia for arts therapies.” The authors suggest that art therapy should not be offered on a broad basis to all patients, but targeted at those most likely to make use of it, based on an assessment of the patient’s interest and motivation to attend sessions.

Currently, the UK’s National Institute for Health and Clinical Excellence recommends that doctors “consider offering arts therapies to all people with schizophrenia, particularly for the alleviation of negative symptoms.” This should be provided by a registered therapist who has experience working with people with schizophrenia.

The guidelines describe arts therapies as “complex interventions that combine psychotherapeutic techniques with activities aimed at promoting creative expression. The aesthetic form is used to ‘contain’ and give meaning to the service user’s experience, and the artistic medium is used as a bridge to verbal dialogue and insight-based psychological development.

“The aim is to enable the patient to experience him/herself differently and develop new ways of relating to others,” the guidelines add.

Professor Crawford and his team think that the lack of clinical improvement in their trial may be due to “the high degree to which people with established schizophrenia are impaired in their clinical and social functioning.” They explain that these impairments are known to increase over time, and the participants had been diagnosed for around 17 years.

It may be that to benefit from group art therapy, “patients need a greater capacity for reflective and flexible thinking,” so targeting interventions at an earlier stage of the illness may be more effective.

Commenting on the study, Dr. Tim Kendall of the UK’s National Collaborating Centre for Mental Health believes that, while art therapy is unlikely to be of clinical benefit for schizophrenia, it “still has great potential for success in the treatment of negative symptoms.”

In an online response to the study, psychiatric hospital art therapist Betsy A. Shapiro, of Alvarado Parkway Institute, La Mesa, California, says the once-weekly nature of the art therapy sessions in the study is a potential problem.

She writes, “I work with patients with schizophrenia and see them 3-5 times a week. Patients not only enjoy group art therapy, they excel in it. Working with a variety of materials keeps them focused, encourages their creativity and appears to increase self-esteem.”

She adds that patients can “show their auditory or visual hallucinations, and express feelings which are difficult for them to do verbally. It provides for safe release of strong emotions such as rage and has prevented them from hurting themselves, others or property.”

Overall, she concludes, “It would be a great disservice to patients if this study influenced a cut-back in art therapy services.”

References

http://www.bmj.com/content/344/bmj.e846

Group art therapy as an adjunctive treatment for people with schizophrenia: multi-centre pragmatic randomised trial. Crawford, M. J. et al. The British Medical Journal February 29, 2012 doi: 10.1136/bmj.e846

Though the book could have used a good editor and been more intuitively organized, it’s still a fairly compelling read, and offers some pointed comparisons between the Spiritist approach and the modern mainstream U.S. approach — the latter of which views mental illness as a physical disease to be medicated away despite the sometimes crippling side effects of medication.

Bragdon begins by introducing us to Gerry, an “attractive young woman” who experienced what seemed to be a psychotic break during a time of extreme stress. About four years ago, Gerry began exploring alternative forms of healing, including consulting with Bragdon, a spiritually-oriented psychologist. Now, Gerry is doing well, engaged, and intending to enter graduate school. The author writes that Gerry’s recovery was facilitated by empathy, encouragement, caring health professionals and family members, and “teachers who helped educate her about lifestyle choices.”

This approach, Bragdon tells us, mirrors the Spiritist methodology that is currently in practice in Brazil, where more than 12,000 Spiritist community centers and 50 Spiritist psychiatric hospitals freely offer “a highly effective… program of integrative care, treating the needs of the public side-by-side with conventional medical practitioners.” It’s a community-oriented, relationally-focused, holistic and welcoming model that treats the patient as a human being who has just as much insight into her illness as any professional. But it also involves some practices that the average U.S. citizen might find unfamiliar.

“According to Spiritists,” writes Bragdon, “optimal wellbeing is ours when we are 1) doing the mission that we agreed to do before coming into this life and 2) treating ourselves and others with compassion consistently.” She goes on to explain that a Spiritist “considers that a pervasive and long-lasting mental imbalance that threatens life may come because a person is rebalancing themselves after a life experience that was not compassionate or may come from having lost his/her purpose in life.”

That part may not sound unusual, save for the part about making agreements before we were born. But the Spiritist approach offers multiple techniques that a non-religious, States-bound consumer might find “out there.” These include the laying-on of hands, inspired speech and prayer, blessed water, peer support for the patient and the family (called “fraternal assistance” in the book), interactions with mediums and psychics, and a post-hospital program of study and philosophical and spiritual conversation. It also welcomes family members and loved ones to be involved.

Although it’s unlikely that the U.S. healthcare model is going to follow the Spiritist one anytime soon, and although the author doesn’t provide objective proof of the success of the treatment, what I found fascinating about Bragdon’s book is how the Spiritist approach reflects some of the insights the mainstream psychological community has come to about mental health. The differences are obvious, but the underpinnings between these two very disparate models is surprising. Some descriptions of the Spiritist approach that may sound more familiar:

“The inspired speech directs the patients to focus on the value of compassion and love, helping them recollect loving relationships they may have had or may long for, assisting them toward greater self-acceptance, compassion, and tolerance,” one description goes.

“Perhaps Spiritism has been so successful in its treatments because it facilitates individuals clarifying their life purpose and aligning with that purpose,” Bragdon posits.

“The treatment aims at working with the patients’ motivation and with their state of readiness or eagerness to change.”

Another passage describes spirits that cause negative thoughts. Taken together, these concepts of forgiveness, self-acceptance, compassion, life purpose, negative thoughts, and motivation are all vital aspects of established psychotherapy modalities such as Cognitive Behavioral Therapy, Buddhist Psychology, Acceptance and Commitment Therapy, and Motivational Interviewing.

Bragdon’s book may be of limited value unless one is interested in different cultural approaches to psychological treatment. For those who are intrigued, however, it draws a compelling Venn diagram of the similarities between seemingly separate schools of thought. The author’s description of several U.S.-based holistic mental health clinics certainly gives the reader hope that there are people in the States working to change the dominant “medication-not-meditation” paradigm — even as we’re slow to accept alternative healing methods.

Resources for Extraordinary Healing: Schizophrenia, Bipolar and Other Serious Mental Illnesses
CreateSpace Independent Publishing Platform, February, 2012
Paperback, 264 pages
$24.95

Medication

With most psychiatric illnesses, medication is optional, and individuals can improve with other treatments, such as psychotherapy, said John Preston, Psy.D, a psychologist and co-author of Loving Someone with Bipolar Disorder and Taking Charge of Bipolar Disorder. However, “Bipolar disorder is probably the main psychiatric disorder where medication is absolutely essential. I’ve had people ask me if there’s any way to do this without medicine. [My answer is] absolutely not.”

Patients typically need to take multiple medications. “On average, people with bipolar disorder take three medicines at the same time,” Preston said. A large study by the National Institute of Mental Health found that 89 percent of people with bipolar disorder who were doing well were taking several medications.

“Don’t be discouraged if it takes a while [to find the right medicine]. Almost everyone who’s successful has to go through the same process.” That’s because in order to find the best treatment for each individual, doctors prescribe various medications and combinations. The goal is to find the right combination with the fewest side effects.

Unfortunately, troublesome side effects are the rule, not the exception, Preston said. In fact, around 50 to 60 percent of patients stop taking their medication or don’t take it as prescribed. This is why having regular and honest communication with your prescribing physician is critical.

But many people feel uncomfortable. They don’t want to “complain,” or assume their physician will be upset with them, Preston said. “I find that clients often don’t think they’re allowed to disagree with their doctors, and often end up going off their meds rather than having candid discussions with their doctors,” said Sheri Van Dijk, MSW, a psychotherapist and author of five books, including The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder.

Remember that you and your doctor are a team. “You have every right in the world to talk about every problem you run into,” Preston said.

The other reason people stop their medication is denial or wishful thinking, he said. It can take months after stopping medication for an episode to occur. This only validates the person’s belief that they don’t have the illness.

But while episodes may not be fast, they tend to be furious. Episodes typically get more and more severe, Preston said.

“Long-term studies that have followed people with bipolar disorder who have stopped taking their medication and have current episodes show progressive damage to parts of their brain.”

Lifestyle Management

According to both experts, cultivating healthy habits is paramount. Sleep deprivation and substance abuse exacerbate bipolar disorder and derail treatment, Preston said. Even patients who receive effective treatment don’t end up getting better if they’re abusing drugs and alcohol, he said.

If you’re struggling with substance abuse, seek professional help. Make sleep a priority. Try to get seven to eight hours of slumber per night, and wake up at the same time each morning. Consult your doctor if you’re traveling between time zones, which boosts the risk for manic episodes.

Social Support

“Often the success or failure of treatment has to do with how the family is involved,” Preston said. Family can either play a positive part in treatment or unintentionally undermine it. For instance, a family member who finds out their recently diagnosed loved one is taking medication might say, “You don’t need to take medication; you can handle this on your own,” Preston said. Again, not taking medication for bipolar disorder “can spell disaster.”

On the other hand, families can advocate for their loved ones. For instance, a parent might accompany their child to therapy when they’re in the throes of an episode and can’t articulate their concerns or symptoms.

Support groups, whether in person or online, also can be helpful, Van Dijk said. They remind individuals they’re not alone.

Psychotherapy

“The backbone of treatment is medication. But psychotherapy is enormously important,” Preston said. “While medications help to stabilize mood, they don’t change our thinking patterns, and the way we think affects the way we feel,” Van Dijk said. For instance, learning to change the negative stories swirling in your head may help prevent depressive episodes, she said.

Take the example of a client who was upset because her family pretended to forget her birthday, so they could give her a surprise party. “Instead of focusing on the surprise and the thought that her family had put into the surprise party, she was focused on how ‘cruel’ it was for them to pretend they had forgotten her birthday,” Van Dijk said. She helped this client “take a less negative and more neutral perspective on these kinds of situations.”

Van Dijk also teaches her clients mindfulness or “living in the present moment and practicing acceptance.” This helps clients not only accept their diagnosis but also become more self-aware. “We become more aware of our thoughts, our emotions, and our physical sensations because we’re in the present moment more often, and because we’re working on allowing ourselves to have these experiences, even if they’re painful.”

This self-awareness may prevent symptoms from escalating. By being more mindful, patients can spot an emotion and figure out what to do about it — “if anything” – before letting it careen into a full-blown episode.

According to Preston, “Numerous studies show that family-focused psychotherapy plus medication is really successful.” The goal of family-focused psychotherapy is to help the patient and family fully grasp the gravity of the illness and the importance of ongoing treatment, he said. It also teaches families how to provide support.

Interpersonal and social rhythm therapy also involves the family or significant other. The goal of this therapy, Preston said, is for “families and couples to learn to communicate more effectively and reduce really intense emotional experiences. It also incorporates strategies for lifestyle management.”

A big problem with psychotherapy is that clinicians who specialize in these treatments can be tough to find. Preston recommended checking out the Depression and Bipolar Disorder Support Alliance for facts on finding a professional along with other valuable information.

Accepting that you have bipolar disorder can be difficult. But not following your treatment will create a life filled with “one catastrophe after another,” Preston said. Instead, as both experts stressed, be honest with yourself. And make a strong commitment to taking your medication as prescribed and practicing healthy habits, without abusing drugs or alcohol.

Further Reading

Preston recommended these additional resources:

• The Bipolar Disorder Survival Guide
• Bipolar 101
• Bipolar Medications: A Concise Guide to Medication Treatments for Bipolar Disorders in Adults and Adolescents
• Consumer’s Guide to Psychiatric Drugs
• The website Bipolar Happens

Managing Depression and Suicidality

It is common for clients with schizophrenia to feel grief and loss due to the myriad life changes that it triggers (Wittmann & Keshavan, 2007). In this sense, during treatment, it is essential for clinicians to help clients navigate through the grieving process. According to Tait, Birchwood, and Trower (as cited in Wittmann & Keshavan, 2007), depression has been found to lead to the abandonment of treatment by clients due to the isolating characteristics of the disorder. Abandonment of treatment poses serious drawbacks for clients.

Wittmann and Keshavan (2007) assert that the grieving process is a necessary component to coming to terms with a new diagnosis of schizophrenia. Due to the sense of loss experienced by individuals newly diagnosed with schizophrenia, it is essential for them to navigate and work through the grieving process (Wittmann & Keshavan, 2007). According to Lewis (as cited in Wittmann & Keshavan, 2007), by doing so, clients will learn to mourn the life and identity changes that have occurred, along with establishing the ability to integrate such change into their lives. It has been shown that counseling can be beneficial in such a situation.

Grief and mourning are a common component in clients diagnosed with schizophrenia (Wittmann & Keshavan, 2007). This is because the diagnosis of a serious, permanent mental disorder is a major life crisis for most. The disorder affects the mind in very serious ways (Wittmann & Keshavan, 2007). In some cases, clients might spiral into psychosis as a means of dissociating, or defending against facing, the losses their disorder has caused (Wittmann & Keshavan, 2007). Clinicians have a major hand in helping clients manage this crisis.

Numerous models exist to explain grief and mourning, and can also help professionals guide grieving individuals. Elizabeth Kubler-Ross (1969) proposed five stages of grief that individuals can experience while grieving. They include denial, anger, bargaining, depression, and acceptance. In contrast, Worden (2002) proposes four tasks, as opposed to stages of grief. These include accepting the reality that loss has occurred, feeling the pain and emotional responses to the loss that has occurred, readjusting to life after the loss, and finding ways to remember the lost individual. Although these models are meant to aid in grieving a person, individuals diagnosed with schizophrenia are, in fact, grieving the loss of the person they once were and will potentially no longer be. In this sense, these models offer a framework that can be used in counseling to help a client adjust to life after their loss of self.

A Safety Plan for the Newly Diagnosed

Clinicians should develop a safety plan for use in the event that a client presents with suicidal intent or depressive symptoms, as these are both common in newly diagnosed clients. One of the first issues to address is the onset of depressive symptoms or suicidal thoughts. A safety plan can involve listing symptoms characteristic of depression, including those characteristic to the client, as well as those that the client has not felt before, but could potentially feel in the future. This would help foster the client’s awareness of their own symptoms.

Along with such a list, clinicians can help clients determine the course of action to be taken if suicidal thoughts or feelings occur. Action plans can include emergency contact numbers, such as a suicide hotline and that of the primary therapist, the psychiatrist and other medical doctors, and family members or other individuals who serve as the client’s support system. One of these individuals could sit with the client and support them through the situation while attempting to contact appropriate clinicians. If the client has no close friends or relatives, suggest that they join an in-person or online support group.

Clients should be asked to keep a list of depressive or suicidal triggers. During sessions, the counselor and client could develop and implement ways for such triggers to be managed.

Clinicians should urge clients to remove from his or her home any items that could be used to self-harm. Making access difficult reduces the temptation to use them. This might be especially useful for clients who have already made attempts, and would also potentially increase the likelihood of them seeking some form of support or following an appropriate plan of action, rather than engaging in self-injurious behavior.

Clients can be encouraged to keep an up-to-date medication list with them at all times. This will help them if they need to seek out emergency services. During a crisis, it might be difficult for them to recall each of the medications they take, as their minds will be preoccupied.

Clinician should keep a current list of service providers to which clients can be referred. For example, if the client’s symptoms become more intense and overwhelming for them, and more in-depth treatment is required, the clinician should be able to make an appropriate referral or direct the client to an appropriate provider. This could further ensure the client’s safety, as he or she would receive the necessary services, especially if more in-depth treatment is required.

Conclusion

A diagnosis of schizophrenia presents serious implications for newly diagnosed individuals in particular. Those with schizophrenia have a vast series of challenges to face, including overcoming and grieving the loss of a sense of self, experiencing a loss of hope for the future, accepting the diagnosis, facing the fact that social, occupational, educational, familial, and romantic arenas might undergo marked change, and integrating new insights, coping strategies, and processes learned on their journey into their life.

Because the diagnosis of a serious mental illness can cause a major life crisis (Wittmann & Keshavan, 2007), clinician support is critical. This is especially true because depression and suicidal ideation are common in the newly diagnosed (Addington et al., 2004). Along with helping the client manage their diagnosis and helping to facilitate his or her grieving process, clinicians can help ensure client safety by establishing and agreeing upon a safety plan for use in the event that the client is experiencing depressive symptoms or suicidal ideations. Not only will this help clients to feel supported and cared for, but it will also potentially help save a life in the event of an emergency or crisis.

References

Addington, J., Williams, J., Young, J., & Addington, D. (2004). Suicidal behaviour in early psychosis. Acta Psychiatrica Scandinavica, 109(2), 116-120.

Kubler-Ross, E. (1969). On death and dying. New York: Scribner.

Wittmann, D. & Keshavan, M. (2007). Grief and mourning in schizophrenia. Psychiatry, 70(2), 154-166.

Worden, J.W. (2002). Grief counseling and grief therapy: A handbook for the mental health practitioner (3rd ed.). New York: Springer Publishing Company.