Menninger recently adopted standards of behavior that are intended to guide our actions and promote a culture of excellence. This month the Psychology discipline was charged with bringing attention to one standard: “We are linked to one another by a common purpose: serving our patients and our community.”

We had differing thoughts about what this statement means, but we agreed that we are linked in our battle to fight mental illness and the stigma associated with it. We believe that mental health matters, not only for the people we treat at The Menninger Clinic, but for our families and community as well.

We wanted to share our views about why “Mental Health Matters” in hopes that it will create a discussion with others about why mental health matters to them. Ultimately, we are all linked together by mental illness, and despite differences in opinions, we can stand next to each other and fight to reduce the stigma.

Here’s what some of our psychologists have to say about why mental health matters (stay tuned for more of our views in an upcoming blog post):

It’s not just my job but how I live my life. If I encourage my patients to take risks and be vulnerable, then I hold myself to the same standard. It’s the only way our culture can begin to change:  the belief that mental health matters. Patricia Daza, PhD, Hope Program for Adults

To be ill means that you cannot recover by a mere act of will. If you’re mentally ill, you can’t just change your mind—think positively if you’re depressed or stop worrying if you’re anxious. We increasingly understand the complex psychological, social and biological bases of mental illness. We have increasingly diverse treatments. But the foundation of treatment for all illness is caring and compassion, along with hope—which must be founded on realistic expectations that respect the often daunting challenges of recovery. Jon Allen, PhD, senior staff psychologist

Mental illness affects everyone, regardless if we are the one who is diagnosed. As a society we are linked together and constantly influencing each other. If one person is ill, then the effect will be experienced widespread. “Mental health matters” because we have a responsibility to take care of ourselves and our society. Rebecca Wagner, PhD, coordinator, Eating Disorders Services

Nothing convinces me that “mental health matters” more than the wealth of scientific evidence on the unity of mind and body. Examples include the strong relationships between stress and immune system function, depression and heart disease, smoking and suicide risk, exercise and depression – the list goes on and on. It behooves all of us to remember that mind and body are one – when we treat one, we treat the other. Tom Ellis, PsyD, ABPP, director, Psychology

Someone very dear to me is about to deliver her first child, a son. She is preparing for him; my instinct and need is to prepare her. There’s so much I wish I could tell her about motherhood and parenting, yet there’s no way I could even begin to encompass it all. I’ve winnowed it down to these pieces of advice:

1. For a while you will be the most important person in your son’s life. You will be his world. His eyes will light up when he sees you or hears your voice. His need for you, his absolute dependence on and reverence of you, will be humbling.
2. Your capacity for love will astound you. Your instinct and need to protect this tiny person will turn you into a momma tiger when you sense he is about to be hurt; you will gladly exchange your life for his if you think you can save him.
3. He will believe what you teach him about himself. Do you see him as smart, kind, good? If so, tell him. When he’s a teenager, he may forget these seeds you’ve planted, but the plants will eventually sprout and then bloom and then thrive.
4. Tell him the good things you see in him. Often.
5. Ensure his safety, both physical and emotional, to the best of your ability.
6. Teach him that if he gets lost, to find a mother with children, or to stop and sit down and you’ll find him.
7. Support him in doing whatever it is that he loves. Don’t let him do everything he wants.
8. Don’t stop him from feeling sadness or anger or fear or guilt; these emotions will teach him about himself and about life. It will be hard to see him suffer these emotions, Momma Tiger, but you must.
9. Don’t make him the center of your life. Instead, show him that sometimes he’s the center, sometimes he’s not.
10. Show him the importance of family.
11. Teach him to respect adults.
12. When he’s about 11, his devotion to you will change; it needs to change. For a period of time, his friends will be more important. One day – if you’ve taught him well – his wife or partner will be. This can hurt, Momma Tiger. But you must encourage it to happen … it’s how he’ll eventually find out how much he can love. And this – realizing the depth of our capacity to love –  is the gift of this lifetime.
13. You are grooming him for all future relationships with women. Teach him that we are trustworthy, dependable and strong. Teach him that there will be times when even strong women need someone’s arms around them, saying, “Everything’s going to be all right. I’ve got you.”
14. Love him even when he’s hard to like.
15. Hold him responsible and accountable. This is how he learns that he is.
16. Model for him how to deal with conflict; he will learn this by watching the adults in his home. Teach him to talk it out rather than fight it out, punch it out or numb it.
17. Forgive.
18. Forgive again.
19. Teach him to laugh at himself. This makes life so much easier and a lot more fun. If he’s like me, he’ll have enough material to keep himself amused his entire life.
20. Apologize to him when you’ve made a mistake, but not for setting limits, having an opinion or saying no.
21. Say no.
22. Let him experience the consequences of his choices; this is how he’ll learn what is right and what is wrong.
23. Teach him to believe in something bigger than himself.
24. Help him see his gentleness; help him see his strength.
25. Imagine the man in the boy; remember the boy in the man.
26. Enjoy him.
27. And finally … relax … you’re going to do great.

I think these are pretty good parenting guidelines; I certainly can look back to when I didn’t see the importance of some of them and instead learned them the hard way. I expect I’ll keep adding to the list as life goes on, which probably means a lot more mistakes from me. Sigh.

Looking simplistically at psychotherapy, many of these things are what we attempt to show, teach or experience with our patients.

Imagine the healing and growth that can come when we do.

Every time I hear a media story about “the war on __,” I automatically become suspicious. Considering America’s history of the “war on drugs” and the “war on terror,” my skepticism meter perks up, and I feel the urge to cringe.

Despite hailing from the state of “live free or die,” I am usually puzzled by any grandiose display of self-righteousness. Why must we always be fighting these nebulous enemies? How am I supposed to respond to the battle cry if I am dumbfounded by the cause?

New York City & the fight against obesity

At least I can give New York Mayor Michael Bloomberg credit for placing the culprit front and center: On various NYC Health Department advertisements and campaign videos, you can find glasses of “fat” representing the number of pounds one can gain from sugar and soda. Signs ask you if you are “pouring on the pounds” and caution you not to “drink yourself fat.” The city’s war on fat and obesity nearly resulted in a ban on super-size sodas this past month. But will such strict rules and fearless public service announcements really curb the prevalence of obesity?

Research has shown that unhealthy weight control behaviors (dieting, laxative use, purging), as well as body dissatisfaction, have been linked to weight gain, obesity and the development of an eating disorder. This data suggests that obesity and being overweight are not solely products of genetic make-up or uninhibited eating – weighing more can also be an indicator of disordered eating.

Shaming vs. condoning

Unfortunately, society tends to envision individuals with an eating disorder as extremely thin, but the truth is they present in a range of body types and sizes. A person who binges may experience as much distress as a person who restricts food intake, and both individuals are attempting to achieve a similar goal: to regulate emotions and experience a sense of control. Therefore, it is upsetting that our society shames those who are heavier and condones those who are thin, for we are only feeding the disorder. If we idealize the very thin, we are only encouraging the eating-disordered patient to accomplish thinness, be it through restriction or other compensatory strategies.

I would like to set the record straight that I am not blind to the preponderance of fast food and unhealthy food choices accessible throughout the country. Yet, before we banish the super-size cup, isn’t it important to also explore why we are so hungry for bigger portions? Yes, cravings for and consumption of sugar and fat beget additional cravings, but I speculate that we are yearning for something else. If we can look past our focus on food and how it is consumed, we may be able to identify that missing piece.

Serious mental illness is debilitating, confusing and overwhelming. As a society, one might imagine our response to mental illness might model the response to other public health challenges like heart disease, diabetes or breast cancer. Sadly, the opposite seems to be the case. Take the time to Google “mental illness is” and you find “mental illness is a myth” is the top search result, and “it does not exist” is the third result.

Prisons as providers of mental health treatment

In the 1950’s, there were more than 500,000 inpatient state hospital beds in the U.S. Without going into too much detail, suffice it to say that this system suffered from underfunding, mismanagement and abuse. Lawsuits were brought to reform the system of mental health treatment and did succeed in shutting down numerous facilities that provided substandard care.

Presently, there are 50,000 public hospital beds in the U.S. available for inpatient care. Judging by the decrease in these beds since the 1950’s, one might conclude that serious mental illness has been eradicated in America. But the truth is that the vast majority of such cases are now treated in outpatient clinics, intensive outpatient programs, support groups, etc. (Keep in mind that the U.S. population has effectively doubled in the same timeframe.)

If one were to imagine the most inhumane and ineffective way to address the ongoing issue of mental illness in America, incarcerating people with mental illness would surely be near or at the top of our hypothetical list. Yet the largest mental health facility in the country is the L.A. County Jail; the second largest is the Harris County Jail in Houston.

Just to be clear, the largest treatment providers for mental illness in the U.S. are jails.

Jails, prisoners and mental illness

The U.S. Department of Justice statistics (from September 2006) are grim:

• 43 percent of state prisoners and 54 percent of jail inmates met criteria for mania
• 15 percent of state prisoners and 24 percent of jail inmates met criteria for psychotic disorder
• state prisoners were twice as likely to have been homeless in the year prior to their arrest compared to those without mental illness (13 percent vs. 6 percent)
• inmates with mental health problems were three times as likely to report physical and sexual abuse in the past (24 percent vs. 8 percent).

Keep in mind that the overall incidence of serious mental illness in the U.S. population, according to statistics from the National Institute on Mental Health, is about six percent. If we just look at symptoms and not full-blown diagnostic criteria, a staggering 60 percent of county jail inmates, 49 percent of state inmates and 40 percent of federal inmates had symptoms of major depression, mania or psychosis in the 12 months prior to incarceration.

More than half of those incarcerated who met criteria for a serious mental illness also met criteria for a dual diagnosis, that is, a psychiatric illness AND substance abuse or dependence. Nearly one in three inmates with mental health diagnoses receive treatment while incarcerated and that number has been rising during the last few decades.

The cost of caring for inmates with mental illness

According to the National Alliance on Mental Illness, the cost to house – and, in one-third of cases, treat – prisoners with mental illness is at least $9 billion dollars per year. This illustrates a basic and fundamental reality: Mental illness does exist, and there is a cost associated with it that cannot be avoided.

As a society, we can relegate serious mental health treatment to jails, or we can choose to shift those responsibilities back to hospitals, clinics, providers and support groups. The cost to provide community support and mental healthcare on an outpatient basis is significantly less than the cost to treat a prisoner with mental illness. A novel study by the University of South Florida examined the highest users of mental health services in the criminal justice system in Miami. What the researchers discovered was that 97 individuals, mostly people suffering from schizophrenia, were arrested a whopping 2,200 times, spent 27,000 days in jail and cost the county $13 million over a five-year period.

The preceding comments have generally been approached from a pragmatic perspective. However, it might be useful to avoid eschewing morality altogether. If you think of the mentally ill as a subset of the needy, then I think comedian Stephen Colbert framed it quite aptly; just take a look at this clip:

How many of us can relate to awakening from a dream that felt so real the residual emotions remained with us for hours afterwards? Or eagerly recounted the unusual plot of a recent dream to friends or coworkers in an attempt to interpret what it might mean? The phenomenon of dreaming has been romanticized by poets, studied by scientists and even analyzed by the father of psychoanalysis himself. Many have proposed theories of how to interpret dreams, and scientists have even mapped the biological underpinnings of the dream-state, yet much of our understanding of why we dream remains elusive.

Dreams are a curious thing: We often don’t recall the content of our dreams, and many people are completely unaware of even dreaming. Yet studies have found that people over the age of 10 dream, on average, four to six times per night, most frequently during the stage of sleep known as rapid-eye movement (REM).¹ During the REM stage, our minds are active, as they are during waking hours, but the rest of the body remains, for the most part, immobilized.

Purpose

Many people believe that dreams communicate to our conscious minds the emotional state and wellbeing of our unconscious mind through symbolic imagery. Others believe that dreams are the mind’s attempt to consolidate knowledge or solve problems encountered during waking hours. There is no universally agreed upon theory as to why we dream, and some reason that because so few dreams are even remembered, they serve no purpose whatsoever.

When dreams aren’t so sweet

Many people experience recurring dreams – identical or thematically similar dreams that can occur with regularity over several weeks or even a lifetime. For those suffering from recurring distressing dreams (nightmares), these experiences can be extremely upsetting and cause disruption in waking hours (residual emotional turmoil, fatigue from sleep interference and frequent distressing thoughts about dream).  

Recurring nightmares can result from stressful or traumatic experiences in life; in fact, it is not uncommon for people suffering from posttraumatic stress disorder to experience recurring nightmares about the trauma they experienced. In many cases, recurring dreams last only a short period of time and disappear on their own. However, when nightmares persist for long periods of time or become impairing, intervention may be necessary.

In a new research undertaking soon to be implemented at The Menninger Clinic, clinicians will help patients with recurring nightmares “re-script” their dreams using image rehearsal therapy (IRT).² Unlike the psychoanalytic approach through which one seeks to understand the underlying meaning behind dreams, IRT seeks to help patients cope with distressing nightmares by disrupting a negative behavior cycle, akin to the way cognitive behavioral therapy (CBT) works.

How it will work

The procedure will be similar to that introduced by Dr. Barry Krakow in 2001, in which patients are asked to keep a nightmare log, write a brief summary of the distressing dream and create an alternate “script” of a dream that is a pleasant alternative to the nightmare. The re-scripted dream ideally has a therapeutically relevant theme (such as a theme of power and control for a victim of a sexual assault). Studies have shown that when a patient sets aside time once or twice a day to visualize the new dream, nightmares tend to diminish in frequency and intensity, and sometimes disappear altogether. The typical course of treatment requires three sessions with the therapist over a period of two weeks.

Dreams can evoke a number of emotions that can carry over into waking hours. With pleasant dreams, this can be an enjoyable experience, but with recurring nightmares, such residual emotions can lead to impaired functioning during waking hours. For those suffering from recurring nightmares, developing a “new script” might help to alleviate the symptoms experienced during waking hours.

Editor’s note: If you enjoyed this post of Heather’s, check out some of her other recent posts:

• Losing faith in times of suffering
• Pseudologia fantastica: the truth about pathological liars
• Calling in depressed: a look at the limitations of mental illness in the workplace

References

¹ Schneider, A., & Domhoff, G. W. The Quantitative Study of Dreams. (2009). Retrieved from http://www.dreamresearch.net/.

² Krakow, B. et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. Journal of the American Medical Association. 2011; 286, 537-545.

If you had the opportunity to live a “golden life” and achieve your dream of success and fame, would you do it? What lengths would you take to pursue this image or pathway to success? Would you too fall into the traps that both star athletes Lance Armstrong and Manti Te’o now find themselves? And, lastly, would you be willing to let go of years of hard work and future dreams in the name of truth?

The recent exposures of Armstrong and Te’o’s dishonesties, deceit and deception have been the topic around the water cooler: “How could Lance lie about doping for so long?” “How could Manti confidently and publicly mourn the death of a fake person?”

Consider the last time you told a “white lie.”  You had to leave your best friend’s party early because you “felt sick,” or you could not run an errand for a loved one because you were “too busy.” After a while, once you had repeated this explanation to yourself, you began to believe that you indeed did have a headache and that you did not have enough time at lunch to run by the pharmacy for a loved on. In order to preserve our image of ourselves as good people, or, even as superhuman figures, we block out the memory of our initial self-serving motives.

Across cultures, “superhuman” and larger-than-life individuals are valued in society. Olympic athletes, pop stars, actors, and national leaders are idolized as legendary characters by many of us and have been so in the history of our countries. These individuals feed our own regressed desires for perfect heroes and heroines to emulate and, one day, possibly become.  But when we publicly or personally witness someone’s fall from grace, it reminds us of the messier, flawed side of humanity and of ourselves. Clients often speak of the difficulty of admitting their own faults and limitations to themselves.  And they are right; to admit to oneself that a mistake has been made or that a change needs to occur can be excruciatingly scary and painful.

This process of honesty towards the self can be immensely humbling. I think that’s the silver lining of any lie or fabrication – the potential for humility. Once we are able to grieve the loss of the “ideal image” or that “perfect self,” we then can explore our actual strengths and limitations, and begin a plan to move forward.

On a more selfish note, I find it reassuring that people like Lance Armstrong and  Manti Te’o are human, just like me (okay, a lot more athletic, but still). If only society would no longer push for worship of superlative human beings, then maybe our public figures would not feel the pressure to live lies, and, personally, we could be more honest with ourselves. Until then, I am not sure that we are ready to handle the truth about humanity – that each and everyone one of us is flawed.

How are Iraq and Afghanistan war veterans dying? Is there an epidemic of premature deaths, relative to their civilian counterparts, among the still relatively young men and women who saw combat deployment over the past decade? In an era of big headlines and the twenty-four hour news cycle, the average American citizen might justifiably presume that suicide is the leading cause of death among veterans of the Iraq and Afghanistan wars. We have all heard variations on these startling pronouncements: “More Iraq veterans have died by suicide than were killed in combat operations!” “One Iraq war veteran commits suicide every hour!”

Despite the media-driven answers one might think exist to the question that heads this post, the factual truth is no one really knows. The reason we do not know is that all-cause mortality among these veterans has not been carefully studied or tracked.

Texas-based study

A few months ago, the Austin American-Statesman published results of an examination of all-cause mortality among Iraq and Afghanistan war veterans who were listed as VA beneficiaries in Texas. Their results, published in a three-part series September 30, October 1 and 2, 2012, indicated that drug overdoses or toxic combinations of drugs (mostly prescription medications, such as painkillers like Oxycontin) accounted for approximately as many deaths as those that were clearly suicide. Of the 266 deaths with known causes in this study, 16.9 percent were ruled as suicides, 18.8 percent were as a result of motor vehicle accidents and 17.7 percent were drug-related deaths.

This is important information, and yet the Statesman study raises more questions than it answers. This is true for several reasons:

1. We do not have a clear understanding of the number of veterans who were VA beneficiaries in each year of the study. Without this denominator, it is impossible to calculate rates of the various causes of death.
2. Causes of death were only obtained in about two-thirds of the cases, leaving us with many individual mysteries about how and why these veterans died.
3. We have no contextual information to compare these data to. How do these Texas veterans’ deaths compare to an age-gender-race matched comparison group of non-veterans from Texas? 

What remains are some very interesting raw numbers, but we still do not have all the answers needed to guide prevention efforts.

Now what?

So, where does that leave us?  As we wrote in a blog post for the Huffington Post recently, there is good reason to be more concerned about prescription medication deaths among veterans. This is an issue that has received only scant attention. Few people involved in the national dialogue on combat veterans’ issues are talking about this or seem to recognize the grave threat it poses to the health and well being of our active-duty troops and more than two million veterans. This is despite the fact that prescription drug use of opioids rose dramatically over the past half-generation, and is now America’s deadliest drug epidemic. The CDC reports that more than 15,000 people in the U.S. die each year from overdoses or toxic combinations of prescription medication painkillers. This is more than a 300 percent increase since 2000, and the numbers continue to rise. In fact, more people die from abuse of prescription painkillers than from cocaine, heroin and all other illegal drugs combined. Three years ago opioid-related deaths surpassed traffic accidents to become the leading cause of accidental death in America.

Young veterans, with their catalogue of blast injuries, headaches and chronic back/joint pain, may be especially vulnerable to the dangers of opioid prescriptions. Even for those who do not overdose, opioids change the brain, rewiring neural circuitry that leads to a host of other ripple effects – physical, emotional and social. Of course, we also should be concerned about the tragedy of suicide among our veterans. Especially since suicide has risen dramatically over the past decade among active-duty military personnel and since suicide may be more prevalent than it was historically when compared to wars of the past, such as the U.S. Civil War (1861-1865).

In an encouraging follow-up story, the Statesmen reported that since their study ran – and possibly because of their effort – the VA has announced plans to conduct a large national study of all-cause mortality among veterans of Iraq and Afghanistan. This is good news, as it will shed light on veteran suicides and drug overdoses, and will help answer the question posed in this post’s headline. As a nation we have a duty to help veterans live long and productive lives. An important step toward realizing this is to ensure that we fully understand all causes of veterans’ deaths, especially premature deaths. It is encouraging that perhaps we are about to begin a national effort to do this.

I am fortunate to have a challenging job that requires flexibility and creativity, but it’s often difficult and sometimes downright exhausting. One time I complained about this effortful experience to our former chief of staff, Richard Munich, and he responded, “That’s why they call it work!” I find Dick’s matter-of-fact attitude toward the difficulty of work to be consoling, and I repeat his words to myself when I struggle to marshal the required effort.

Living requires brain power, and challenging work pushes brain power to the limit. Of all our body organs, the brain uses the most energy. Compared to other animals, the human prefrontal cortex occupies a disproportionate amount of brain territory. This brain region plays a key role in challenging work, and its activity consumes a lot of energy.

Demanding work

I was dumbstruck when I came across a list of specific challenges that tax our prefrontal cortex; I thought immediately, “That’s work!” Here’s the list that grabbed my attention, compiled by Paul Burgess and colleagues at University College London:

1. A number of discrete and different tasks have to be completed.
2. Performance on these tasks needs to be dovetailed in order to be time-effective.
3. Due to either cognitive or physical constraints, only one task can be performed at any one time.
4. The times for return to task are not signaled directly by the situation.
5. There is no moment-by-moment performance feedback … failures are not signaled at the time they occur.
6. Unforeseen interruptions, sometimes of high priority, will occasionally occur, and things will not always go as planned.
7. Tasks usually differ in terms of priority, difficulty and the length of time they will occupy.
8. People decide for themselves what constitutes adequate performance.

Broadly speaking, these challenges call for multitasking. These prefrontal capacities are called “executive” functions, and the list I just quoted would be as familiar to “executives” at work as it was to me. We are all executives. In our increasingly multitasking world, this list is typical of the demands of many persons’ daily lives, going far beyond professional work. Review the list while holding in mind the demands of raising children and running a household.

The prefrontal cortex and mentalizing

Consider also challenging interpersonal situations with this list in mind. A common example is working on a complicated project while trying to forge collaboration among several group members — or family members. Yet much of the list also pertains to difficult negotiations in a relationship, for example, parents coordinating the demands of work, childcare and household responsibilities. As you may have noticed, relating to people can be hard work. Mentalizing — attending to mental states in others and yourself — is part of this interpersonal work. Consistent with the complexity of interpersonal problem solving — and managing our own desires, thoughts, and feelings — the prefrontal cortex plays a key role in mentalizing.

Unfortunately, common psychiatric disorders impair the functioning of the prefrontal cortex, thereby compromising the capacity to engage in complex problem solving — intellectual and interpersonal — that our contemporary multitasking world demands. Thus it is not surprising that psychiatric disorders can be associated with significant disability in occupational and social functioning.

Some appreciation of their neurobiological basis helps us take psychiatric disorders seriously as physical illnesses, which can help combat stigma. Fortunately, treatment of psychiatric disorders — not only with medication but also psychotherapy — normalizes brain function, enabling patients to resume the challenging work of everyday living.

Editor’s note: If you enjoyed Dr. Allen’s post, please check out some of his other recent posts:

• POT: What’s new in plain old therapy?
• Was the Sandy Hook mass shooting “evil?”
• Can’t AND won’t

Reference                 

Burgess, P.W., Gonen-Yaacovi, G., & Volle, E. (2012). Rostral prefrontal cortex: What neuroimaging can learn from human neuropsychology. In B. Levine & F.I.M. Craik (Eds.), Mind and the frontal lobes: Cognition, behavior, and brain imaging, pp. 47-92. New York: Oxford University Press. (The list of challenges is quoted from page 81.)

More than two years ago, I wrote a post on this blog entitled, “Is psychotherapy going to POT?” Tongue in cheek, I was protesting the proliferation of brand-name, evidence-based therapies with all their acronyms: CBT, DBT, ERP, EMDR and the like. There’s no way any therapist can learn to practice 150+ brands, and a half-century of research attests to the difficulty of demonstrating that any one brand is generally superior to any other. Accordingly, I declared myself a practitioner of plain old therapy — relatively unstructured “talk therapy” without any special technical procedures. And I liked the acronym.

This post led to an interchange on the blog with my colleague, Tom Ellis, an expert therapist and research-minded psychologist who expressed some reservations. In his post, “Make my psychotherapy plain, but with a twist,” he took issue with the implication that there is nothing new happening in the field of therapy and pointed out the benefits of recently developed specialized procedures and treatments for certain disorders, such as panic and obsessive-compulsive disorder.

POT vs. BEER?

In conversation, Tom expressed concern that I might be communicating to therapists that whatever they’ve been doing all along is perfectly fine and they don’t need to learn anything new. I responded with another post, “Can we grow more potent POT?” In so doing, I acknowledged the need to continue refining psychotherapy on the basis of new knowledge, which I had aspired to do in homing in on mentalizing in the context of attachment relationships as a common therapeutic factor that cuts across different brand-name therapies. “Mentalizing” refers to being aware of mental states such as desires, feelings and thoughts in oneself and others, and “attachment” refers to relationships with strong emotional bonds, such as parent-child relationships, romantic partnerships and patient-therapist relationships. Tom responded with a second rejoinder, “Psychotherapy: Bring on the POT, but don’t forget the BEER,” a new acronym for “But Empirical Evidence Required.” In other words, Show me the data!

Therapists like POT

There was a playful quality to this blog-post interchange, but Tom and I are equally serious about current debates in psychotherapy, often pitting two broad camps against one another, that is, the clinicians versus the researchers. Tom and I share allegiance with both camps. After this initial foray in the blogosphere, I started to take the idea of plain old therapy more seriously, and for the past two years I’ve been talking about it in presentations and workshops locally, nationally and internationally. As intended, “POT” elicits amusement, but I’ve been surprised at therapists’ sheer enthusiasm for it. I went public in print, responding to an invitation to write for the “From the Expert” column in Psychiatric News with an editorial, “Reviving Plain Old Therapy.”¹ Ultimately, I took it so seriously that I wrote a book about it, entitled Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy.²

Why POT?

I have a few ideas about the basis of therapists’ enthusiasm:

1. Like me, many therapists are put off by the implication that they should learn a whole bunch of different therapies.
2. Many of the brand-name therapies were developed to treat specific psychiatric disorders and, like me, many therapists are generalists who work with patients with diverse problems, many of whom struggle with multiple disorders at the same time. We generalist therapists are the counterparts to general practitioners in medicine. Such physicians, too, must refer patients to specialists when indicated.
3. My emphasis on plain old therapy is consistent with the well-demonstrated contribution of the therapeutic relationship to the treatment outcome³ as well as a current humanistic counter-reaction to increasingly technological approaches to psychiatry, now abetted by enthrallment with neuroscience.⁴
4. I use the “old” in plain old therapy with some irony, because I find a substantial evidence base supporting the effectiveness of plain old therapy in contemporary attachment theory and research, including the recent work in mentalizing.⁵ When I discuss this work on attachment with patients and clinicians, many find it intriguing and eye-opening. Hence I was pleased when my colleague, psychiatrist Robert Fischer, who is executive director of the Optimum Performance Institute commented in an article that plain old therapy “actually is the most novel approach I have heard in the past 15 years!”⁶

Notwithstanding my confidence in the value of reviving plain old therapy, we therapists have no reason to be complacent about our work. The fact that a half-century of horseraces comparing different brand-name therapies has failed to reveal champions and that their commonalities are therapeutically significant does not mean that all are equivalent for a given individual.⁷

In the face of disagreement among proponents of different approaches as well as between clinicians and researchers, there is considerable consensus on one point: We are far from understanding the specific psychological and interpersonal processes that render psychotherapy effective.^{8, 9} I think mentalizing in the context of attachment relationships points us in the right direction, and new research supports this path.¹⁰ Indeed, we always desire more empirical evidence but, meanwhile, I think plain old therapists stand on solid ground.

Editor’s note: If you enjoyed this post from Dr. Allen, please check out some of his other recent posts:

• Was the Sandy Hook mass shooting evil?
• Can’t AND won’t
• Can’t OR won’t?

References 

1.       Allen JG. Reviving plain old therapy. Psychiatric News. 2012;47(10):3.

2.       Allen JG. Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy. Washington, DC: American Psychiatric Publishing; 2013.

3.       Norcross JC, ed Psychotherapy relationships that work: Evidence-based responsiveness. Second ed. New York: Oxford University Press; 2011.

4.       Bracken P, Thomas P, Timimi S, et al. Psychiatry beyond the current paradigm. British Journal of Psychiatry. 2012;201:430-434

5.       Allen JG. Mentalizing in the development and treatment of attachment trauma. London: Karnac; 2013.

6.       Fischer R. Reflections on “Reviving plain old therapy”—A recent article featured in psychiatric news. Optimal Performance Institute. 2012;June 7.

7.       Budd R, Hughes I. The Dodo bird verdict—controversial, inevitable and important: A commentary on 30 years of meta-analyses. Clinical Psychology and Psychotherapy. 2009;16:510-522.

8.       Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology. 2007;3:1-27.

9.       Mansell W. Core processes of psychopathology and recovery: “Does the Dodo bird effect have wings?” Clinical Psychology Review. 2011;31:189-192.

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Providence—the belief that God sees all things, reigns over all things and is concerned for all things, to bring about the ultimate divine purposes of creation—is always at the forefront of discourse and reflection whenever tragedy strikes. The issue of providence for people today, in light of the Sandy Hook school shooting, arises out of the incongruity between the revealed character of a benevolent and omnipotent God and the circumstances or life events one has experienced or is experiencing. As Rabbi Harold Kushner’s book When Bad Things Happen to Good People plainly asks:

“How can a loving and powerful God allow something this awful to happen?”

I’ve been an ordained minister for more than 18 years, the last 12 of which have been in healthcare chaplaincy; and my feeble attempts at a response only serve to raise more questions than answers. However, my experience in providing ministry, even in the most difficult and challenging moments, has taught me many lessons about providence.

Temptations to avoid

I’ve learned that for theological and pastoral reasons some temptations must be avoided. One temptation is to try to turn off the angry accusation of God as unworthy or irreligious. Another is to let the person asking the question take the blame or acquiesce a wicked fallen world without hope. Yet another is to attempt a defense of God by explaining how some natural forces or some evil acts of others have caused the event. And still another is to insist that while God has indeed done this act, it will turn out for good.

Another form of the questioning comes in the opposite situation, when good things happen to bad people. This is the frequent biblical question: “Why do the wicked prosper?” Again, for sound pastoral and theological reasons, I’ve learned to avoid the temptation to explain the evil away or defend God by denying it. More importantly, I’ve learned how vital listening is to pastoral care and how it can open doors to healing.

I’m reminded of a story attributed to Franz Kafka, one that is being passed around lately following the Sandy Hook tragedy. This story is about a little girl who was late arriving home one day. Her mother asked her where she was. The girl said that she saw her friend Ruthie on her way home, and Ruthie’s doll had broken. “Did you help her fix it?” her mother asked. “No,” the girl replied, “I don’t know how to fix it. I stopped to help her cry.”

Affirmations

As chaplain, I believe that what I am called upon to do is to affirm what I can affirm about God. I continue to hold on to the reality that God is at work in the natural order in its regularity. I continue to affirm self-agency—that individuals have independence and responsibility. I continue to acknowledge that God is always opposed to evil and that God shares the suffering and pain of human life.

Providence has proved to be an invaluable resource in my engagement with people as well. Providence affirms the reality of the goodness of God as expressed daily in the world and in the lives of individuals. The natural order is an expression of God’s care. And history is the arena of God’s working to achieve through human beings and for human beings the good fulfillment of God’s purposes for all humankind. The world is not subject to blind necessity or chance, but is in the hands of a just and loving God.

A way forward

Such an understanding sustains me as I live my life and how I offer care, love and justice to the people I minister. Both my experience and faith tells me that providence is just not an archaic teaching that only helps to explain the past. It is rather the basis for a trust about the future. There may be little help in the teachings of providence at the moment of pain for the question, “Why did this happen?” or “Why did my child die?”

But there is very great help for the haunting cry, “I am afraid! How can I face the future?” Providence, drawing from biblical theology, points to a present and a future that are securely in the hand of God.

Finally, providence offers the basis for serious venture into social change. This principle shift’s one’s attention from “What will happen to me or to the world?” to “What is God’s purpose for me and for the world?” It’s heartening to note that out of the ashes of the terrible tragedy in Newtown, there seems to be the beginning of an earnest conversation that can pave the way for advocacy and meaningful action that can address gun violence. Providence leads one to care for others and to take action to change the concrete situations in the world.

Editor’s note: For more posts exploring the Sandy Hook tragedy, please read:

• Shifting Sandy Hook information landscape means understanding will have to wait
• Was the Sandy Hook mass shooting “evil?”
• Responding to the Sandy Hook tragedy: What of the soul?