Alex and Me

Last night I finished reading Dr. Irene Pepperberg's book, Alex and Me. If you are curious about her work, check out The Alex Foundation. I was recently given the book by someone who knows I share my home with Toby, and African Grey parrot.

Pepperberg weaves her own life story with the research discoveries made during over 30 years of study with African Grey parrots. Through exhaustive and rigorous research Pepperberg demonstrated the amazing cognitive abilities of the African Grey. Among other things, she demonstrated that he possessed  more than 100 vocal labels for objects, actions, and colors; could identify some objects by what material they were made of; could count sets of objects up to six; developed his own "zero-like" concept; could infer connections between written numbers, object sets, and the vocalization of the number; and had the concept of phonemes which are the sounds that make up words.

A pretty impressive bird!

However, I was more struck by Pepperberg herself. Her personal story, as revealed by her book, is not an easy one. Her research has not always been popular or well received by peers. Funding for her work has not come easily. Despite the difficulties, she stuck with her passion and her science, opening up a window into the unseen world of nature.

I finished the book thinking of how often the unconventional, unorthodox, or different viewpoint is squashed by a society that values sameness. While we often give lip-service to diversity, we very rarely celebrate it or encourage it. I was left thinking about how much we lose when the chorus of the masses drown out a new voice asking us to see something in a different way.

I'm glad Dr. Pepperberg used her voice and opened up a new world of discovery for all of us. I hope we all find a way to learn by her example and find the courage to pursue our individual voices in a disciplined, organized, and thoughtful way.

Friday News Roundup

Grocery Chain's Decision to Drop Mental Health Coverage Raises Concerns

As I feared, the loopholes in the coming requirement for health insurance plans to offer parity for mental health treatment are starting to cause problems. One Wisconsin supermarket chain has cut the mental health portion of its health care benefit "because it will be too costly due to the passage of the federal mental health parity law." Shame on them!

Could Acetaminophen Ease Psychological Pain?

A team of researchers at the University of Kentucky uncovered evidence indicating that acetaminophen, the active ingredient in Tylenol, may blunt social pain. On a self-report measure of hurt feelings, participants taking the medicine reported lower levels of social pain than those who were not taking the medication. Watch out for side effects: too much acetaminophen can be toxic!

How Psychotherapy Works

Bruce Wampold, Ph.D. is the author of the recent book, "The Great Psychotherapy Debates." In that book he puts together empirical research on psychotherapy using rather sophisticated methods. He even places that research in an historical and anthropological context. In this article, he answers questions about how psychotherapy helps people. He notes the differences between different treatments in terms of benefit to patients are small if not negligible as long as the treatments are intended to be therapeutic, are delivered by competent therapists, have a cogent psychological rational, and contain therapeutic actions that lead to health and helpful changes in a patient's life.

Happy Holidays

What's in a Name?

There are so many different kinds of psychotherapists in the world practicing so many different kinds of psychotherapy. At one point in my post-doctoral fellowship the training director gave us a hand out with a non-exhaustive list of over 300 different kinds of therapy! We spent some time sorting through that list--what had we heard of? What have we tried? What do we think works? What do we think is little more than a modern snake oil?

Different kinds of psychotherapy would be an interesting discussion. I'll save that for a future blog post.

Today I thought it would be helpful to define the alphabet-soup bowl of terms one encounters when looking for a therapist. Ph.D.? MSW? LMHC? Psy.D.? M.D.? What are all these letters and what do they mean to you?

The importance of these letters depends a lot of what kind of question you are asking. If you are looking for someone with a specific kind of training, skill set, or viewpoint, these letters mean something. If you are looking for someone compassionate and can listen, the individual letters mean somewhat less.

Most terms (psychologist, psychiatrist, social worker, counselor) are terms that are set aside by the Commonwealth of Massachusetts to legally define a profession. To call oneself a psychiatrist, for example, one must have a medical degree. Likewise to call oneself a psychologist, one must have a doctoral degree in psychology. The Commonwealth (and every other state) does this to ensure public safety: these professions are regulated by law so that the public can be assured that they are going to a professional with a specific kind of training.

Here is a quick run down of the different kinds of professions that are licensed and regulated by the Commonwealth. Today's blog post is going to be on a basic level: in the coming weeks I'll write more detailed blog entries about the differences between how the different professions view people and their problems.

Psychologist


Psychologists are licensed in Massachusetts by the Board of Registration of Psychologists. According to statue, a psychologist is defined as the following:

Psychologists observe, describe, evaluate, interpret, and modify human behavior by the application of psychological principles, methods and procedures, in order to assess or change symptomatic, maladaptive or undesired behavior. Psychologists' work may focus on issues such as interpersonal relationships, work and life adjustment, personal effectiveness, and mental health. The practice of psychology includes, but is not limited to, psychological testing, assessment and evaluation of intelligence, personality, abilities, attitudes, motivation, interests and aptitudes; counseling, psychotherapy, hypnosis, biofeedback training and behavior therapy; diagnosis and treatment of mental and emotional disorder or disability, alcoholism and substance abuse, and the psychological aspects of physical illness or disability; psychoeducational evaluation, therapy, remediation, consultation, and supervision. Psychological services may be rendered to individuals, families, groups, and the public. Certification as Health Service Provider (HSP) is required in order to independently offer health services to the public or to supervise such services. Psychologists may also teach and do research (license not required), and consult to organizations. The title "psychologist" is protected by law and cannot be used unless the individual is licensed by the Board   

A psychologist must have a doctoral degree (Ph.D., Psy.D., Ed.D.) which normally involves 5 to 7 years of study beyond an undergraduate degree. During school, psychologists-in-training normally complete between 1,500 and 2,000+ clock hours of supervised psychotherapy experience. Prior to graduation psychologists-in-training are required to complete a minimum of a 1 years 2,000 clock hour internship. Prior to licensure, the Commonwealth requires an applicant to receive a passing score on two different examinations and have had a minimum of one full-time year of supervised experience.

Social Work


Social Workers are licensed in Massachusetts by the Board of Registration of Social Workers. According to statue, a social worker is defined as the following:

Social workers provide services to consumers as defined by the statutes and described in the regulations. Generally, social work professionals provide services to individuals, couples, families, groups, and communities directed towards specific goals. They may also assist or refer individuals or groups with difficult day-to-day problems, such as finding employment or locating sources of assistance. Social workers at an advanced level (LCSW, LICSW) may diagnose and treat emotional and mental disorders. Some social workers organize community groups to work on specific problems and help to create social policy and planning.

A social worker must have a masters degree (MSW, MSSA, etc.) which normally involves 18 months to two years of education beyond an undergraduate degree. During the course of training social work programs require a minimum of 900 hours of supervised clinical experience. A social worker may, but is not required, to have a doctoral degree (Ph.D., DSW, etc.). To be an Licensed Independent Clinical Social Worker (LICSW) the commonwealth requires an social-worker-in-training to have at least 3,500 hours of post-masters social work experience under the supervision of a social worker and pass an exam. In order to be a Licensed Clinical Social Worker (LCSW) one is not required to have any documented post-masters experience and pass an exam. 

Licensed Mental Health Counselors (LMHC)


LMHCs are licensed in Massachusetts by the Board of Registration of Allied Mental Health and Human Services Professionals. According to statue, a psychologist is defined as the following:

Mental Health Counselors render professional services to individuals, families or groups. They apply principles, methods and theories of counseling and psychotherapeutic techniques to define goals and develop a treatment plan of action aimed towards the prevention, treatment and resolution of mental and emotional dysfunction and intra or interpersonal disorders.

A LMHC must have a masters degree (MA, MS, etc) which normally involves 2 years of study beyond an undergraduate degree. They can, but are not required, to have a doctoral degree (Ph.D., Ed.D., etc.). During school, LMHCs-in-training normally complete a practicum of 100+ clock hours of supervised psychotherapy experience. Prior to graduation LMHCs-in-training are required to complete a minimum of a 600 clock hour internship. Prior to licensure, the Commonwealth requires an applicant to receive a passing score on an and have had a minimum of two full-time years of supervised experience.

Licensed Marriage and Family Therapists (LMFT)


LMFTs are licensed in Massachusetts by the Board of Registration of Allied Mental Health and Human Services Professionals.  According to statue, a psychologist is defined as the following:

Licensed marriage and family therapists apply principles, methods and therapeutic techniques to individuals, family groups, couples or organizations for the purpose of resolving emotional conflicts, modifying perceptions and behavior, enhancing communication and understanding among all family members and preventing family and individual crises. Individual marriage and family therapists may also engage in psychotherapy of a nonmedical nature with appropriate referrals to psychiatric resources. In addition, professionals engage in research and teaching in the overall field of human development and interpersonal relationships.

A LMFT must have a masters degree (M.A., M.S., etc) which normally involves 2 years of study beyond an undergraduate degree. During school, LMFTs-in-training normally complete 400+ clock hours of supervised psychotherapy experience. Prior to licensure, the Commonwealth requires an applicant to receive a passing score an examination and have had a minimum of two full-time years of supervised experience.

Psychiatrist


Psychiatrists are licensed physicians in Massachusetts by the Board of Registration in Medicine. I was not able to locate a specific legal definition of a psychiatrist from the Commonwealth. According the the American Psychiatric Association:

A psychiatrist is a physician who specializes in the diagnosis, treatment, and prevention of mental illnesses and substance use disorders. It takes many years of education and training to become a psychiatrist: He or she must graduate from college and then medical school, and go on to complete four years of residency training in the field of psychiatry. (Many psychiatrists undergo additional training so that they can further specialize in such areas as child and adolescent psychiatry, geriatric psychiatry, forensic psychiatry, psychopharmacology, and/or psychoanalysis.) 

A psychiatrist must have a medical degree (M.D., D.O.) which normally involves four years of medical school beyond an undergraduate degree. A psychiatrist-in-training then completes a rotating internship (one to four years) divided between a number of different medical settings; a psychiatric residency lasting four to six years; and receive passing scores on several different exams. 

Tuesday's Tweet

What is certain is that I am sometimes this, sometimes that. Sometimes pleased, sometimes not; sometimes confident, sometimes not; sometimes compassionate, sometimes not. The ice doesn't melt at my whim. It doesn't melt no matter how well I understand its origins or believe I understand its origins. It may not melt despite my persistent efforts to change the circumstances that I believe to be maintaining it. In such cases what else is there to do but shiver and go on about living? -- David K. Reynolds

Friday News Roundup

Since signing up for Twitter I've become deluged with information. Some of it is rather banal ("I'm heading out for  a cup of coffee") while other is much more interesting (breaking news from the environmental summit). In an effort to slow down the flow of information enough for me to understand it I'm going to experiment with aggregating tweets that I find most interesting and post it here on a Friday News Roundup.   Think of it as a companion to the Wednesday Smile that I post on Maggie's blog.

• Doodling Improves Memory and Concentration. Jackie Andrade had 40 participants listen to a monotone two and a half minute phone message. Each were told the message would be dull , they should not memorize it, but they should write down the names of the people who would be attending the party that the message discussed. Half the participants were instructed to doodle as they listened . The study indicated that those who doodled could remember more names (7.8 for doodlers vs 7.1 for nondoodlers, which represented a significant difference). When presented with a surprise memory test later, those who doodled remembered 29 percent more details. It has long been taught that multitasking reduces productivity: this research suggests otherwise. 

• Evidence Does Not Support Theory of Different Learning Styles. It has become common belief that people exhibit different learning styles (visual, auditory, etc.). An industry full of tests to measure these styles and educational tools to teach to these styles has grown. However a report that reviews the existing literature finds that while there are many studies that show the existence of different kinds of learns, those studies have not used research methods that would make their findings credible. The article concludes that research has not shown that people learn differently, at least in the ways the learning-styles proponents claim, and thus the widespread use of learning-style tests and associated teaching tools is a wasteful use of educational resources.

• Antidepressants Help Suicidal Youth. Many parents have expressed concerns about their adolescents taking antidepressants. The FDA required a black box warning on antidepressants about suicide risks with youth and there was significant reports in the media. This is however much  more complicated than a black box warning. A study from Ohio State found that the use of antidepressants in adolescents was related to a dramatic reduction in hospital readmissions.

Brain Music Therapy

Now here is an interesting article. The Department of Homeland Security is examining an existing biofeedback technology to help with sleep. They are investigating the use of brain music therapy which has been in use since the early 1990s to treat medication conditions such as insomnia. Apparently brain waves are recorded and run through algorithms that analyze the waves and translate them into a music composition. According to the company Human Bionics, which sells this technology, these musical compositions are effective and scientifically proven treatments for stress, insomnia, anxiety, and depression. The technology has also been "found to increase productivity and concentration, and help reduce headaches."

I've not done the background research to see if these claims are reasonably true. The sample clip, however, makes for pretty music (though a bit repetitive).

Office Views

Starting psychotherapy can be an anxiety provoking experience in-and-of itself. I have found that  much of this anxiety can be quenched with knowledge--or at least it has seemed that way from my experience. Over the years I've answered numerous questions that people have had about therapy. Most of them fall into two different categories: logistical or technical.

Logistical questions include how to find my office, where to park, whether to knock on the door or not, and so on. Questions of the technical nature have included how to use medical insurance for therapy, how therapy is done, and whether therapy works.

From time to time I'm going to post some answers to these types of questions on my blog. If you are reading this and have a question, enter a comment on this post or e-mail me. You can ask your question anonymously via the comment feature and I'll do my best to answer it in a future blog posting. To easily locate blog entries of this nature, look for blog posts labeled "starting therapy."

I've already complied answers to many questions about health insurance. You can locate that on my private practice website.

Valuing Psychotherapy

A recent study published in the August issue of the Archives of General Psychiatry report that between 1996 and 2005 the rate of people reporting they have used antidepressants increased by 75%. During the same time period there was a 35% decrease in the use of psychotherapy. It was reported that only 32% of people taking antidepressants saw a psychologist or social worker.

While this study only looked at people taking antidepressant medications and did not look at people who were in therapy who were not taking antidepressants, the numbers are troubling. It has been shown repeatedly that if you are depressed and want to feel better quicker, using both antidepressants and psychotherapy is the most effective treatment.

What  might account for this drop in the use of psychotherapy? Some suggest that out-of-pocket costs to patients are a barrier. A co-pay for medication might be as low as $10 a month while insurance coverage for psychotherapy might have a deductible of $500 or even more than $2000 before coverage begins. It is also suggested that comparatively low insurance reimbursement by insurance companies to psychotherapists has lead to declining use of psychotherapy. This second factor is likely complicated: low reimbursement rates move more psychotherapists to cancel contracts with insurance companies. This increases the fee to patients because they would then have to pay the entire cost of their treatment rather than a portion.

While the article did not discuss this, my guess is that individuals with HMOs are probably the least likely to be in psychotherapy: traditionally these plans have are the most restrictive (small lists of therapists from which to choose, many of those therapists are not taking new patients, session limits, etc.). I'm anticipating some, but not all, of this inequity will change once the mental health parity law goes into full effect (see, here, here, or here).

What does depression cost? The National Institute of Mental Health has estimated that the annual cost of depressive illnesses in the United States was about $27 billion dollars. $17 billion of that figure represents time lost from work. An MIT study in 1990 found the depression costs the nation $43.7 billion. This later figure puts the costs of depression on par with illnesses such as HIV/AIDS, cancer, and coronary heart disease.

Despite these figures, it seems that society as a whole--as well as individuals--are not willing to spend money on psychotherapy.

• Significant investment. Depending on geographic region and the training of the psychotherapist, a therapy appointment can cost anywhere between $80 and $200+. 
• No quick fixes. While  many people feel better after just a few short sessions, enduring change can take more time. Medication offers the allure of a quick fix, though in reality antidepressants can take three of four weeks to take effect.
• Mysterious. Therapists spend most of their time in private one-on-one conversations. Most people are left to Hollywood or talk shows to learn about psychotherapy. 
• Not a cookbook. With the increase of cognitive behavioral therapies, many develop the notion that psychotherapy is a technology/commodity that one can learn from a workbook. While this is a whole lot less mysterious, it cookbook approaches really don't help teach the value of the investment in psychotherapy. Why spend money for therapy when you can get the book from the library?

Psychotherapy represents an important investment in health, wellness, life, and society. How do we get the news out there? I've got two really important ideas:

• Psychotherapists need to get out of the office and into the streets. We need to talk about what we do, be comfortable in talking about the value of what we do, and find more ways to offer our knowledge and skills to society.
• Clients, when comfortable, need to talk with those they care about and tell them how they have found psychotherapy valuable. 

For more, try reading, here, here, here, or here.

Parity Law Part Two

Yes, another week has gone by and the Irreverent Psychologist is still thinking about mental health parity laws. I'm still contacting insurance companies here in Massachusetts trying to get an articulation how the law is going to be implemented.

To read the actual law, go here.

A recent study reviewed the successes and failures of the California parity law during the 2000 to 2005 time period. Among the findings:

• Costs of parity were in line or below the projections.
• Most health plans lifted limits on the annual number of days allowed for both inpatient treatments and the number of visits allowed for outpatient treatment.
• Concerns were raised that insurance companies might use the medical necessity clauses to control costs in an arbitrary way.
• Consumers had difficulty finding therapists from individuals who were contracted with the specific insurance company.
• Doctors expressed concern that treatment would no longer be paid for if a patient improved an no longer met the criteria for a particular diagnosis: even if stopping therapy would was not in the best interest of the patient. 

To read more about this study go to the LA Times blog or the abstract of the article.

Psychotherapy Training in Psychiatrists

Ever wonder what kind of psychotherapy training psychiatrists get in medical school? Apparently it isn't a lot. If I wasn't sitting down when I read this article I very well might have fallen out of my chair.


I was recently forward an article from The Psychiatric Times. I'm just going to bullet point the things that shocked me:

• residents must have an equivalent of 12 months of full-time, organized, continuous, supervised clinical experience in the assessment, diagnosis, and treatment of outpatients in both short-term and long-term care
• forty medical schools in the US and Canada report some limited instruction in psychotherapy as part of the curriculum 
• the instruction occurred at varying times throughout the four years of medical school and was often part of a one hour session

I'm beyond shocked and am going to have to phone a psychiatrist friend or two. While I'm sure the article is true, I'm feeling the need to do my own fact checking. I know many talented psychiatrists that I would comfortably refer a loved one to for psychotherapy. Surely they must have had more than the minimum training.


As a comparison, they average psychologist has had at least 1,200 hours of training while in school, a 2,000 hour internship, and an additional 2000 hours of training after earning their doctoral degree. That's just work experience, not classroom instruction.


My no means am I posting this to suggest that psychologists are better than psychiatrists. I've not personally done a comparison of how the two different fields train students to do psychotherapy.
I am posting this because I am shocked. I am reminded how important it is to be an informed client. 


Don't be afraid to ask your therapist about their training. In light of this information, I think it's important to know if a psychiatrist has done the minimum training or if they have sought additional education and experience.


Want to read the article?

http://www.psychiatrictimes.com/display/article/10168/1491210?verify=0

Tucker, P.M., Garton, T.S., Foote, A.L., and Candler, C. (December 1, 2009). In Support of Early Psychotherapy Training. Psychiatric Times, 12. 

Napping Improves Learning

Well here is an interesting research article. Taking a brief nap after learning can help consolidate learning when sound cues are introduced while sleeping. Northwestern researchers conducted a study in which subjects were shown objects on a computer screen in a specific location. Those images were associated with a sound (e.g., an image of a cat and the sound of a cat meowing). Subjects were then instructed to take a nap. While sleeping the sounds of some of those images were played. Subjects were more likely to remember the positions of images if they had heard the sound in their sleep. Additionally, the subjects reporting having not heard anything while napping.

The researchers concluded that consolidation of learning occurs during sleep and can be influenced by auditory stimulation.

Apparently the learning has to happen before the sleeping part. This is evidenced by my inability to remember anything from morning classes in high school. Then again, it could just be because that was a long time ago.

Can Counseling Change Your Brain?

I recently was tweeted about an interesting study about the effects of psychotherapy. In a study authored by Jakob Koch of Christian-Albrechts University in Kiel, Germany, it was suggested that psychotherapy with depressed patients is associated with chemical changes in the brain.

This is pretty exciting stuff. I've seen many studies that associate psychotherapy with behavior change or change in self-report of moods. I've never seen a study that has associated psychotherapy with actual biological change in brain chemistry. This study does that. The research found that psychotherapy, in-and-of-itself, was demonstrated to be associated with positive changes in brain chemistry.

Wellstone-Domenici Mental Health Parity Act

Mental Health Parity is coming to a health insurance plan near you on January 1st, 2010. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (commonly known as the Wellstone-Domenici Parity Act) was enacted into law on October 3, 2008. After a long lag time, most insurance plans are required to be in compliance with this law by the first day of the new year.

This bill is designed to end the health insurance benefit inequity between mental health/substance use disorders and medical benefits for group health plans with more than 50 employees. This means that there cannot be arbitrary limits for the coverage of biologically based conditions (e.g., 12 sessions a year for the treatment of depression if there are no similar limits for medical visits).

It is estimated that under this law, 113 million people will have the right to non-discriminatory mental health coverage.

Massachusetts has had a parity law for sometime. However, under this law individuals who are enrolled in self-funded plans (fully funded by the employer) were not covered by the parity law in the Commonwealth. This is changing on January 1st, 2010.

There are some important caveats. Mental health and addictions coverage is not mandated. No insurance plan is required to offer this type of coverage. Mental health coverage is offered at the discretion. An employer can elect to purchase a plan that offers no benefit at all. Additionally, companies with less than 50 employees are not required to provide parity. Lastly, there is a cost exemption. If, after six months of meeting the requirements of this law, a company can demonstrate and have certified by a licensed actuary that the costs of providing this coverage are excessive, their group health plan can be exempted. Excessive is defined as an increase of the actual total costs of coverage by two percent during the first year or one percent in subsequent years.

For more information:

Mental Health Parity Summary

Have a complaint about your insurance plan?

Commonwealth of Massachusetts, Division of Insurance 

National Day of Listening

This coming Friday is the National Day of Listening. The goal is to reserve one hour of the day to record a conversation with someone you find important: an older relative, friend, teacher, or someone you've noticed but have never taken the time to learn about.

Want to know more? Head to the National Day of Listening website to learn how to participate.

Twitter

It's interesting really. I consider myself a pretty tech-savvy person in my day-to-day life. I'm a fan of electronic gadgets and tend to be an early adopter of new technology.  Those of you know know me in my private practice would feel differently: according to some my little paper calendar makes me look like a dinosaur.

I'm making a slow crawl toward moving my psychotherapy practice into the 21st century. I've opened up a Twitter account. If you look to the toolbar on the right, there is a box in which you can click to follow my tweets.

For now, I'm going to use Twitter to make general annoncuments: updates to my website or blog, my vacation schedule, inclement weather or traffic calamity alerts, and notifications of being out sick. Twitter will not be my primary way of notifying current clients about changes in my schedule: I will always contact by phone and/or e-mail first. I will not utilize Twitter as a primary way to contact clients.

Twitter raises some privacy concerns that I'm working on sorting out. I believe that anyone can see who follows me on Twitter. If you choose to follow me on Twitter, you will need to agree that it is okay that other people know you are doing so. In that Twitter is not confidential and thus I cannot protect the privacy of such communications, I will not be using Twitter for any direct contact with individual clients.

Hang in there with me as I develop this tool. I also am working on the development of a revision of my privacy policy that will include Twitter, this blog, and communications in the electronic realm in general. When it is finalized, that privacy policy will be posted on this blog, on www.drjasonmihalko.com, and discussed in my office.

Animal Assisted Therapy

Since I've started bringing Maggie into the office on a regular basis I've been fielding a lot of questions about the benefits of animal assisted therapy. Here are a few interesting research articles. I found them to be interested and thought I'd share a few abstracts. I am particularly struck that even the presence of an aquarium in an ward of patients who have Alzheimer's has been shown to have a significant positive effect.

Barak, Y., Savorai, O., Mavashev, S., & Beni, A. (2001). Animal-Assisted Therapy for Elderly Schizophrenic Patients: A One-Year Control Trial. American Journal of Geriatric Psychiatry, 4, 439-442.

In a blind, controlled study, the effects of animal-assisted therapy were studied with elderly patients diagnosed with schizophrenia. The study indicated that there was a significant increase in mobility, interpersonal contact, communication, personal hygiene and self-care through the use of cats and dogs as modeling companions.

Barker, S. B., Pandurangi, A. K., & Best, A. M. (2003). Effects of Animal-Assisted Therapy onPatients' Anxiety, Fear, and Depression before ECT. The Journal of ECT, 19, 38-44.

This study was done to determine whether animal assisted therapy is associated with reductions in fear, anxiety, and depression in psychiatric patients before electroconvulsive therapy (ECT). The effect of AAT on fear was significant in the study and the conclusion was drawn that animal assisted therapy may have a useful role in psychiatric and medical therapies in which the procedure is inherently fear-inducing or has a negative societal perception.

Edwards, N. E. & Beck, A. M., (2002). Animal-Assisted Therapy and Nutrition in Alzheimer'sDisease. Western Journal of Nursing Research, 24, 697-712.

This study was really interesting to me. It examined the influence of animal-assisted therapy--this time fish aquariums--on the nutritional intake for individuals with Alzheimer's disease. The researcher's collected baseline nutritional date for two weeks before the study began and then every two weeks after the aquariums were introduced. Nutritional intake increased significantly when the fish were introduced and continued to do so over a 16-week period. They study also found that the participants required less nutritional supplementation (they were eating better) and thus had a net savings effect on their health care costs!

Filan, S. L., & Llewellyn-Jones, R. H., (2006). Animal-Assisted Therapy for Dementia: A Review of the Literature. International Psychogeriatrics, 18, 597-611.

This article reviewed several small studies that suggest the presence of a dog reduces aggression, agitation, and promotes social behavior in people with dementia.

Martin, F., (2002). Animal-Assisted Therapy for Children with Pervasive Developmental Disorders. Western Journal of Nursing Research, 24, 657-670.

This study evaluated the effects of interaction with dogs on children with pervasive developmental disorders. These disorders are characterized by a lack of social communications and abilities. While interacting with a therapist, children who were also exposed to a therapy dog exhibited a more playful mood, were more focused, and were more aware of their social environments.

Folse, E. B., Minder, C. C., Aycock, M. J., & Santana, R. T., (1994). Animal-Assisted Therapy and Depression in Adult College Students. Anthrozoos: A multidisciplinary Journal of the Interactions of People and Animals, 7, 188-194).

This study investigated the effects of animal assisted therapy on self-reported depression in college students. Students were randomly assigned to one of three groups: animal assisted therapy in conjunction with psychotherapy (directed group), animal assisted therapy only (non-directive), and a control group. They study demonstrated a significant difference between the control group and both the directive and non-directive group, suggesting that that just the presence of a therapy dog can have a positive effect on depressive symptoms.

You Make Me Mad

"No one can make you feel something. You choose to feel that way." How many of us have heard this from a school teacher or parent?

"You create your own reality." Have you heard that one a lot? I have. I've heard it in the context of self-help discussions, discussions about mindfulness, and from more than a few psychologists.

I did my postdoctoral training in Dialectal Behavior Therapy. At the clinic where I worked, most of the clients who sought help did so because they were no longer able to continue life overwhelmed by their feelings and emotional reactions. Most of my clients were diagnosed with borderline personality disorder and specifically came to the clinic to receive some of the best DBT therapy that was provided in the area.

I heard many excellent psychologists and psychiatrists say that no one could make us feel something. The gist of this way of approaching emotions is the following: Another person can't open us up and make the complicated series of reactions that cause anger, fear, shame, guilt, or joy. Our feelings are on in the inside and we are responsible for our own feelings and emotional reactions. As one of my mentors would say, another individual might make the situation optimal for an individual to create a particular feeling.

I've said this over and over again to clients. Recently, I said it again only to stop, apologize, and say that this is just a bunch of poppycock. Yes, each of us are completely responsible for how we respond to our emotions. However, our emotional experience is not necessarily under our control at all.

When a driver cuts in front of me during in Boston traffic, my heart beats a little faster and my rate of breathing increases. I am having a physiological response that is out of my immediate control.

From a cognitive perspective, I interpret these physiological cues. I might worry that I might get into an accident (fear) or I might be annoyed at the offending drivers' sense of entitlement (anger). I have agency over my interpretations and thus the popular statements of "you create your own reality" and "no one can make you feel something."

At this level of iterpretation I do not disagree with these statements. I do expect myself to have a degree of agency over how decode my physiological cues.

I might have a variety of behaviors. Perhaps I might duck and start to cry in fear (not likely), or maybe I might issue some sort of special hand signal to express my annoyance (more likely). Again, I agree with the notion that no one can make me cry or make me use special hand signals. At this level of interpretation, I again expect myself to have a degree of agency over how I behaviorally respond to my decoding my physiological cues.

You might be saying "Wait just a minute Jason, you started this off by disagreeing with the notion that we create our own reality."

That's true, I do. It's because these statements contain an a major invalidation of our physiological responses. That initial quickening of our sympathetic nervous system happens without our consent or control. The driver cuts me off and my body responds. I don't make my sympathetic nervous system turn on, it is designed to turn itself on and protect me. While the driver who cuts me off doesn't not have direct control of it either, his/her actions are the stimulus that causes the whole chain of events to start: physiological response, decoding of physiological cues, interpretation of cues, behavioral response.

I try hard to never invalidate another person's experience. If you fall, I don't tell you it doesn't hurt. If you tell me you've fallen and share that you were told it wasn't supposed to hurt, I make it a point to underline the essential invalidation of your experience. It's kills our humanity, a little bit at a time, to invalidate our experiences like this.

Now don't get me wrong. If you've fallen and stubbed your toe, collapse to the ground, and hide in your house in fear for several weeks I'll have a few things to say: you very well may be having difficulty decoding your physiological cues and selecting effective behaviors.

I try very hard, however, to never tell you that it didn't hurt, wasn't important, or didn't happen at all.

Therapy Dog

Magnolia the therapy dog had her first full day of work as a therapy dog. I had hoped to slowly start introducing her to work in January however due to some unexpected circumstances, she joined me for the day yesterday.

Maggie did extraordinarily well. She greeted clients at the door and said hello to them as they settled onto the couch or chair. She joined some up on the couch and settled into their laps. At other times, she curled up in her bed next to my chair and silently slept. Not bad for a 14 week old puppy.

Traditionally, a therapy dog is an animal that is trained to provide affection and comfort to people in hospitals, retirement homes, nursing homes, schools, people with learning difficulties, and even stressful situations like disaster areas. Any breed of dog has the potential of being a therapy animal. The temperament of the animal is what is important. Dogs working as therapy dogs need to be friendly and patient. They need to possess a sense of confidence and ease in all situations. Most importantly of all, they need to be gentle and enjoy interacting with humans--whether that be the gentle pet of someone in a nursing home or the clumsy roughhousing of a child in school.

There are several different organizations that sponsor certification of therapy dogs. Therapy Dog International is a group founded in New Jersey. Therapy Dogs Inc. is another similar organization based in Wyoming. The organization that I am choosing to work with is the Delta Society and their New England affiliate, New England Pet Partners Inc.

I've elected to work with Maggie toward certification with the Delta Society because I like that they differentiate between Animal Assisted Activities and Animal Assisted Therapy. On their website, they write that "Animal-assisted activities are basically the casual "meet and greet" activities tat involve pets visiting people. The same activity can be repeated with many people, unlike a therapy program that is tailored to a particular person or medical condition." Animal Assisted Therapy is defined as "a goal-directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/human service professional with specialized expertise, and within the scope of practice of his/her profession."

While Maggie will certainly be engaged in Animal Assisted Activities in my office from time to time, I am also hoping she will be amenable, when needed, to becoming a more integral part of the therapy process and engage in activities that are more akin to Animal Assisted Therapy.

This I Believe

I've been listening to a podcast for the last several months that has captured my attention. This I Believe describes itself as "an international project engaging people in writing and sharing essays describing the core values that guide their daily lives." I have found most of them to be amazing and inspiring.

I've been reflecting upon one essay in particular for the last couple of weeks. Ann Heywood was a military wife and held more than 30 different jobs before she started her own business helping other people find the right job. Some consider her to be the precursor to the "follow your bliss" movement.

Her essay offered two things that stood out. Heywood wrote "I believe that every human being has a talent--something that he [or she] can do better than anyone else. And I believe that the distinction between so-called "create" talents and ordinary run-of-the-mill talents is an unnecessary and man-made distinction." She also wrote "I also believe that in the process of searching, no experience is ever wasted, unless we allow ourselves to run out of hope."

What an important lesson this essay offers in self-discovery and understanding. Each of us offers the world a gift that no one else can offer. Each person is valuable. None of our experiences are wasted--even the painful ones. They all drive us to a place that makes us uniquely ourselves, uniquely gifted, and uniquely valuable.

Is there a more powerful act that any one person can take other than transforming a difficult or traumatic experience into something that propels oneself toward finding one's unique gifts?

Neighborliness

I recently adopted a puppy. She and I are spending a lot of time together as I'm training her to be a therapy dog. Eventually she'll be joining me in the office. Part of Magnolia's training involves a lot of socialization. We go to parks, malls, and other places where she can encounter lots of different people. I have a list of experiences that she needs to be exposed to: older people, children, people using crutches, people in wheelchairs, etc.

I've heard people in the past joke about the best way to meet new people is to buy I dog. I had no idea how real that joke actually is. Admittedly, Magnolia is tiny and cute. Still, I didn't anticipate that people would actually stop their cars, roll down their windows, and start up a conversation. Since bringing Magnolia home on Saturday I've had no less than ten conversations with different people while I am out walking.

It got me thinking about why this is. I'm not doing anything different except walking with a prop--a cute dog on the leash. At least I didn't think I was doing anything different. After observing a little more I am realizing that I'm actually a lot more mindful of my surroundings. Sometimes big dogs come along and I need to snatch my eight week old pup off the ground. Sometimes little children come running to pet her, and I need to be ready to help negotiate the contact so neither party is afraid. Sometimes, I'm just making more eye contact with people. They notice me and what I'm doing. I notice them and what they are doing.

It made me wonder what other kinds of props people might use to start conversations and meet new people. Dogs and puppies help. Not everyone can have one. I've sent clients out in the past with homework assignments to hold the door open for people and make a few seconds of small talk, or comment on a pair of earrings that they notice and admire while in the check out line. Other clients, who spend lengthy amounts of time commuting on the T, get the homework assignment to make a comment or ask a question about a book they see someone reading.

The prop--or situation--really doesn't seem to matter. When people try out these homework assignments they are always successful: they have a brief conversation with a stranger. While it doesn't guarantee a new friendship is formed, it at least creates the opportunity for a moment of interpersonal contact.

Summertime Distress Tolerance

After a month of so much rain and cool temperatures that I thought I might start to rust, it's finally become more seasonable in New England. That means hot and humid weather. I fled my under-air conditioned home to look for a cooler spot.

I went to Target looking for a few electronic items and started to wander around looking at end caps. It became more interesting for me to wander around looking at people who were wandering around looking at the end caps for bargains. I got to thinking that this is a great summertime distress tolerance activity.

Distress tolerance, simply put, is any activity that can help someone get through a crappy experience or sensation without making the situation worse. Any tool that is healthy and non-destructive that helps distract from an unpleasant, intolerable, or not resolvable in-the-moment situation is a distress tolerance skill.

Target keeps the air conditioner on full blast, so it was nice and cool. Maneuvering a cart with one hand, holding a diet Pepsi in the other, I roamed the ends of the aisles totally absorbed in looking for interesting items--or people.

What a great way to lose track of time, distract from unpleasant situation, and make a positive non-destructive choice? A perfect distress tolerance skill.

Distress tolerance skills don't solve the problem--they just help us tolerate the problem until the crisis passes or until we can get into a space where we can make more effective choices.

As I come across interesting, unusual, or particularly effective distress tolerance skills I'm going to post them on this blog. I'll label the posts "distress tolerance" so they can be easy to find.

Welcome

Welcome to the Irreverent Psychologist. Over time, I'm hoping this will become a helpful resource detailing useful facts about therapy, psychology, and life in general. I'm also going to occasional write about tools to use for coping, distress tolerance, and enhancing your life.

Hang in there with me while I'm feeling out Blogger and finding a way to make this a useful place.

Who knows, maybe I'll get on a roll and figure out a way to make Twitter and Facebook useful too. Have any ideas?