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Maui 2008 178

One of the sticking points with some folks in AA is the step that says you will surrender to a power greater than yourself. Surrender is not the American way, or maybe more accurately, not the Protestant work ethic way. You must give 110% even though that is not really possible. For example in running, you bonk before your glycogen levels fully deplete. Your brain takes care of you by telling you to take it easy. Think of what happens to the motherboard on your computer when you overclock the processor to increase power. You overheat and fry it. And yet, if we don’t succeed we are encouraged to keep trying to the point of attempting to get out of a hole by continuing to dig. I think of it as a Vietnam syndrome – just keep sending troops and keep bombing and victory will inevitably come. Somehow we didn’t learn much from that experience.

In Chinese philosophy there is the concept of wu wei or nonaction, trying not to try, or effortless effort. A similar state in western psychology is the flow state described by Mihály Csíkszentmihályi. It is when you are in the zone. You cannot force yourself into flow or wu wei, you have to let go – surrender – and just be with it. When you become aware you are in that state, you are out of the moment and you lose it.

We have known for a long time that outcomes for people diagnosed as mentally ill have better outcomes in third world countries than in the west. People are treated differently in the “less advanced” cultures. In the west, we also put labels on people and then try to force them to behave in what we consider socially appropriate ways. For over 50 years the work of Brown, Birley, Vaughan, Leff, Wing and others found that the expressed emotion in families was a primary causative factor in rehospitalization in psychiatric facilities. Behaviors that got on family members’ nerves were more likely to cause trouble than the psychiatric symptoms. I came across their research in the late 1970s while working on a rehospitalization factors study at a state hospital. Expressed emotion was not touted as a factor in causing mental illness – no schizophrenogenic mother theory. It was just that when someone is criticized in certain ways, even when caring and concern are at the heart – sometimes feeling judged and pushed does not lead to the outcomes that are desired by the one expressing concern. And that is true regardless of whether one is ill or not.

In the recovery movement, the shift is to treat people with dignity and respect. Ezra E. H. Griffith has edited a comprehensive book that covers issues like involuntary commitment. It is called Ethics Challenges in Forensic Psychiatry and Psychology Practice. It is an excellent read addressing all the variables we face in social control when we treat people with psychological problems differently than those with physical problems, for example, diabetes.

It also got me to wondering about how wu wei might come into being when treating those considered chronically and seriously mentally ill. The July 1, 2016 Invisibilia episode has an intriguing take. You can listen to it here. It is called The Problem With the Solution. It starts with an American dream kind of product invention, and then looks at solutions in mental illness. It reminded me of Scott Miller saying that once something is defined as a problem, it gets worse. Could a reframing, a surrender into acceptance, be one solution? The podcast looks at the story of Ellen Baxter and her search for understanding with her family. That search took her to college and to Geel, Belgium, where people diagnosed with mental illness live with foster families who accept them for who they are and have no idea of the person’s diagnosis. Does Geel, Belgium have a humane, kind and respectful solution? Baxter began a project in New York called the Broadway Housing Project. It is not only humane, it is also cost effective. Also mentioned is Jackie Goldstein and Voices of Hope. You can read more about Jackie Goldstein and Voices of Hope here. Be sure to listen to the bonus story of William Kitt at Invisibilia. Information about the Broadway Housing Project and Ellen Baxter is at http://www.broadwayhousing.org/. There is also this 1993 New York Times article – https://www.nytimes.com/1993/12/19/magazine/ellen-baxter.html.

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2013 Burlington Vermont 015

 I think my life began with waking up and loving my mother’s face. George Eliot

We are social beings. We have survived as a species because of our ability to live and work together. The idea of rugged individualism is a relatively recent myth strongly believed in the West, particularly the US. I remember a study from years ago in which people were asked to draw a circle representing the self, and another representing other. Americans drew circles much larger for the self than for other. People in Asia and Africa tended to make the circles the same size or maybe even make the circle for other larger.

We are born helpless and dependent. We rely on others to help us develop as humans, and we rely on others our entire lives. Attachment teaches us how to get along in life. John Bowlby wrote about attachment after noticing how infants in orphanages after World War II in Europe failed to thrive and, in some cases, died, despite having the basic physical needs met.

How hard wired are we for attachment? Take a look at this video.

According to the polyvagal theory, we help regulate each other’s emotions throughout our lives by how our ventral vagal nerve “reads” and responds to facial expressions. In “The Emotional Foundations of Personality: A Neurobiological and Evolutionary Approach” by Kenneth L. Davis and Jaak Panksepp, the emotion of panic/sadness is linked to separation from our caregiver in our developmental years.

Martin Seligman wrote in “Learned Optimism” that he could predict the winner of a presidential election by the optimism of the acceptance speech. In “The Attachment Effect,” Peter Lovenheim looked at politics in the US and looked at politicians and even speeches from another angle – from the view of attachment.

There are four kinds of attachment – secure, anxious, avoidant, and disorganized. He writes that those with secure attachment “tend to be more giving and tolerant toward others, and they show more resilience in the face of challenges such as personal illness and the death of a loved one.” They are comfortable with intimacy and depending on others. Insecure attachments – avoidance and anxious – are more problematic. They do have strengths. A person with anxious attachment may be more successful getting a parent’s attention as a child (though the attention may not be positive) and the avoidant person becomes more independent and is less likely to feel the hurt, at least consciously. Anxious people may perceive danger more quickly, and avoidant people may see ways to escape more quickly. Anxiously attached people tend to be uneasy and vigilant about threats to relationships and are worried. Avoidant people tend to be very self-reliant and disinterested in intimacy. Disorganized attachment is coming to fear and be drawn to your care giver at the same time. They tend to be fearful of rejection, suspicious and shy.

Lovenheim found a correlation between secure attachment and centrist beliefs – more moderate, more flexible, more realistic, and more self-confidence, empathy and trust. Both anxious and avoidant people are more likely to be drawn to extremes. Avoidant may be drawn to the far right and anxious to the far left, but not necessarily. What does happen is that both are drawn to a dogmatism that gives them a sense of safety and security. “Anxiously attached voters, in particular, may project their unmet attachment needs onto leaders (and) may so crave attaching to a strong, care-giving leader that they nay be unable to distinguish between a transformative leader –one who protects encourages and empowers them – and a leader without such qualities.” The relationship of style to political leanings may be much more complicated. He also did an attachment style interview with Michael Dukakis and found the former presidential candidate and governor as avoidant. You may remember his detached analytical nonemotional answer during a presidential debate that was widely seen as costing him votes.

In speculating about recent presidents, Lovenheim found both anxious (like Clinton) but mostly avoidant including both 2016 candidates. Often anxious attached people wind up with avoidant people in relationships (and it generally doesn’t go well), and I wondered about voters and candidates. I didn’t find any data, but I am also curious because several presidential nominees (and at least two of those elected) have a history of being bullies. Is there an attachment style associated with bullies? At least among adolescents, avoidant attachment style was likely to be the style of bullies. But the relationship may be a bit more complicated. As usual, more research is needed. It also got me to wondering about cultural attachment styles. If a country tends to elect leaders with avoidant attachment styles, how does that affect the country’s relationships with the rest of the world? Also complicating that are cultures sense of the self in relation to others. The nonsecure styles would tend to lead a culture and a country to more extreme and have more rigid positions based on fear and the need to be right so that all are safe and secure, at least in our tribe. It also got me to wondering about attachment and religious belief. A concept of a power greater than yourself can give you a sense of safety. Lovenheim found that attachment styles in religion tend to reflect those we have in every day life. A secure attachment leads one to a feeling of God as loving protector, “available, reliable and responsive.” Those with anxious styles who see relationships as unreliable and unpredictable may be “deeply emotional, all consuming, and clingy.” The research he cites sees avoidant as tending towards agnostic or atheistic, but there are philosophies such as Buddhism and Daoism that have no deity or deities, and then there is rational empiricism all of which can be had by one with a secure attachment style. What I wondered about is more the disorganized style. If God is both loving and vengeful and to be feared, how would one get beyond that paradox and have a secure attachment? Again, with all the variables in daily life, it is complicated, and more research is needed.

I didn’t find any research on attachment style and likelihood of voting. I do wonder how outcomes of elections would change if a greater percentage of people voted. The best estimate I could find for the US population as a whole is that about 65% are secure attachment style, 20% avoidant, 10-15% anxious and 10-15% disorganized. About 75% of people live their whole lives in one style with no change. As Lovenheim writes, “If we’re going to raise emotionally healthy people, a consistent attachment figure must be present at least for the first eighteen months to two years of life. This is not a gender-specific role; it could be mother, father, grandparent, nanny, among other possibilities. But someone has to do it.”

Attachment is not static across a lifetime, and one can earn secure attachment. And, your attachment style may even affect your relationship with your dog.

Other books of interest in this area are “The Neuroscience of Human Relationships”, by Louis Cozolino; “The Feeling Brain” by Elizabeth Johnston and Leah Olson; and “The Pocket Guide to The Polyvagal Theory”, by Stephen Porges.

If you are curious about your own attachment style, there is an online test at http://web-research-design.net/cgi-bin/crq/crq.pl.

Kona Hawaii 2013 116

I remember Dr. Peter Derks, my very first psychology professor, many years ago discussing a study in which people were asked to find patterns in flashing lights. Lights would flash in a sequence and participants were supposed to figure out the pattern so they could predict which light would flash next. What the participants didn’t know was that there was no pattern. The lights were programmed to flash in a random pattern. In every case, however, people found a pattern. When they were ultimately proved wrong, they would typically say, “now I see what you’re doing,” and would change their theory to a different pattern. No one ever figured out that there was no pattern, it was all random.

The NPR podcast, Invisibilia, recently did a story about patterns in the context of trying to predict behavior. One story was about a woman who had a history of abuse and arrests. She had turned her life around and was trying to become a lawyer in Washington state. Her appeal went to the state supreme court, and her attorney was a man who had convictions of bank robbery. Another story was about a Princeton study that used longitudinal data to try to predict outcomes in children. The researchers, despite massive amounts of data and coding efforts were not able to predict outcomes. You can listen to the podcast at https://www.npr.org/podcasts/510307/invisibilia (it is the March 18, 2018 podcast) or you can read the transcript here. People long for patterns and predictability and typically feel very uncomfortable with randomness. With randomness you can’t predict what will happen next. And life just has way too many variables to be completely predictable.Our brain takes shortcuts to give us the comfort that we can predict things. We inherently look for patterns. It enhances our chance at survival. It is part of evolution. It also gives us a sense of self, of who we are. We are those patterns we fall into.

Michael Puett, a professor at Harvard, and Christine Gross-Loh wrote a book called, “The Path: What Chinese Philosophy Teaches Us About the Good Life.” Rather than looking inside for our “authentic true self” we are urged to “recognize that we are all complex and changing constantly. Every person has many different and often contradictory emotional dispositions, desires, and ways of responding to the world. Our emotional dispositions develop by looking outward, not inward. They are not cultivated when you retreat from the world to meditate or go on a vacation. They are formed, in practice, through the things you do in your everyday life: the ways you interact with others and the activities you pursue. In other words, we aren’t just who we are: we can actively make ourselves into better people all the time.” Every moment can be a moment of redemption or a moment of damnation. For all of us. Puett says that Zhuangzi, a Chinese philosopher of the Warring States period, said that labeling yourself is dangerous. It limits you. Saying you are an inherently shy person limits you to being that, you become stuck in that pattern. Instead, you can look at each moment for what you can become. We are not static beings.

That moment of becoming reminds me of solution focused therapy and narrative therapy. You start with small steps, like a small snowball at the top of a hill that gets bigger as it rolls down. The problem is outside yourself, and does not define you. Instead of staying with your past patterns and stories, you look at how you would like to be. It reminds me of flow – you become one with the moment you are in. But that takes practice. Humans tend to fall off the Way or Dao. We get caught up in thinking and patterns and ruts. Joseph Campbell, when interviewed by Bill Moyers on the Power of Myth, spoke about the Coptic Christians for whom the everlasting life was living forever in the moment – transcendence. Confucius used rituals to help us get there.

Chance life encounters with their randomness play a large roll in our lives, too. That can be for better or for worse. The better are situations like that if Theodore Geisel, or Dr. Seuss, who had given up on publishing his first book and planned to destroy it. That changed with a chance encounter on a walk home. You can read that story here. For worse could be an instance of just being in the wrong place at the wrong time. I remember years ago a man driving home from work, just as he did every week day, was killed when a car, driven by an adolescent girl and friends, went airborne with the front end coming down into his windshield and killing him instantly. Albert Bandura wrote an excellent article on chance life encounters in the APA Monitor back in 1982. You can read it here.

So in this life, with all its messiness and randomness and chaos, how can be live in a way of growth and loving kindness? How can we live in the present so that we are not captured by the past, but have a chance at a better future? How can we change our relationships into skillful ones? How can we flourish? The Path gives us some practical ideas from the Chinese philosophers whose ideas have been found to be supported by neuroscience.

I think a part of changing and just being in this life is to be comfortable with that randomness and ambiguity. We learn that going with the flow is being open to the results of that butterfly flapping her wings off the coast of Africa, and we adapt and adjust as best as we can. That may go against our nature of desiring predictability and a world of where everything is easily judged right or wrong, good or bad, and we always know what comes next. Rather than judge harshly and condemn or overly praise and think that something is solved for good, we look at how skillful we are and how we can improve that. We have a sense of curiosity. The Chinese philosophers all sought to teach us how to be decent people, each in their own way. It is a constant life long process, and our skill levels vary from moment to moment. The philosophers from Confucius to Xunzi all have ways of reaching a place where we automatically find and live the Way. But for all the teachings, there is an inherent paradox. The harder you try, the more difficult it becomes. In Chinese, the process similar to flow is “wu wei” or effortless effort. Edward Slingerland gives a good overview.

Kona Hawaii 2013 116You may have heard someone say, “I can’t believe I did that, that’s not me!” And sincerely believe it and be baffled at what they said or did. You may have felt that way about someone else. “My son/daughter/friend would never do something like that.”

There are at least two versions of us – the one in the moment, and the one we construct in our story over time. In the updated edition of “Full Catastrophe Living,” Jon Kabat-Zinn cites research from the University of Toronto about these two versions of the self. The study looked at people who had completed the Mindfulness Based Stress Reduction program and found “increases in neuronal activity in a brain network associated with embodied present-moment experience and decreases in another brain network associated with the self as experienced across time.” That second self is the narrative self or the self we experience as ourselves in the story we tell ourselves over time. The research findings encourage us to be in the present moment rather than caught up “in the drama of our narrative self.” “Non-judgmental awareness of our wandering mind may actually be a gateway to greater happiness and well-being right in the present moment, without anything at all having to change.”

Jeffrey Zimmerman in “Neuro-Narrative Therapy” goes a step further and cites the work of Dan Siegel. “Narrative therapy rejects the notion of a single, true self and instead embraces the idea of multiple identities or multiple versions of the self.” Siegel says that the notion of a unified self is “missing the point of the multiplicity of our normal, adaptive, ever-changing selves.” We need these multiple states to be able to adapt to the changing situations in our lives. We do tend to have states that we favor and see those override states or dominant style as our personality. Our brain is constantly taking short cuts so that we can cope with all the information we are constantly bombarded with internally and externally, and we see that dominant style as our self. “… (O)ur brain likes coherence, it has a bias for making the world appear solid and stable. To do so, it constructs an unbroken picture, giving us a continuous sense of self out of these multiple brain states.”

Mindfulness can help us be aware of those states, and to be with them in a nonjudgmental way and lessen the drama and the pain of everyday life.

I think it also helps to look deeper, even on the physical cellular level of the self. What we perceive, for example a chair, is not solid at the microscopic level. And we are not solid beings or even mostly made up of human cells, at the microscopic level. Take a look at this “Nova Wonders” called, “Nova Wonders, What is Living in You?” It not only tells about how in terms of numbers our human cells are vastly outnumbered by the bacteria, viruses, and other micro-organisms that co-habit our bodies with us, but gives some thought provoking ideas and findings about the function of our gut bacteria in illnesses ranging from C. diff to Parkinson’s to autism. You can find it at https://www.pbs.org/video/nova-wonders-whats-living-in-you-fnbfuy/. Fortunately, our human cells are bigger than all our fellow micro-organisms. Their total weight in our body is about three pounds – about the same as the weight of our brain.

When you hurt another, you may ask forgiveness from them. The Pope has asked forgiveness of those molested by priests and for the treatment of indigenous people in the New World. People convicted in court may ask forgiveness just before sentencing. Preachers and politicians ask forgiveness when caught in sin and then enter rehab to prove just how sincere they are. All of us do wrong at some time. Forgiveness is an issue that comes up often in life and in counseling. What does that word mean?

It does not mean saying that the wrong is now okay. “Sure you hurt me, but I forgive you, now it is okay.” That definition makes forgiveness extremely difficult if not impossible. It is giving a gift of dispensation to the one who harmed you. There is another view. Forgiveness can mean, “I don’t like what you did, and it is not okay but I will let it go. It doesn’t mean I want to have anything to do with you again, but I am not going to let anger and resentment devour me.” A quote attributed to the Buddha is that holding onto anger is like grasping a hot coal. The one who gets burned is you.

Many years ago I was having a conversation with a person who was working on recovery in AA and was doing step work. The eighth step is making a list of people you have harmed and you become willing to make amends to them. The ninth step is to make direct amends to those you have harmed except when to do so would injure them or others. It became quickly obvious that the person’s goal was to seek forgiveness even though in that case it would cause pain to the person wounded and to others. There was no talk about making amends. One universal principle throughout cultures and spiritual traditions (including secular ones) is to give without thought of return. When the Bodhidharma met with the Emperor Wu, one of the questions Wu asked was how much merit he had earned for all the monasteries he had built and all the other good deeds he had done in the name of the Buddha. “None,” said Bodhidharma. According to the story, the conversation was a short one. There are times when asking forgiveness is a manipulative act. We are asking forgiveness of the one we have already harmed with the sole purpose of making ourselves feel better. What is the merit of that? None. You are just doing more harm.

This is a place where the steps give good guidance. Look into your heart. It may be better to seek how you can make amends to those you hurt rather than ask forgiveness. Forgiveness belongs to the one harmed, and it is for them and within them that forgiveness occurs. If you are going to ask anything, ask how you can make amends and even then, only ask when doing so causes no further harm. Making amends with no expectations (including the expectation of forgiveness) may be a better way and work better at allowing yourself forgiveness with time.

For further thoughts on working on reconciliation and the process of forgiveness I strongly recommend “Negotiating the Nonnegotiable: How to Resolve Your Most Emotionally Charged Conflicts,” by Daniel Shapiro. Shapiro is the founder and director of the Harvard International Negotiation Program. As a psychologist and negotiation specialist, he has worked with families as well as corporate and governmental groups including conflicting parties in the Middle East. He provides a very thoughtful and guided method for the process of forgiveness and reconciliation.

The American Medical Association voted not long ago to classify obesity as a disease.  The intentions were good, for obesity and the associated health problems, do need attention. There are problems with this, for example if one uses only body mass index to diagnose, then an individual with heavy musculature could conceivably be diagnosed as “obese” when clearly that is not the case. Some, such as National Review, write that this is another attempt to lessen personal responsibility and allow government to enter into our lives and our bodies.

Physicians’ attempts to change what were at one time called “conditions” or “failings” or other terms into “disease” is nothing new.   You can read an excellent summary on the evolution of the term “schizophrenia” in the November 2011 Schizophrenia Bulletin.  The article quotes Berrios, “… schizophrenia research can be described as a set of research programs running in parallel, each based on different concepts of disease, mental symptom, and human mind.” For an overall critique of schizophrenia as a disease, Models of Madness is a good start. Alcohol dependency has been defined as a disease for decades. Dr. Benjamin Rush, a founding father of the United States, is credited with declaring that alcoholism is a disease. The research of E. M. Jellinek aoubt 60 years ago is credited with giving this diagnosis credence. David J. Hanson, PhD, of SUNY-Potsdam, gives a thoughtful critique of the disease model at http://www2.potsdam.edu/hansondj/Controversies/Is-Alcoholism-a-Disease.html.

Mosher et al in Models of Madness review the relationship of causal beliefs to attitudes.  While at times part of the motivation to define something as a disease is to lessen the stigma, often the reverse happens.  John Read and Nick Haslam wrote the chapter, “Public Opinion.” They cite numerous studies that find that when something is defined as a biological illness, the stigmatization increases. “A belief in categories that are discrete, immutable, and invariably rooted in a biological abnormality reflect the medical model’s essentialist view of mental disorders as ‘natural kinds’. Viewing mental disorders in this essentialist fashion is associated with prejudice along multiple pathways.  Believing in immutability may promote pessimism and avoidance. Believing in discreteness promotes the view that sufferers are categorically different, rather than sharing in our common humanity. These essentialist beliefs form a toxic ensemble.” This unintended consequence should be no surprise. It is rather common among diseases for which there actually are lab tests to diagnosis. Several members of my family, including my father, had tuberculosis. People, including family members, shied away for fear of catching the disease. Virginia mandated testing and x-rays for immediate family members (despite negative tests) from my earliest memories until about college age.  Susan Sontag wrote about cancer in Illness as Metaphor, and how there was an exception in confidentiality laws at the time for one disease due to stigma, and that was cancer. She later wrote about AIDS as well. I once visited Kalaupapa, which was a leper colony on Molokai. There were still people living there, now cured of Hansen’s disease. These folks also took you on the tour of the site. You got to hear stories about how people who were even suspected of having the illness were snatched off the street and taken here, banished from their lives, and isolated from friends, family, and home forever. Kalaupapa is a very moving place to visit. You can most likely think of other diseases with stigma, perhaps even some you fear. Based on our history as humans with a fear of disease, it is remarkable that anyone thought that defining a behavior, any behavior,  as a disease would make it less stigmatizing. In some ways, it is metaphorically throwing gasoline on a fire hoping this time a miracle will happen and the liquid will extinguish the blaze.

I think there are at least two issues at the foundation of this disease problem. And this excludes the political and economic and ego issues associated with the businesses of academia and treatment programs and medicine and pharmaceutical companies. That is a whole other thing. The first issue is thinking we know what a disease is, and that we all agree on what that means. But at the foundation of these troubles is deciding just what is a disease. That is how diagnoses got started – when we research and treat or even just talk about a condition, we need to know we are talking about the same thing. Let’s define it. Unfortunately in behavioral health, from the start egos and later egos and money were involved and muddied the good intentioned waters.  Berrios mentions the different concepts of disease above in the study of schizophrenia.  A quick web search gave me many definitions for disease, among them:

  • a disorder of structure or function in a human, animal, or plant, esp. one that produces specific signs or symptoms or that affects a specific location and is not simply a direct result of physical injury.
  • an impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically manifested by distinguishing signs and symptoms, and is a response to environmental factors (as malnutrition, industrial hazards, or climate), to specific infective agents (as worms, bacteria, or viruses), to inherent defects of the organism (as genetic anomalies), or to combinations of these factors
  •  A pathological condition of a part, organ, or system of an organism resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms.
  • A condition or tendency, as of society, regarded as abnormal and harmful.
  • Obsolete Lack of ease; trouble.

Pretty much anything out of the ordinary can be called a “disease.”  I remember folks going back 30 years who have justified the disease model in mental health and substance use by relying on the last – the obsolete – definition of dis-ease. These days, the term would be unease. So when people argue about what is a disease and whether something specific is a disease, they may be talking about very different concepts.

The second issue is, I think, with the problem of defining words and giving them great power. Steve deShazer was right, that words were originally magic.  But we use words to define words, and the definitions are circular. They have to be, and they are imperfect. The words defining an apple in the dictionary will never give you the experience of an apple.  Even experiencing one apple will not give you an idea of the taste and look and fragrance of all apples, or of the potential of apples or of the creation and life and death and return to the earth of an apple. Putting a label on an individual will not give you an experience of that individual. Being with that individual in one situation will not give you the experience of the whole ever changing person. Words have the power that we give them. We need to be careful.  I remember years ago in graduate school reading about a study in which individuals with no psychiatric problems gained admission to mental hospitals, and then just acted as themselves. Other patients caught on rather quickly that these folks were not mentally ill, but staff – not so much. The individuals took notes about their time in the hospitals, and nursing staff charted that they were exhibiting “writing behavior.”  David Rosenhan writes about the study here.

I will leave you with two quotes from Alan Watts, and also the remarkable story of Eleanor Longden in her own words.

“We seldom realize, for example, that our most private thoughts and emotions are not actually our own. For we think in terms of languages and images which we did not invent, but which were given to us by our society.”

“Trying to define yourself is like trying to bite your own teeth.”

Eleanor Longden: The voices in my head

Recently I spoke with a graduate student in counseling who needed to interview someone in the field for a paper he was writing for class. He told me he had called numerous therapists but was told that they were too busy to talk. I have gotten to talk to many students, both graduate and undergraduate, over the years and it has always been a very enjoyable experience. I encourage therapists to make time for students and to give back to them. Many have helped us along our path.

What follows is a result of several conversations with students looking for internships. It was originally published in the newsletter of the Virginia Counselors Association.

Even though it is spring, it is not too early to begin planning for a fall practicum or internship for your graduate program. Slots at agencies and programs can fill up early, especially with the number of graduate programs these days. You are not only competing for spaces with others in your program, but with students from programs at nearby schools, from online degree programs, and sometimes from students who may go to a school from a distance away but who live close by you and look for placements near home.

The first step is to check with your school for a list of agencies and programs with which the school already has a valid affiliation agreement. Affiliation agreements involve the school and the program exchanging agreements signed by the directors of both entities with each program having an original of the agreement. The agreement states the responsibilities of both parties and the liability insurance information. Students can get liability insurance for free with their ACA membership, or at a tremendous discount (approximately $35) with their membership in VCA. It is a good idea to have your own insurance even after you are licensed and working for an agency that has insurance that covers you. The insurance that the agency has looks out for you, but the primary responsibility is to the agency. If the agency can prove you failed to follow policies or procedures, you may be left on our own. Your own insurance’s responsibility is to advocate for you. If you find a place that you would really like to intern and there is no agreement, most likely you will need to find a person at the agency who is willing to follow through on getting an agreement. This can take time, and if the process is not started early, it may not be done in time for the start of the placement, if it occurs at all.

Larger agencies and schools may use the same process for taking on an intern as they would for hiring a new employee (except without the pay). This includes going through an interview process, having references, providing a transcript, resume, and completing a job application. Make sure your references are easily reachable. I remember instances when a reference had a full voicemail box and did not respond to several messages left with the receptionist nor to multiple emails. I had to ask the student for an alternate reference. Also make sure that you provide documentation as requested. If a sealed transcript is required, providing a personal copy will not work. Your placement may be delayed or may not occur at all. If a job application is required in addition to a resume, repeatedly writing “see resume” for questions on the application may not be acceptable either. Sometimes bureaucracies put their needs over user friendliness to applicants.

Once you begin at the placement, you may go through an orientation in which you learn about the organization and its structure, policies and procedures. There may also be criminal background checks, DMV and social services checks, finger printing, and drug screens. And then there is training to be done. If you are at a facility that is licensed by the Dept of Behavioral Health, that will include things like CPR and First Aid (if you have these already and the certifications are valid through the time you will be at the agency, you may be able to present your card and not have to take the training again), behavior management, client rights, cultural competency, ethics, confidentiality and privacy of health records, developing treatment plans, health record documentation, and infection control among others. You would also have to learn the ins and outs of whatever health record system the agency uses and more and more that means an electronic health record. Being comfortable with computers has become a pretty essential part of the behavioral health workplace. You may also learn about whatever other forms the agency uses, such as incident report forms.

You will probably have an easier time finding a placement at larger agencies, or at least places that provide for fee services. Since you are not licensed yet, services that you provide cannot be billed to insurance companies. If you are at a stage where you could meet the Medicaid criteria for qualified mental health provider, the agency might be able to bill for services such as case management or intensive in-home services, but not for psychotherapy at the office, unless the client pays out of pocket. The for fee services would be things like services contracted by entities like courts, Community Corrections, probation and parole, Alcohol Safety Action Program, jail programs, or social services. This may involve intake evaluations, individual counseling, group counseling and psychoeducation. The focus may be mostly on groups. Groups can be for drunk driving offenders, possession of marijuana, underage possession of alcohol, family violence, and anger management. Groups may also be part of programs like intensive outpatient programs and partial hospital programs. You may also be asked to do breathalyzers and drug screens, including observing urine drug screens. You may also have to make reports to referring agencies like probation or social services.

You will also learn the ins and outs of the culture of the workplace. Some are very nurturing and mentor very well. At the other end are toxic places with lots of office politics rife with turf and ego wars. And many have a various mix of the two. Like most things, office cultures seem to follow a bell curve from very healthy to very unhealthy with most somewhere in between. You may run across hierarchies based on credentials and clashing philosophies. The practitioner as expert pathology-based medical model versus client centered strength-based recovery model are two examples of competing philosophies that cause friction in the workplace and a difference in ideas of how best to work with clients. How would you cope with that?

It is imperative that you research the places you are applying to as much as possible and make yourself a list of questions to ask when you talk to them. They are interviewing you to see if they want to work with you and for fit, but you are also interviewing them to see if it is a place you would want to be and if it would be a good fit for you. You may feel you need to positively impress them, but they also need to positively impress you for you to consider them. This research is crucial, particularly trying to talk to folks who work there to get an idea of what it is like. Management isn’t always straightforward on what the real conditions and expectations are like, so sometimes interviews have about as much predictive value as say an SAT or GRE for academic performance – none. Write out the questions you want to ask during the interview and take them with you so you are sure to remember them. It is useful, too, if you know someone who has gotten services at a place to talk with them and see how they were treated – more than one person if possible. Also people who make referrals to a place can be a help, though less so for various reasons. But I think those who get counseling from a place can give you a pretty good idea of the treatment philosophy of the program. Also talk to students and graduates who have been placed there before if you can. Find what kind of situations they were put in and what kind of guidance and mentoring they received or did not receive. Find out if there are individuals there who will advocate for you, and who can do so effectively. And always advocate for yourself, and that especially includes after you begin the placement. If things are not going well, do not wait to the end of the semester to bring up what has not been going well.

So if you are planning on starting a practicum or internship in the fall, the time to start working on it is now. You can find out more about the Virginia Counselors Association at http://www.vcacounselors.org/.

It seems to me like the distribution of most everything conforms to the standard bell curve to one degree or another. There may be a skewing to the right or the left, but there is a curve.  By nature we need stories to make sense of our lives, and we make sense according to how we are taught.  We put people and everything else into categories that make sense with how we want/choose to see the world. We don’t even realize that what we have is a construct culturally made up. We see it as just “what is.”

 The thing about bell curves, about “normal distributions” is that there are always outliers.  Take those behaviors we thing of as addictive for example.  Now anything that can act on the pleasure center of the brain and anything that can ease stress and tension can be “addictive.”  It becomes a behavior that we come to rely on to make us feel better.  People can be “addicted” to drugs, shopping, a person, work, the online world, sex, exercise, gambling – whatever relieves stress and works.  There may be consequences that aren’t pleasant, but that rush of adrenaline, dopamine, oxytocin – that instant vacation from what is ailing us and gives us a longed for feeling is difficult to let go.

 One of the Founding Fathers, Benjamin Rush, classed addiction to alcohol as a disease back in the 1700s as a way to ease the stigma.  But when addictive behaviors are called an illness and unusual behaviors are classed as mental illness, the danger is that the stigma actually increases.  They can’t help it, they have a disease, and as often happens with physical illnesses, people ostracize them and fear them.  The fear them not because they are worried about contagiousness, but because “that person has no control over his behavior – you just can’t trust him.”

Think for a moment of “unusual” behaviors as outliers, and take alcohol as an example.  A small percentage of people on the right side of the curve drink more than the average daily consumption of the alcohol, and consume a lot of the alcohol drunk. The middle of the curve drinks but no individual drinks “more than their share.” At the left of the curve are outliers that drink nothing at all. There is no moral judgment in that curve, just differences in behavior mapped on a graph. There is also no notion of disease. People do what they do. Some of the outliers to the right that drink a lot get into trouble.  Some don’t. There are individual differences.  Just as there is no pure yin or yang, there is no pure 100 percentile person or 0 percentile person.  What is important is what tends to happen to you when drink (or do any of those behaviors). What is your relationship with the behavior? Is it overall healthy or unhealthy?  Is it overall positive or negative?  How would you like it to be?  Is it how you would like it to be and if not, what do you need to do about it.  How can you get there?  The thing about outliers is that they stand out, just because they are different.   A person may love computers or art and may spend a lot of time on programming or drawing.  A parent may be concerned that the kid is “addicted” to the behavior. Again, look at the effects.  The child may be passionate about the behavior and may struggle against the parent to follow that passion. Another thing about outliers, people often want to change them to be more like the middle of the distribution. Power struggles can be destructive or constructive. They can be destructive when each side has to win no matter what the cost and control is the goal.  They can possibly be constructive when the individual learns to get better at what the passion is. But again there is rarely a pure yin or yang and there is a cost either way.  It comes down to how you choose to see or live the story.

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