Passive vs. Aggressive Anger

Passive Anger vs. Aggressive Anger: Anger Management

Passive Anger and Aggressive Anger

What are Passive and Aggressive Anger?

Frequently, when we talk about anger, we’re really talking about the emotional experience of an anger phenomenon. But with that, there are also certain action tendencies and behaviors that go along with it. The most obvious, of course, are sorts of aggressive anger. And really aggression is the behavior that frequently accompanies anger. And it usually has an intention to harm another individual. So this could be very direct, in the form of physical assault, it could be in the form of property damage or something like that. There are also forms that are even more direct and might even be relational. Sometimes people talk about passive anger or passive aggression and things of that nature, where I might be spreading rumors about someone at work, or simply saying negative things about them behind their back. Again, I might expect that that’s going to eventually do them harm but it’s more passive or indirect and it’s not a specific physical threat.

anger management

Video to Control Anger with Deep Breathing

Anger Management – How to Control Anger with Deep Breathing

I am Dr. Ryan Fuller and I am going to talk to you a little bit about how to control anger with deep breathing. So anger is an emotion that has high levels of arousal associated with it. In fact, anger is one of two emotions that really go along with the fight or flight stress response. So in the case of a crisis or a danger, our sympathetic nervous system, that is part of our autonomic nervous system, goes into motion increasing respiration, increasing heart rate, driving up blood pressure, releasing glucose into the limbs so there is energy. All these things are really about speeding things up, so that the organism, or the human in this case, is prepared for fighting or fleeing. Now, with that said, when we’re really angry or when we’re aroused in those ways, one good way to modulate or change the anger experiences, is, in fact, to change the physiology. There are different ways to go about that, so in using relaxation techniques, one form is progressive muscle relaxation. And that doesn’t have to do with breathing techniques. But we’re going to talk today about breathing, as a form of relaxation, which makes sense in the case of anger management, because as I just said, anger has high levels of arousal in terms of physiological activation. And the research in anger management techniques has shown that relaxation skills alone are highly effective in helping people to manage their anger. So one of the skills that I like using with breathwork is very simple and easy to remember and there is scientific research to show that it really does a good job of helping to temp down the sympathetic nervous system activity. And so it’s really slowing respiration and it’s looking at a 4-7-8 ratio. What that means is we’re going to have clients inhale for 4 counts, hold for 7, and then exhale for a count of 8. Now, what’s important to know is 1, anytime you’re trying a technique like this, you do want to make sure you have spoken to your physician and to make sure there is no contraindications based on any health risk factors you have, or asthma, or heart condition. But typically, what I find is after my clients have spoken to the physician, most physicians are highly encouraging of this kind of relaxation activity. The other important thing to keep in mind is, it’s the ratio that matters the most. We don’t want people to think they have to count for 4 seconds, 7 seconds, and 8 seconds where they get a very long count and they end up passing out or straining themselves. You really want to just find the amount of time that works for you but to try to keep the ratio close to 4, 7, and 8. The main thing is that the exhale becomes much longer than the inhale. So, I will give a quick demonstration. It’s not perfectly necessary that you have to inhale through your nose and exhale through your mouth, but that’s generally the way I teach it. So the client is going to inhale to the count of about 4, hold for the count of about 7, and then exhale from the mouth to the count of about 8. So it looks like this, inhale, hold, and then exhale. And sometimes I have them exhale from a pursed lips. So even though it is a very simple, easy-to-use breathing exercise, if you do that a number of times, say you do 5-10 rounds, you’ll likely experience a relaxation response. And oftentimes, especially if I have clients who are somewhat skeptical, I’ll ask them to take their pulse beforehand especially if they are kind of worked up, to practice the response, and then take their pulse again. Again, you want to speak to your healthcare provider, your physician or otherwise, and you don’t want to do it if you are driving or something like that. But if you practice it first with a professional, and then on your own, it is something that might help you reduce intense physiological arousal, especially if it’s an anger response.

Robin Williams

Robin Williams’ Full Life

Robin Williams

I am not sure anyone would have predicted how many thoughts and feelings of so many people would be dedicated to the loss of Robin Williams. Personally, I found myself thinking about it during a morning jog, and the rest of that day. I wondered what clients of mine and everyone else would think about someone probably considered by most of us as incredibly successful, loved, rich, fortunate, and funny taking his own life. How would we make sense of it? Would there be judgment? Would people sympathize or empathize? Would people not at all be able to connect to someone seemingly having so much of what some of us long for and still suffering enough to choose to end his life? Or would this passing not have much of an impact?

It turns out my clients and, it seems Americans in general, have been spending considerable time reflecting on the passing. I was astounded how much his passing affected the national consciousness. I was also touched by the gentleness expressed in so many posts online about how his work had brought enjoyment and how much sympathy fans had for him and his family.

Initially as I ran that morning, I imagined writing about suicide and how difficult it is for many if us to truly imagine suffering so great we would do almost anything to make it stop. Hoping that with greater understanding more people could bring support to those in need and perhaps create policies and fund research to aid treatment efficacy. Originally I thought I would list some of the predictors of suicide, explain how the primary psychological mechanism was responsible, and discuss which treatments could be preventative, and how there are still people we can’t reach. I planned on explaining that many people who could be helped aren’t and there is still a group of people who receive treatment for which it isn’t effective and that these are the reasons we need more research and more open dialogues about this too common tragic end.

But as I listened to people talk about Robin Williams and as I read about him, about all of the other days of his life- not his last one, about all of his other behaviors; all of his other choices seemed so incredibly important.

While I can never know what his experiences were, it seems likely from much of what he shared publicly, even mentioning details in his stand-up acts, that he battled addiction. I don’t claim to know what or even if he had other diagnoses, but I imagine that there was considerable emotional and psychological pain that often accompany addiction issues.

But with that internal pain, there were still so many days, performances, and interactions. What became clear as I remembered movies of his I had seen, and discovered as I talked to people, was that in part so many people were so moved by someone they didn’t know because of the sheer magnitude of his contribution to our memories- he was prolific. His performances were not only Oscar worthy- but they were frequent – he gave tons of performances for children, adults- for everyone. There is no doubt there had to be many days he didn’t feel like it. Yet he gave.

I have found myself many times quoting his Scottish golf bit from one of his performances. In fact, in between finishing that last sentence and this one, I went and watched it again- his performances are that enjoyable. And who won’t laugh while watching Mrs. Doubtfire or laugh and fight back tears watching Good Morning Vietnam? So many days he gave performances- and probably carried emotional pain and psychological conflict with him, even on some of those days. We all benefitted from those choices, our lives have been richer because of those choices- hopefully his life was richer from choosing to work and persist too.

Psychological Pain and Values

Maybe his suffering was far greater than many of ours- we can never know. What I do believe is that as humans, we all carry the capacity to suffer intense psychological pain, and if you can’t imagine that, please consider yourself fortunate. I also believe his great body of work is a testament to what one can do, acting even while carrying pain, instead of waiting for all pain to cease- valuing what is most important, persisting, and persevering. He gave performances that moved us, entertained us, and will continue to do so for generations to come.

His wife, Susan Schneider, said “As he is remembered, it is our hope the focus will not be on Robin’s death, but on the countless moments of joy and laughter he gave to millions.” While it may seem impossible not to think of his death, if anyone can make us forget about pain and loss, Robin Williams may be the guy. I’ve said many times that I believe humor to be a potent therapeutic tool. In fact, it seems laughter in therapy sessions is typically a very good prognostic indicator from my standpoint. He gave us laughter and joy- what gifts. Those gifts could be enough to make us appreciate him- but as I read there was more. Outside of professional life, and apparently many times outside of the public eye, he gave in other ways.

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I heard an amazing anecdote that may give those of us who didn’t know him an idea of what he found important. Jessica Cole, a young girl, diagnosed with brain cancer, had been granted her dying wish, to meet her hero, Robin Williams. Unfortunately, she became too weak and was not going to be able handle the long flight. After hearing that, Robin Williams paid for his own chartered flight to go to her. Other stories have surfaced as well- all indicating other ways he connected to people outside of acting and stand up comedy.

He will surely be missed by his family and friends. He will also be missed by the rest of us whose lives were enriched by his work- choosing on so many days to give his best. Perhaps we can also benefit by recognizing and emulating the behaviors in his life that were dedicated to values like compassion, connection, and generosity.

At times we may hope with the next achievement or insight we will discover the life without the dark shadow, the sky without storm clouds, the emotional life free of bad feelings- but are any of us ever free of that? Perhaps that too is why this particular loss, the death of a man that brought us such joy and laughter doesn’t make sense to us. How could he have elicited so much joy and appeared so energetic and ebullient- while at times suffering underneath to such an extent? I hope we can all open up to the possibility that meaningful work and satisfying lives may not be free from emotional pain. Robin Williams most certainly had emotional pain in his life and struggled, and for so many years continued to work, connecting us to him, and to each other. We can all learn from choices like that.

As always Kahlil Gibran gives a perspective that may elucidate some of these issues.

On Joy and Sorrow

By Kahlil Gibran

Your joy is your sorrow unmasked.
And the selfsame well from which your laughter rises was oftentimes filled with your tears.
And how else can it be?
The deeper that sorrow carves into your being, the more joy you can contain.
Is not the cup that holds your wine the very cup that was burned in the potter’s oven?
And is not the lute that soothes your spirit, the very wood that was hollowed with knives?
When you are joyous, look deep into your heart and you shall find it is only that which has given you sorrow that is giving you joy.
When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight.

Some of you say, “Joy is greater than sorrow,” and others say, “Nay, sorrow is the greater.”
But I say unto you, they are inseparable.
Together they come, and when one sits, alone with you at your board, remember that the other is asleep upon your bed.

Verily you are suspended like scales between your sorrow and your joy.
Only when you are empty are you at standstill and balanced.
When the treasure-keeper lifts you to weigh his gold and his silver, needs must your joy or your sorrow rise or fall.

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Dialectical Behavior Therapy – DBT

What is Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) is an integration of Cognitive Behavior Therapy (CBT), a Western science based psychotherapy, and a Zen Buddhist approach to mindfulness, an Eastern philosophical and mediation practice.  Together these approaches help DBT clients achieve their behavioral goals by learning how to accept and change both feelings and thoughts, and by learning how to control their attention to these internal experiences.

DBT Development

Dialectical Behavior Therapy (DBT) was developed by Dr. Marsha Linehan. She had been using traditional Cognitive Behavior Therapy (CBT) and Behavior Therapy (BT) with chronically depressed women with high levels of suicidal ideation, suicide attempts, and self-injurious behaviors, e.g., cutting.  Unfortunately, while these psychological treatments had been shown to be very effective for many depressed patients, these women were not responsive, and some in fact, became worse during the CBT treatment.

In an attempt to understand how CBT therapy was making these clients worse, she and her colleagues began conducting behavioral analyses of the sessions.  What they discovered was that these patients and therapists were reinforcing and punishing behaviors in the exact opposite direction of the therapeutic goals.  When these patients directed high levels of anger toward the therapist in response to an intervention, the therapists would frequently avoid that intervention and shift to something else.  Rather than helping the client learn to tolerate, understand, assertively communicate, or decrease her anger response, she learned that expressing anger aggressively would allow her to escape from an uncomfortable exchange with the therapist.  Likewise the therapist learned to avoid that topic.  Of course neither may have been aware in session of what was being reinforced, but nonetheless the pattern was being strengthened, leading to more anger and avoidance, and less growth.

Cognitive Behavior Therapy (CBT)

Cognitive Behavior Therapy (CBT) at the time was also ill suited for this population for a few other reasons.  Most CBT therapies, e.g., Cognitive Therapy of Aaron Beck, Rational Emotive Behavior Therapy (REBT) of Albert Ellis, posit that one of the most significant causes of our emotions is our beliefs or interpretations about a situation, ourselves, other people, or the world.  For example, it is not only that someone stepped on my foot as I waited in line at the DMV that leads to my anger, but also that I thought to myself and believed strongly that, “He must be a selfish guy to not look where he is going and should know better given that he is an adult.”   Together the trigger (having my foot stepped on) and my belief about the action and the guy who did it lead to my incredibly strong feeling of anger.  Standard Cognitive Behavior Therapy (CBT) suggests the best way to change that anger is to take responsibility for identifying one’s beliefs and then challenging the accuracy and logic of those interpretations and rehearsing something more rational.  While this technique had been shown to work for many depressed and anxious patients previously, these chronically depressed, suicidal, self-injuring women often experienced this as invalidation.  In fact, challenging their beliefs, may have made them “feel” as though their feelings about the situation were being challenged and therefore that the CBT Therapist didn’t believe the patients’ anger experience was valid.  This often led to an increase in anger or other negative emotions, like shame or guilt for feeling angry, when they shouldn’t have because it wasn’t a valid emotional response.  While the CBT Therapist was attempting to decrease the negative emotional experience, instead through invalidation the CBT technique of disputation of irrational beliefs were making these patients symptoms worse.

Standard CBT sessions are typically held once per week for approximately 45 minutes, and include setting an agenda at the beginning of the session.  Dr. Linehan, and others who have since treated patients like this, discovered that both the high number of crises presented in session and the intensity with which they were often present make it anywhere from challenging to impossible to follow and complete the therapy agenda.  These patients simply appear to present in ways and to be experiencing crises in a way that make one individual 45 minute session suboptimal as an effective treatment.

Borderline Personality Disorder (BPD)

Although Dr. Linehan was unaware at the time, the symptoms presented by these women seem to fit quite well under the diagnosis of Borderline Personality Disorder (BPD).  BPD involves at least five of nine possible symptoms.  This, of course, means that many different presentations are possible as some clients will present with very different symptoms.

BPD Symptoms include:

  • extreme fears and other feelings about abandonment
  • intense and often volatile interpersonal relationships with lovers, parents, siblings, friends, and co-workers
  • unstable and poor self-concept, impulsive and risky behaviors that could include unsafe sex, overspending, overeating
  • frequent suicidal ideation and/or urges to self-injure
  • intense and often rapidly shifting emotional states
  • chronic feelings of emptiness
  • anger management problems, often involving intense emotional experiences and self-defeating ways of expressing the anger
  • dissociative symptoms

When she began this work, no effective treatment for Borderline Personality Disorder (BPD) existed.  Therefore, her work to first conduct a thorough assessment of why standard Cognitive Behavior Therapy (CBT) was making these women suffering from BPD worse, was the beginning of the development of Dialectical Behavior Therapy (DBT).

Dialectical Behavior Therapy (DBT)

Dr. Linehan had some experience with Christian contemplative prayer and also Zen Buddhism.  And she had already been well trained as a behaviorist, i.e., the scientific and clinical approach to psychotherapy based on learning principles such as classical and operant conditioning.  The challenges to treating women with BPD were numerous and complex.  They were experiencing high levels of emotional suffering, had few healthy and stable interpersonal relationships, had difficulty inhibiting impulsive urges that were self-defeating, and were not benefitting from standard CBT Therapy.

Therefore Linehan’s new approach had to provide tools for CBT Therapists that did not invalidate the emotional suffering of clients, provided enough time and a format that could facilitate addressing a multitude of crises, provide BPD patients with tools to better communicate in interpersonal conflicts and to initiate, nurture, and maintain relationships.  And that was just for the BPD patients.  What she and her colleagues also learned during this time is that the CBT Therapists who were treating this group were also experiencing high levels of stress.  Therapy sessions with BPD patients are incredibly intense, often involve high levels of anger, high potential for suicide, and so many presenting problems- there is never a sense of completion.  These therapists were at risk for burnout.

A new CBT Therapy for BPD would need to include high levels of validation to BPD patients, a way to provide patients with a lot of tools while not triggering emotional upset, and more support for both BPD patients and the CBT Therapists providing treatment.  Dialectical Behavior Therapy (DBT) has developed to address these issues.

Dialectical Behavior Therapy (DBT) Comprehensive Program

Dialectical Behavior Therapy as a comprehensive treatment involves four components.  There is weekly individual therapy, weekly DBT Skills Group, coaching calls between the BPD client and individual CBT Therapist, and weekly Consultation Group for DBT Therapists.  Together these components allow greater support for everyone involved in the therapeutic process and a number of scientific studies have demonstrated that comprehensive DBT results in fewer days of hospitalization, self-injuries, and suicides.  It also requires a 12-month commitment from the BPD patient.  Shorter treatment is believed to be less effective.

A DBT patient therefore would see her individual therapist to learn how to better handle the current problems in her life.  And also, once enough fluency with her new DBT Skills are present, more significant symptoms, like those of Post-traumatic Stress Disorder (PTSD) may be treated with exposure therapy in individual therapy sessions.  Problems that came up during the week are often understood by conducting a chain analysis, which is a DBT term for doing a behavioral analysis of the event. The DBT client with her therapist identifies all of the links in the chain of the episode from beginning to end.  This helps both of them understand what likely predicts future episodes and how to best intervene.  For example, after conducting a number of chain analyses on anger episodes with her co-workers, it may become clear that a common pattern is a link in the chain that involves going to bed late and not getting enough sleep.  Problem solving skills are then implemented to efficiently test new ways of handling the situation moving forward while practicing self-compassion.

DBT Skills Group are conducted weekly.  These are typically led by a therapist other than the individual DBT therapist.  While this is part of the comprehensive DBT program, it is largely seen as psychoeducational.  Four modules of skills are taught to clients in a warm, supportive, and efficient manner.  DBT Group Leaders provide structure so that the content can be discussed without unnecessarily triggering and emotionally dysregulating group members.  For instance, DBT Group members are prohibited from discussing self-injury in ways that would trigger another member.  The DBT Group is begun with a mindfulness exercise, which is one of the four content modules that is taught during the 12-month program.  Similarly to CBT individual therapy homework is checked at the beginning of sessions and assigned at the end of sessions.  The four modules that are taught during DBT Group are Core Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation.

DBT Coaching Calls are another component that typically sets it apart from other Cognitive Behavioral Therapies (CBT).  Many CBT Therapists are concerned that coaching calls between sessions can lead to dependency and prevent CBT clients from developing self-efficacy skills by practicing their newly developed skills in between sessions.  However DBT believes that properly conducted DBT Coaching Calls facilitate the generalization of skills learned in session into the real world for BPD patients who may otherwise fall back on older more reliable ways of managing interpersonal conflicts and emotional suffering, strategies like self-injury or substance use.
Targets for coaching calls can include:

  • Decreasing suicidal and self-injury behaviors
  • Increasing the generalization of DBT skills into the real world setting
  • Decreasing conflict or “feelings” of distance from the individual therapist

DBT Coaching Calls need to be conducted properly though, or like standard CBT Therapy they can in fact exacerbate the symptoms of a BPD client and lead to burnout for the individual therapist.

DBT Consultation Teams meet weekly as well.  During these meetings DBT Therapists who provide both individual DBT Therapy sessions and DBT Skills Group meet to improve their own DBT Skills as therapists and group leaders. DBT Team Members share information about DBT patients and do so in a non-judgmental manner.  They work to utilize dialectical philosophy, e.g., acknowledging that there is no absolute truth.  And as such, accepting that and moving forward through synthesis can best support all of the members of the team.  This support allows the DBT Therapists to prevent themselves from burnout, hone their skills, receive technical guidance from other team members who may have a different perspective on a problem that has yet to be successfully addressed by a particular DBT Therapist.

BPD clients clearly face very serious challenges given the number of ways they suffer.  It is also clear though that comprehensive DBT, is just that comprehensive.  It provides very specific content, format, and clear parameters for how each is to be conducted.  It also provides DBT Therapists with the training and support necessary to effectively treat these courageous people diagnosed with BPD who through this process can dramatically reduce their suffering and create lives worth living.

Ben-Porath, D.D., Koons, C.R. Telephone coaching in dialectical behavior therapy: A decision-tree model for managing inter-session contact with clients. Cognitive and Behavioral Practice, Volume 12, Issue 4, Autumn 2005, Pages 448–460.

Sleep and Health

Sleep patterns matter- don’t they?  Early to bed, early to rise, makes a man (or woman) healthy, wealthy, and wise. Health, financial security, and wisdom are probably pretty valuable for most of us. There may even be scientific evidence that sleep can help in the pursuit of these values. But the recipe of going to bed early and waking up early could be a recipe for disaster for those who are just naturally late risers- and there may not be a need.

Unless we are college students studying or partying excessively, most of us sleep daily. Sleep is as common as a behavior gets for humans. We all do it frequently and we spend lots of time doing it relative to other behaviors. Can you think of another single behavior you spend more time doing? Despite all of our experience with it, many of us may not be good at it and may have many questions about it.

Questions about Sleep

Is it better for me to wake up early and go to bed early?

Is sleep the best way to relax?

Is reading a good way to cure insomnia?

Is it better to sleep a lot?

Sleep Patterns

We are going to look at the answer to this first question, “Does the early bird really get the worm, leaving the night owl to starve?” Early birds and night owls refer to two different extreme sleep patterns- those who prefer to wake up early and those who like to sleep in, these extreme patterns are called chronotypes. Most of the colloquial sayings indicate that a chronotype of sleeping late probably leads to poor outcomes across the board. But research on chronotypes demonstrates something quite different.

Productivity and Sleep

Research indicates that when early birds and night owls are directed to follow their own natural cycles, night owls may outperform early birds on tasks after a significant amount of time has passed from their wake time. For example, a night owl who wakes at 12:00 pm may perform better on tasks requiring sustained attention at 11:00 pm than an early bird who woke at 6:00 am trying to complete the same task at 5:00 pm. Even though they have both been awake for 11 hours, it seems early birds have a tougher time as the hours pass. Of course early risers likely can get a lot of worms before the night owl even wakes up- so technically the early bird does likely get the first worm. But for those of us who are early risers we may want to take heed and plan accordingly- scheduling tasks that require sustained attention earlier and recognizing efficiency and attention may decrease in late evening. Other research has indicated that rotating shifts, which is often the most challenging shift and has the poorest health outcomes seems to be better tolerated by early birds or those said to have “morningness”, i.e., those who are more alert early, compared to the other extreme of eveningness. Research indicates that sleep quality was much worse for those with eveningness (the night owls) than the early birds.
Scheduling shifts or personal schedules according to our chronotype could really improve our output and increase our accuracy, avoiding errors due to decreases in sustained attention, and ensuring that the quality of our sleep is protected.

So it may be a good idea to know if you are naturally an early bird or night owl, not forced into that schedule by work demands. And if you are one of the two, you should schedule your tasks accordingly, and perhaps even change jobs or advocate with your employer for the shifts best suited for your biological clock.

Sleep References

Chung, M.H.; Chang, F.M.; Yang, C.C.; Kuo, T.B., Hsu, N. (January 2009). Sleep quality and morningness-eveningness of shift nurses. Journal of Clinical Nursing, 18 (2): 279–284.

Gibertini, M., Graham, C., Cook, M.R. (1999). Self-report of circadian type reflects the phase of the melatonin rhythm. Biological Psychology, 50 (1): 19–33.

Schmidt C, Collette F, Leclercq Y, Sterpenich V, Vandewalle G, Berthomier P, Berthomier C, Philipps C, Tinguely G, Darsaud A, Gais S, Schabus M, Desseilles M, Dang-Vu T, Salmon E, Balteau E, Degueldre C, Luxen A, Maquet P, Cajochen C, Peigneux P. (2009).  Homeostatic sleep pressure and responses to sustained attention in the suprachiasmatic area. Science, 324 (5926):516-9.
Sleep Chronotype Additional Reading
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Couples Therapy – How can you tell if you need couples therapy?

Healthy Relationships and Couples Therapy

The previous blog on couples therapy reviewed the efficacy rates of couples therapy. It is clear that some therapies have the potential to help the majority of couples improve. This is good news, but there may be even more pressing questions for a husbands, wives, boyfriends, and girlfriends, i.e., is what I’m experiencing in my relationship normal? Is how I’m being treated typical? Do I deserve more, do healthier relationships really exist, or do they all descend into what I’m experiencing? Maybe this is as good as it gets. When is the time for change (either improving this relationship by each partner learning new behaviors or improving life by leaving the partner) and when is the time for acceptance?

Regardless of your creed, hopefully the serenity prayer’s request to know the difference between the things we can change and those that require acceptance is wisdom we would all like to acquire. Both change and acceptance can be difficult and applying them to the wrong things is certainly a waste of resources. So how do we know if the relationship could use some work in terms of change or acceptance? First let’s touch on a few things that a healthy relationship may possess and then we can look at a few questions in different areas that are similar to what you might hear from a couples therapist if you begin marital counseling or couples therapy.

Here are some of the hallmarks of a healthy relationship according to some couples theorists (Jourard & Landsman, 1980):

1. Good communication
2. Realistic expectations in the relationship and reasonable demands on your partner
3. Genuine concern for the well being of your partner
4. Freedom to be oneself

While some of us may take these four components to be common assumptions, others may struggle with a few of them. At a minimum, even with both partners endorsing the component, partners may disagree about the meaning, or have difficulty successfully executing.

Good Communication

Few clients I have seen in couples therapy have ever said they believe good communication is a bad idea. But the vast majority of couples have at least one partner who believes their partner does not communicate enough, communicates too much, or communicates incorrectly, and often both partners take one of these views. The stereotype that men do not communicate as much about their feelings is something supported in the research, and is something I have seen men in heterosexual and homosexual relationships. With that said, I prefer not to operate with that assumption, as I have seen enough exceptions in couples therapy, in terms of women who do not share and express certain if not all emotions, and some men who are very emotionally expressive. It becomes very obvious in early sessions how comfortable and how able each individual is at identifying their emotions, wishes, desires, frustrations, etc. and how willing and able he/she is to express them to the partner.

One fundamental skill that can be taught as a communication skill in couples therapy is assertiveness training. Simply put, assertiveness is comprised of both communicating feelings, thoughts, wishes, wants, desires, and requests in an effective way and accepting the response or lack of response from one’s partner. The second part is often something that is not emphasized enough. But it is critical that each of us learn to accept (that does not mean agree or endorse), i.e., acknowledge and effectively take appropriate actions. Specific statements can be learned and certain provocative aspects are to be avoided when assertively communicating. But even once these skills are learned, it takes lots of practice to reliably execute them. For most of us making requests of others or making ourselves vulnerable by sharing our intimate wishes is an extremely charged experience, and so it takes doing it again and again, even while having emotions to make it a dominant way of communicating.

Expectations and Demands

These are components of a relationship that are highly variable both in partners in a particular couple and between couples. While each partner doesn’t have to share the same expectations and demands for the other, agreement is necessary to make the partnership satisfactory.

Fairness is a theme that comes up a lot in couples therapy, and it often elicits feelings of anger, resentment, and at times guilt. It is rare that two people will have the same strengths, weaknesses, or tendencies. So the division of labor may differ, their capacity to be emotionally intelligent may vary, and one may be more equipped to financially support them both. Fairness then is unlikely to mean each does the same thing for each other, but rather that it is clear and acceptable what each expects and demands from him or herself and the partner.

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I have seen many couples where deep resentment exists as a result of an admittedly slight difference in the workload between them. Likewise I have seen perfect harmony achieved when one partner is clearly burdened with the majority of responsibilities in the relationship. What is critical is that each is transparent about what is expected and required and that there is open communication about this, which can include appreciation.

Welfare of others

In couples therapy work, you do find times when the resentment has been growing for so long or a recent transgression has elicited so much anger that concern may not be something that is readily exhibited. But even in the latter case, when a sincere conversation explores the topic, there is often concern for the general well being of the other (although not always). What I see more often in couples therapy, is a partner who “He clearly isn’t concerned about my feelings or well being, or he wouldn’t treat me like this.” This requires both individuals to do some work. And this is not always easy to hear, especially for the person who believes he/she isn’t being cared for. Without question the couples therapy has to address the behavior that is or isn’t occurring that leads one partner to believe the other doesn’t care. The other piece though, may include both partners as they uncover what attributions are being made about that behavior. For example, one partner may state, “He doesn’t care about me because I tell him how stressed I am about making my work deadlines in order to get my next promotion, yet he is constantly guilt tripping me to leave the office. If he cared about me, he would support me right now, instead he says the very things he knows hurt me.” In a case like this, uncovering what each believes the other’s reasons are for the behavior, i.e., calling her to come home and staying late away from home to complete work, is going to be critical for them to achieve understanding and change the emotional and behavioral pattern in which they have become stuck.

Free to be me

Some of us may find this component to be one that shouldn’t be included in what makes a couple healthy. Isn’t being in a relationship about merging? Shedding our individuality in search of a more meaningful union? In fact, I have treated many couples where one complains that the partner’s very desire to “be him/herself,” is the problem. There is a fine line to walk when it comes to understanding what this freedom constitutes. No matter how open a couple is, clearly some expectations of each partner change when couplehood is undertaken. But what that looks like varies greatly. Does that mean every guys’ night is eclipsed by a date night, or girls’ weekends can never happen because weekends are family time? Those are questions very much in need of discussion and often times, negotiation.

I have seen people in couples therapy where the presenting problem centers on this issue. One partner doesn’t believe the other has changed enough, or matured enough. “He will never grow up and put away his toys, it is like nothing has changed- there is no growth.” Meanwhile some partners give up activities or relationships that are central to who s/he believes s/he is. This can create resentment or depression- and some times both.

Healthy romantic relationships certainly take on an identity of their own, but it does appear to be critical for them to thrive that each partner also has an identify of his/her own and has time and aspects of his/her life that are his/her own. It is easy to see how frequently there is interplay among the four components of a healthy relationship. To balance this component there needs to be clear communication and negotiation as well as explicit expectations and an understanding of what it means for each partner to maintain certain aspects of his/her identity or to preserve certain activities or relationships. Depending on what the activities are or who the relationships are with, the decision to maintain these may be more or less acceptable to the partner. But before a lot of communication is required on this topic, self-inventories are a good idea. Each partner really needs to understand what these activities and relationships (e.g., time with friends, coworkers, family, etc.) mean to him or her and how dissatisfied s/he would be without or with less of each.

Once it is clear to each partner how much of a priority each of these are, communicating about what it means to the partner begins the dialogue. Again attributions are crucial to the negotiation process, as it is often what the partner believes it means that is more important than how many guys’ nights occur. Likewise, once it is clear why the freedom bothers the partner, there may be practical tradeoffs that can be made in order to satisfy both parties. Maybe two guys’ nights are acceptable, as long as that partner takes care of breakfast on the weekends.

Couples therapy is a process of identifying areas of dissatisfaction, understanding the function of each problematic behavior, and recognizing what strengths can be built upon, and what behaviors may be missing that can be added. With those targets in mind, it can be an exciting process. Of course, there are many apparent barriers that present themselves- but with careful self-inventories, an understanding of the meanings that are being made, and communication and negotiation many of these can be overcome, and some of those that can’t be, can be accepted, leading to greater personal and relationship satisfaction. If your relationship could benefit from couples counseling, you can contact a couples therapist at at New York Behavioral Health.

fasting

Intermittent Fasting – Lose Weight and Cheat Death?

Intermittent Fasting

Weight loss may be the reason you are reading this, but intermittent fasting advocates believe IF can offer health benefits beyond ripped abs.  Very low calorie diets (VLCs) have scientific support for extending life in animals and humans.  But have you ever seen the meals those folks eat?  Caloric restriction may the best way to live longer, but if you feel the way I do about food, you may not want to live longer if you have to eat like that.  You have probably heard people say, “You may not live longer, but it will sure feel like it.”  After all the quality of life needs to be considered in addition to quantity of years.

Intermittent fasting (IF) may be the answer.  There is evidence it has similar health benefits to caloric restriction, but still allows you to eat a lot some times, and many have an easier time adhering to this kind of diet.  Some biohackers do make it sound like a panacea.  If you have been in the blogosphere in the last few years, you have seen claims that intermittent fasting extends your life, prevents chronic disease, increases muscle mass, melts fat, improves concentration, and does your dishes (well it does decrease the number of dishes that you have to wash).  Let’s see how much that picture matches its current scientific status and what intermittent fasting protocols look like in practice. (Photo Credit © Pascu Gheorghe)

What is Intermittent fasting?

Intermittent fasting refers to a temporal pattern of eating and non-eating episodes.  Simply put, there are specific feeding windows, times during which you can eat, and fasting windows, times during which you do not eat- and yes, sleeping counts.  While some IF protocols specify how many calories you can have during a feeding window, most allow you to eat ad libitum, i.e., as much as you want during your feeding windows.  Yes, that is right, after fasting, you can eat as much as you want.  Many encourage you to eat high quality nutrient dense foods, but the amount is typically up to you.  Interestingly, and this surprised researchers, most people do not go crazy and make up for all of the calories they missed during the fast.  In addition in one study, it also appears that hunger levels decrease after two weeks and people get used to fasting, which makes compliance more likely.

If moving between fasting and feeding is what it is, what are the benefits?

What are the benefits of Intermittent Fasting?

If you are a rodent, this is definitely the way to go.  Similar to very low calorie diets, intermittent fasting extended the lives of some strains of mice, (effects varied by genetics and age at which IF was initiated).  Similarly, body weight significantly decreased as well, but the genetic strain of mouse and the age at which it received IF mattered for weight loss too- so not all mice lost weight and lived longer.  But IF has even more specific health benefits for mice than just weight loss and longer life expectancies.

Intermittent fasting appears to protect mice from developing certain cancers, e.g., lymphoma and liver cancer.  In one trial 33% of mice eating at regular times injected with a carcinogen developed cancer, while none of the mice on the intermittent fasting schedule developed cancer.  This is quite interesting, especially considering that the two groups ate roughly the same number of calories- just at different times.  So the timing was the critical component, not a reduction in calories.

Diabetes risk also appears to be diminished in animal studies and cardiovascular risk factors are reduced as well.  So if you want your hamster to live longer and look great, you know what to do.  But what about the rest of us?

Is Intermittent Fasting Healthy for Humans?

Intermittent fasting studies have been conducted in humans.  Both normal weight and obese populations have been studied, and studies have included men and women.  This is important because there have been some gender differences.  The majority of trials have lasted from two to 24 weeks and have involved a particular type of intermittent fasting called alternate day fasting (ADF).  ADF involves alternating a feed day with a day of fasting.  So basically you eat every other day.  That typically means there is a 36-hour fast.  On a feeding day (Monday) you may eat between 8:00 am and 8:00 pm, and then fast the entire next day (Tuesday) until 8:00 am two days later (Wednesday).  One study utilized an alternate day modified fasting (ADMF) protocol where the fast day allowed for one meal between the hours of 12 pm and 2 pm.  So the fasting window here would be shortened considerably.

Will Intermittent Fasting increase Life Expectancy?

In terms of living forever, we don’t have studies following subjects to the grave yet (for IF or extreme calorie restriction). But based on animal studies for calorie restriction, some advocates of the practice hope to live to be 120 years of age.  While some experts, believe 5% to be a more reasonable estimate of how much longer humans might live on caloric restriction.  ADF has shown to increase life expectancy in mice.  But I have not yet seen any computations extrapolating those findings to humans, but I am sure they are coming.  But there are plenty of findings for disease in humans.

Fasting is good for Heart Health

High-density Lipoproteins (HDL), the good cholesterol, was increased by intermittent fasting and triglycerides and Low-density lipoproteins (LDL) decreased in some studies.  Many physicians use these as predictors of cardiovascular disease.  So it appears that intermittent fasting may improve heart health.

Weight Loss from Intermittent Fasting

There is also evidence that overall fat oxidation is increased and the majority of people in studies lost significant weight in a short amount of time.  One study of normal weight men did not find weight loss, but the trial was only two weeks- and they were normal weight.  One trial of obese women that lasted 24 weeks had an overall weight loss of 7% of total body weight, a fat mass decrease of 13%, and a reduction of waist circumference of 6%.  Other studies had ranges of 4-9% weight loss from their initial weight.  Another important finding in one trial was that, unlike in caloric restriction (CR) diets where clients lose both fat and muscle, obese participants losing weight with intermittent fasting, lost fat while preserving muscle mass.  This may be one of the most important benefits of intermittent fasting and hopefully many other studies will replicate this finding in both obese and overweight populations.

Diabetes and Cancer Risk

Diabetes risk factors appear to significantly decrease for men, but it is less clear if there are benefits for women.  Some authors believe that conflicting studies don’t make it clear at this point, but longer trials will likely clarify what the effects might be- which will be positive if they are congruent with the animal studies.  While IF appears to protect mice from some forms of cancer, human studies have not yet been conducted.  Given that the majority of animal studies have found these effects, many scientists are hopeful that IF could be beneficial for humans regarding cancer, but further studies are certainly required to make those conclusions.

So, for humans – it does look like many people can expect intermittent fasting to result in weight loss (hopefully with preservation of muscle), reduced risks of heart disease, diabetes (if you are a male), and possible protection against carcinogens (the jury is still out, awaiting human trials).

Those are the benefits, what are the options?

As I mentioned earlier the majority of animal and human studies use the ADF version of intermittent fasting.  But, many health advocates recommend different IF protocols.  I will detail a few of the most popular.

IF Protocols

An infinite number of IF protocols could be implemented.  It is really as simple as picking specific feeding and fasting times.  What you think the optimal amount of time for a fast is balanced with the likelihood you can maintain that time should be what guides your plan selection.

Full Day Fast

Similar to the ADF protocol in the scientific studies, you have a full day of fasting, followed by a feeding day.  When there are only one or two fast days per week, this is often called Eat Stop Eat, a program promoted by Brad Pilon.  He does recommend eating normal amounts on the feeding days.

Alternate Day Fasting (ADF)

To recap, this is an entire day of eating as much as you want, followed by a day where you do not eat at all.  While ad libitum eating was allowed in the studies I cited, it is not typically recommended to overdo the amount or to eat unhealthy foods.  Instead listening to your hunger cues and eating healthy quality foods is your best bet.

Alternate day modified fasting (ADMF)

This is very similar to ADF, except you are allowed to eat one meal during the fast day.  The scientific trial that utilized this protocol specified the hours of 12 pm and 2 pm to be the feeding time.  It also specified the caloric amount of that meal to be 25% of baseline caloric needs, e.g., 500 calories.  The meals in that trial included an entrée, snack, and even a dessert, e.g., a cookie.

Intraday Fasting

This is a term I use to refer to protocols in which the fast and feeding windows occur on the same day.  In these protocols, the differences are simply how long each window is.  Some popular ones also recommend when to exercise, how much protein to consume, and whether you can have coffee, tea, creamers, butter, etc. during fasting windows.  I will list some of the most popular timings below.

Intraday Fasting-10

IF-10 refers to a 10-hour feeding window and a 14-hour fast.  This timing is promoted by Martin Berkhan in his Leangains program.  This ratio is what he recommends for women.

Intraday Fasting-8

IF-8 refers to an 8-hour feeding window and a 16-hour fast.  This timing is also promoted by Martin Berkhan in his Leangains program, but is recommended for men.

Intraday Fasting-4

IF-4 refers to a 4-hour feeding window and a 20-hour fast.  This timing is promoted in the Warrior Diet by Ori Hofmekler.

Those are the intermittent fasting protocols I have seen promoted the most in the blogosphere.  It is important to note that the scientific literature has not yet tested the majority of these.  ADF and ADMF have been evaluated the most.  There are countless anecdotes of those utilizing many IF protocols on the internet.  Many of those blogging about these report incredible weight loss stories with beneficial indicators in blood panels that result in physician’s amazement.  Based on the research findings, it seems very plausible that many of these reports are accurate.  While the mechanisms are still debatable (something I may tackle in a future blog) as to why or how intermittent fasting works, there are some pretty incredible findings in both animal and human studies in terms of health outcomes.  More studies need to be conducted.  And I would very much like to see not only a wider variety of human subjects used, but longer trials, and protocols other than ADF.

Thus far, I think the scientific findings are pretty remarkable and I am incredibly optimistic that future research may help determine precisely who can benefit from particular protocols the most.  But the research has demonstrated that IF can have significant impacts on various physiological indices without many side effects.  Not many medications have these kinds of effects without creating other health problems.

With that said, there are not many human trials yet, and they certainly have not tracked participants across years.  So it is unclear what the effects will be in the long-term.  My hope is that longer trials will result in an increase the intensity and number of health benefits.  But questions remain about potential adverse effects as well.  Some authors and professionals believe IF may be detrimental to women, diabetics, or those at risk for adrenal fatigue.  And I think given the lack of longer terms studies proceeding sensibly and cautiously makes sense.

I have educated a number of my patients about intermittent fasting.  I have always recommended that they speak to their physician before implementing any protocol.  I work to improve many lifestyle factors of my patients, but without question weight loss is a focus for many of my clients.  Intermittent fasting not my first tool when it comes to weight loss.  While IF may result in weight loss regardless of the types of food people eat, I make sure clients are making better food choices regarding macronutrients, micronutrients, and portions as well- and I typically emphasize food quality and quantity prior to IF protocols.  But, given the scientific support for weight loss and decreases in cardiovascular disease risk factors, I believe intermittent fasting is a promising strategy to consider as long as you are working closely with an informed medical professional that will closely monitor any potential adverse effects.

Overall it appears that for many people, IF could have enormous potential.  Fat loss, without losing muscle, reductions in heart disease risk, diabetes risk (at least for men), possibly protection against cancer and life extending benefits in animal studies, while being more palatable than caloric restriction make it an important strategy to consider.  It may not be right for everyone, but if more studies demonstrate it is safe in the long-term, I believe health care practitioners will be recommending it more frequently to help us lead long, lean lives.

Intermittent Fasting References

Freedland, S. J., Klink, J.C., Mavropoulos, J.C., Poulton, S.H., Demark-Wahnefried, W., Hursting, S.D., Cohen, P., Hwang, D., Johnson, T.L., & Freedland, S.J. Effect of intermittent fasting with or without caloric restriction on prostate cancer growth and survival in SCID mice. The Prostate, 1037-1043.
Howell, A. Effect Of Intermittent Versus Continuous Energy Restriction On Weight Loss And Breast Cancer Risk Biomarkers. Breast Cancer Research, P28.

DISCLAIMER

Information provided on this site is provided for the general public.  It is made available with the understanding that the author and publisher are not providing any medical, psychological, health, or other personal professional service.  Any information provided should not be considered complete and does not cover all diseases, disorders, syndromes, ailments, physical or mental conditions or their treatment.  This information should never be used in place of calling or visiting a medical health professional, mental health professional, or other appropriate competent health professional, who should be consulted prior to making any changes based on suggestions from this site or any inferences drawn from material presented on this site.  Any information about drugs that appears on this site is general in nature.  It does not include all possible uses, precautions, side effects, or interactions, nor is it intended as medical advice.  Anyone reading this information who is considering medication or drug changes should consult with his or her medical doctor.  J. Ryan Fuller, Ph.D. is a New York State licensed clinical psychologist.  He is not a medical doctor.  Anyone considering changes based on information provided on this site or inferred from that information should consult with his or her medical doctor.  The operator(s) of this site specifically disclaim all responsibility for any liability, loss or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the material on this site.
Coffee

Coffee’s Health Benefits

Coffee is Good for You

Whether America runs on Dunkin’ or Starbucks can be debated. But there is no question that many Americans start their day with coffee.  There are plenty of marketing campaigns aimed at getting us to consume the stuff – “The best part of waking up is Folger’s in your cup.”  Once again, the brand aside, for many it probably does feel like the best part of the morning because of all coffee contains.

We don’t yet understand the precise role of all of the ingredients in terms of health benefits.  What we do know is that coffee contains numerous substances and it has been associated with health benefits, e.g., reducing depression, prostate cancer, stroke, and Type 2 Diabetes.  What we don’t know for sure is exactly which of the substances are related to which benefits, and if any of the short-term changes like increases in blood pressure, insulin, and homocysteine are problematic.  But let’s look at a little of what we do know about coffee.  Just what is in that cup of Joe?

Caffeine

First, coffee contains caffeine which is a powerful psychoactive drug that helps many of us see coffee as the best part of waking up.  An average eight ounce cup contains around 100 mg of caffeine.  Caffeine can increase attention, wakefulness, and overall performance.  Of course if the levels become too high it can decrease performance, and cause or exacerbate all kinds of problems like anxiety, irritability, and insomnia.

Caffeine is a stimulant and coffee consumption is where the majority of Americans get their caffeine.  There are of course other beverages that contain caffeine like tea and the growing number of “energy drinks.”  The caffeine in coffee, like other stimulants, is likely the culprit for raising blood pressure soon after coffee consumption.  But, for regular coffee drinkers this effect likely diminishes.  And as we will see, coffee has been associated with benefits that reduce cardiovascular risk factors.  Even decaffeinated coffee has been found to improve some health outcomes, which indicates other substances in coffee may be of interest to healthy minded individuals.

Diterpines

Diterpines are typically known for their anti-inflammatory properties.  Normally I encourage my healthy patients to eat or do anything that reduces inflammation and regularly incorporate it into their lifestyle program (of course if there is a medical issue, I make sure they know to run it past the appropriate physician).  Coffee’s diterpines may present ambivalence for some medical professionals.  Cafestol and kahweol are two diterpines found in coffee.  These two may be responsible for findings that coffee can reduce problems with liver disease.  Paper filters (and there is some evidence mesh screens as well) remove the majority of these diterpines.  So the effect of cafestol and kahweol will be for unfiltered coffees.  If research on their impact on liver disease becomes more conclusive that could be a reason to drink more unfiltered coffee, especially if liver disease is something you may be at risk for developing.  But a study in the American Journal of Epidemiology indicates that unfiltered coffee increases LDL (low-density lipoproteins).  While there is debate about the count, size, or LDL at all as a predictor of heart disease, it is not settled science.  So if you are a coffee drinker and have concerns about liver disease and/or your LDL, having a conversation with your physician may be a logical step.  You may simply want to begin using or doing away with your paper filters which soak up most of the cafestol and kahweol depending on whether you are targeting liver disease or LDL.

Antioxidants

Coffee also contains an important antioxidant, chlorogenic acid.  Antioxidants stop the damaging effects of free radicals that put us at risk for certain cancers.  So in general antioxidants are good for increasing the quality and lengths of our lives.  But chlorogenic acid has also been associated with inhibiting glucose absorption and stabilizing insulin levels.  This antioxidant may be responsible, at least in part, for the dramatic findings that coffee may prevent Type 2 Diabetes.  Once again there may be a caveat.  It has also been associated with raising the levels of something correlated with heart disease, homocysteine.  But as we see later on, the effect may not have a significant impact.

Cup of Joe or No Joe?

Caffeine, diterpines, and chlorogenic acid have all been associated with some negative markers, e.g., increased blood pressure, homocysteine levels.  Given that, it certainly makes sense to speak to your physician about his or her take on the relative risks and benefits of coffee given your particular genetics (some of us metabolize coffee differently), risk-factors, and lifestyle.

With that said, what may be more critical for your physician and you to discuss than the associated markers, are findings from larger scale prospective disease studies.  While markers may be important- the reason we use them at all is in hopes of discovering how they are linked to endpoints like disease or quality of life.  Studies conducted in the U.S., Europe, and Japan have all indicated that coffee appears to reduce the risk of Type 2 diabetes- which is one of the fastest growing health problems facing Americans and people worldwide.  Diabetes also puts your heart health in jeopardy- so doing what we can to prevent it has to be a health priority. Heart disease is the number one killer of men and women.  These studies followed thousands of individuals over years and controlled for many confounding variables that earlier studies had not included, e.g., alcohol consumption, cigarette smoking, and a sedentary lifestyle.  The support for coffee’s role in Type 2 diabetes appears to be quite significant.

Preliminary evidence indicates that coffee may even help prevent the development of Alzheimer’s disease, depression, some breast cancers and prostate cancers, endometrial cancer, and Parkinson’s disease.  And even though certain markers commonly associated with cardiovascular risk-factors are increased by coffee (blood pressure and homocysteine) at least in the short-term, moderate coffee consumption is associated with decreased risks of heart attacks and stroke for those regularly consuming it (as a stimulant it for those infrequently drinking coffee it may increase stroke risk right after consumption).

While it would be easier to remove all scientific details and nuance from health recommendations, coffee doesn’t quite allow for that yet.  What I hope this brief overview does is provide a starting point for you to become an informed advocate about your health with your trusted physician and other health care providers.  There is a great deal of research studying coffee and the hundreds of substances it contains.  While it is not easy to parse out all of the findings, for those at risk for diabetes and heart disease having a candid conversation about all of your lifestyle habits, including coffee is an important step.  Overall behavioral health has to include an ongoing assessment of your nutrition- and for many of us, coffee is one of the more frequent items on our nutrition log.

DISCLAIMER

Information provided on this site is provided for the general public.  It is made available with the understanding that the author and publisher are not providing any medical, psychological, health, or other personal professional service.  Any information provided should not be considered complete and does not cover all diseases, disorders, syndromes, ailments, physical or mental conditions or their treatment.  This information should never be used in place of calling or visiting a medical health professional, mental health professional, or other appropriate competent health professional, who should be consulted prior to making any changes based on suggestions from this site or any inferences drawn from material presented on this site.  Any information about drugs that appears on this site is general in nature.  It does not include all possible uses, precautions, side effects, or interactions, nor is it intended as medical advice.  Anyone reading this information who is considering medication or drug changes should consult with his or her medical doctor.  J. Ryan Fuller, Ph.D. is a New York State licensed clinical psychologist.  He is not a medical doctor.  Anyone considering changes based on information provided on this site or inferred from that information should consult with his or her medical doctor.  The operator(s) of this site specifically disclaim all responsibility for any liability, loss or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the material on this site.
Philip Seymour Hoffman

No Hope for Drug Addiction in America

Tragic Death

Phillip Seymour Hoffman was in so many ways exceptional.

And, like the character he played in Death of a Salesman, Willie Lowman, he was a man struggling with his own personal demons that led him to a tragic end.  While it may give some of us a sense of safety to believe this is a problem for celebrities or those struggling in the projects- the data indicate that while it is a problem in Hollywood and the projects- it is also a problem in each of our neighborhoods.

And from my standpoint the tragic nature of Phillip Seymour Hoffman’s death doesn’t have to do with the many accolades he rightly deserved.  Rather it is tragic because he was one of us, and like all of us- trying his best, and at times failing.  It seems even more tragic to me, perhaps because tragedies like this seem so preventable, if only we could better understand and address addiction, if only we could agree on the goal and effectively use our resources efficiently in pursuit of the goal, instead of waste them in gridlock in service of politics.  And in Mr. Hoffman’s case, here was someone with resources, someone who had been on the wagon for decades, had courageously publicly acknowledged addiction, had been in drug treatment, and still met a tragic end.

Drug Statistics

Drug addiction is a common problem in the United States.  I have seen estimates that approximately 9% of Americans have a substance abuse problem.  Drug and alcohol abuse contribute to 100,000 American deaths each year.  The Robert Wood Johnson Foundation in 2001 identified drug abuse as our number one health problem.  While obesity and related diseases are certainly an incredible problem now, our drug issues haven’t improved much since 2001.  The economic costs are well over $400 billion each year.  While there are a staggering number of people using drugs, the vast majority never seek treatment.  Some estimates indicate that approximately 6% of alcoholics, 16% of drug users, and 22% of those abusing drugs and alcohol seek treatment- most never get professional drug treatment.  What are the reasons for such small numbers of those struggling with addiction to utilize services?  I am sure the answer lies both with the individual and with how services are provided.  Can any society be satisfied with utilization rates that low, when the problem is so costly in terms of lives and financial costs?  This is a serious and widespread problem in our country that is costing us talent, dollars, and loved ones.  Do we as Americans, who put people on the moon, really believe we can’t leverage the same ambition, passion, intellect, and national determination to improve our current system and the behaviors of our citizens?  Do our attitudes about personal and societal responsibility for drug abuse support our moral goals or create barriers to progress?

Philip Seymour Hoffman

I was somewhat surprised by the discourse in the media, even the main stream media regarding Mr. Hoffman- I probably shouldn’t have been.  I read and heard so many comments along the lines of,  “How could Philip Seymour Hoffman do this to his children and partner?”  I believe that question is a good one.   How we answer that question is crucial in developing a more effective response to our drug problem.  Yes, how could one unless there was a level of pain so loud it could drown out the rational, responsible voices.  Or, “He must have been a selfish sociopath, without feelings for his own children. “ Unfortunately, the intention with which I inferred that kind of question may have often times been asked, was more along the lines of other comments that said things like he was prioritizing recreation over responsibility.  It was not a question in need of an accurate answer based on evidence, e.g., “Did he typically display affection and careful attention to the needs of his children, or was he more likely aloof and cold in response to their needs?”  The conclusion was reached before the question was asked.  Or perhaps, fortunately for the person asking, he/she could not imagine a scenario by which a father could make those kinds of choices- and it was a sincere search for understanding of what to all of us seems a terrible decision and outcome that must have involved awful psychological pain.

Professionally and personally I have come across a few people where a particular choice to use may have been about recreation on a particular day or night over a specific responsibility.  But, in my experience, that is rarely the case of anyone who is really struggling with a heroin addiction.  Rather the person addicted, is significantly suffering physical, emotional, and psychological pain and chooses to use drugs to temporarily escape, only to face the same or worse conditions again.  They aren’t turning up the volume on a stereo to make the party more fun, even if it wakes up their young children.  Rather the most ingrained way they have to escape suffering in the moment (turning down the volume on the pain), also happens to put them and their loved ones at risk for greater suffering over the long run.  Certainly the better choice in the long-term is to endure the pain (hopefully with support and coping skills) and to refrain from using, but I do not envy their situation.

I believe each adult is responsible for his or her choices.  By that I mean, he/she will have to face the consequences that follow each choice and therefore he/she is the biggest stakeholder.  I also believe that physiological and environmental experiences and consequences influence our decisions.  Politely passing on a second helping of food is much more difficult if you are starving (physiology).  And yet, one might say, “No thank you,” if he/she expects to be beaten (environment) by a parent for rudely asking for more.   This is an extreme example, but so is heroin use.  Emotional pain and the physiological withdrawal symptoms can be excruciating and the potential consequences of use are incredibly hazardous.  As a society, we have choices to make about environmental consequences.  We must believe our current traditional justice system has an impact on people’s choice to use drugs, otherwise why have it?  Therefore it behooves us if we are spending money to support it, to consider if it is the most effective environment (consequence) for the financial cost.

As a scientist, specifically a behaviorist, providing a jail sentence or any harsh penalty following heroin use could be acceptable to me given my goal to prevent further use, if it is effective.  In fact, I may even consider something incredibly extreme, e.g., public canings, once all other non-corporal interventions were exhausted.  The acceptability of the consequence should largely be based on its effectiveness.  The effectiveness of a jail sentence, corporal punishment, mandatory drug treatment, or any other consequence is what matters most. The punishment should be determined by its effectiveness at reducing the behavior from occurring again.  I see the moral choice for our community as the selection of the consequence that is most successful at helping the individual from choosing what is in his/her long-term best interest the next time (and society’s).  Selecting an intense, severe, aversive punishment can make sense if it is the mildest effective consequence at our disposal.  This is where I believe science can help in the process of following our moral compass.

Public Policy: Morality versus Science

Our beliefs about choice, addiction, and our moral beliefs about drugs likely influence what we think public policy and the legal system should be in the case of drug use.  Is free will – completely free?  Does someone in the throes of addiction have the same kind of choice, or should that matter even be considered in terms of the legal consequences?

My heading Morality vs. Science is often the starting point for an unproductive discussion.  It also seems to be a common theme when it comes to drug policy in this country.  I believe whenever possible morality should be used to inform our thinking as we establish goals, and the scientific method should be used as a tool to determine the best processes to achieve those morally, value informed goals.  Our laws and their enforcement can flow directly from that process.  Polarized sound bites may be effective political rhetoric.  But they lead to an unwillingness to consider and test new possibilities in service of reaching the best possible outcome.  They breed contempt, indifference, and stagnant ineffective systems.

When it comes to drug use, it is unlikely there will be a convergence of everyone’s moral beliefs.  There are those who prioritize freedom for adults to have ultimate liberty regarding personal behaviors that do not directly affect others and believe the individual should face the consequences without governmental intervention, no matter how dire.  There are those who believe that each person has a moral obligation to treat his/her body as a sacred temple, and the rest of the community has an obligation to prevent an individual from doing anything harmful to him/herself.  Without question, drug use is a complex and charged issue.  Regardless of our philosophical viewpoints and the complexities of the issue, can we accept the status quo as a viable option?  Despite the distance between the opposing factions, don’t we have a moral obligation to be engaged- to discuss, open our minds and our hearts, negotiate, compromise, and continually test and evaluate the process and the outcomes?

There is research on our traditional system, Drug Courts, and other alternative systems, e.g., Portugal’s approach.  Sometimes I like to get a sense of my own values, morals, preferences, biases, and emotions on a topic before immersing myself in the data.  I believe that without some level of self-awareness, I may prematurely judge the information I am reviewing or even select or ignore materials based on those biases, unless I am fully aware of what I think and feel in advance.  Below are a few questions I have been asking myself- for a long time, but more frequently recently in response to the many news stories on Philip Seymour Hoffman.

If you are interested in getting a sense of what your attitudes about drug use and what possible changes to our system you may or may not consider- you could take a look at one or two of the questions below.  In order to gain insight about your answers, it may be valuable to ask yourself what values, assumptions, and inferences were important in your reasoning to respond to the question.

If you have any constructive responses or comments and are willing to share here or with your friends and family, I would be interested to see if we can have a more constructive and open dialogue on drug addiction for once. It may be unclear where we go from here, but simply accepting where we are seems unworkable, given what I know of most Americans’ values, goals, and beliefs. Let’s see if our morality and science can let us hope and experiment in order to improve our world.

  1. Should all victimless crimes be legalized, e.g., gambling, prostitution, illicit drug use?
  2. Should any current victimless behaviors such as consuming excessive calories, consuming high amounts of sugar if one is diabetic, smoking cigarettes, drinking alcohol, etc. be made illegal?
  3. If I believe any of these behaviors should be illegal, what criteria should be used to establish the appropriate consequences for a violation of the law?
  4. Are there any reasons a criminal penalty should be considered for a victimless crime?
  5. While keeping in mind the actions I believe should be illegal, the penalties for those acts, and the expected effectiveness of those penalties, what role should society have in treating or providing for someone who a) is engaging in those illegal acts, e.g., illicit drug use, overeating while it is negatively affecting his/her health, gambling, etc., and is asking for help or b) is in need of medical intervention to save his/her life when he/she does not have any resources to cover the costs?
  6. What are the pros/cons the Good Samaritan Laws?
  7. If jail sentences or corporal punishment were scientifically proven to be the most effective treatment for victimless crimes, would I support either?
  8. If decriminalizing victimless crimes, drug courts, simply providing treatment, or some other alternative to incarceration, were shown to be the most cost-effective approach, would I support any or all of them?

 

 

couples therapy

Couples Therapy Part 2

Is this the Best Relationship I can have?

The previous blog on couples therapy reviewed the efficacy rates of couples therapy. It is clear that some therapies have the potential to help the majority of couples improve. This is good news, but there may be even more pressing questions for husbands, wives, boyfriends, and girlfriends, i.e., is what I’m experiencing in my relationship normal? Is how I’m being treated typical? Do I deserve more, do healthier relationships really exist, or do they all descend into what I’m experiencing? Maybe this is as good as it gets. When is the time for change (either improving this relationship by each partner learning new behaviors or improving life by leaving the partner), and when is the time for accepting what I have?

Regardless of your creed, hopefully the serenity prayer’s request to know the difference between the things we can change and those that require acceptance is wisdom we would all like to acquire. Both change and acceptance can be difficult and applying them to the wrong things is certainly a waste of resources. So how do we know if the relationship could use some work in terms of change or acceptance? First let’s touch on a few things that a healthy relationship may possess and then we can look at a few questions in different areas that are similar to what you might hear from a couples therapist if you begin marital counseling or couples therapy.

Here are some of the hallmarks of a healthy relationship according to some couples theorists (Jourard & Landsman, 1980):

1. Good communication
2. Realistic expectations in the relationship and reasonable demands on your partner
3. Genuine concern for the well being of your partner
4. Freedom to be oneself

While some of us may take these four components to be common assumptions, others may struggle with a few of them. At a minimum, even with both partners endorsing the component, partners may disagree about the meaning, or have difficulty successfully executing.

Good Communication

Few clients I have seen in couples therapy have ever said they believe good communication is a bad idea. But the vast majority of couples have at least one partner who believes their partner does not communicate enough, communicates too much, or communicates incorrectly, and often both partners take one of these views. The stereotype that men do not communicate as much about their feelings is something supported by research, and is something I have seen from men in heterosexual and homosexual relationships. With that said, I prefer not to operate with that assumption, as I have seen enough exceptions in couples therapy, in terms of women who do not share and express certain if not all emotions, and some men who are very emotionally expressive. It becomes very obvious in early sessions how comfortable and how able each individual is at identifying their emotions, wishes, desires, frustrations, etc. and how willing and able he/she is to express them to the partner.

One fundamental skill that can be taught as a communication skill in couples therapy is assertiveness. Simply put, assertiveness is comprised of both communicating feelings, thoughts, wishes, wants, desires, and requests in an effective way and accepting the response or lack of response from one’s partner. The second part is often something that is not emphasized enough. But it is critical that each of us learn to accept (that does not mean agree or endorse), i.e., acknowledge whether our request was granted or not, and effectively respond. Specific statements can be learned and certain provocative styles are to be avoided when assertively communicating. But even once these skills are learned, it takes lots of practice to reliably use them. For most of us making requests of others or making ourselves vulnerable by sharing our intimate wishes is an extremely charged experience, and so it takes doing it again and again, even while having emotions to make it a dominant way of communicating.

Expectations and Demands

These are components of a relationship that are highly variable both in partners in a particular couple, and between couples. While each partner doesn’t have to share the same expectations and demands for the other, agreement about what each expects is necessary to make the partnership satisfactory.

Fairness is a theme that comes up a lot in couples therapy, and it often elicits feelings of anger, resentment, and at times guilt. It is rare that two people will have the same strengths, weaknesses, or tendencies. So the division of labor may differ, their capacity to be emotionally intelligent may vary, and one may be more equipped to financially support them both. Fairness then is unlikely to mean each does the same thing for each other, but rather that it is clear and acceptable what each expects and demands from him or herself and the partner.

I have seen many couples where deep resentment exists as a result of an admittedly slight difference in the workload between them. Likewise I have seen perfect harmony achieved when one partner is clearly burdened with the majority of responsibilities in the relationship. What is critical is that each is transparent about what is expected and required and that there is open communication about this, which can include appreciation.

Welfare of others

In couples therapy work, you do find times when the resentment has been growing for so long, or a recent transgression has elicited so much anger that concern may not be something that is readily exhibited. But even in the latter case, when a sincere conversation explores the topic, there is often concern for the general well being of the other (although not always). What I see more often in couples therapy, is a partner who says, “He clearly isn’t concerned about my feelings or well being, or he wouldn’t treat me like this.” This requires both individuals to do some work. And this is not always easy to hear, especially for the person who believes he/she isn’t being cared for. Without question, the couples therapy has to address the behavior that is or isn’t occurring that leads one partner to believe the other doesn’t care. The other piece though, may include both partners as they uncover what attributions are being made about that behavior. For example, one partner may state, “He doesn’t care about me because I tell him how stressed I am about making my work deadlines in order to get my next promotion, yet he is constantly guilt tripping me to leave the office. If he cared about me, he would support me right now, instead he says the very things he knows hurt me.” In a case like this, uncovering what each believes the other’s reasons are for the behavior, i.e., calling her to come home and staying late away from home to complete work, is going to be critical for them to achieve understanding and change the emotional and behavioral pattern in which they have become stuck.

Free to be me

Some of us may find this component to be one that shouldn’t be included in what makes a couple healthy. Isn’t being in a relationship about merging? Shedding our individuality in search of a more meaningful union? In fact, I have treated many couples where one complains that the partner’s very desire to “be him/herself,” is the problem. There is a fine line to walk when it comes to understanding what this freedom constitutes. No matter how open a couple is, clearly some expectations of each partner change when couplehood is undertaken. But what that looks like varies greatly. Does that mean every guys’ night is eclipsed by a date night, or girls’ weekends can never happen because weekends are for family time? Those are questions very much in need of discussion and often times, negotiation.

I have seen people in couples therapy where the presenting problem centers on this issue. One partner doesn’t believe the other has changed enough, or matured enough. “He will never grow up and put away his toys, it is like nothing has changed- there is no growth.” Meanwhile some partners give up activities or relationships that are central to who s/he believes s/he is. This can create resentment or depression- and some times both.

Healthy romantic relationships certainly take on an identity of their own, but it is critical for them to thrive that each partner also has an identify of his/her own, and has time and aspects of his/her life that are his/her own. It is easy to see how frequently there is interplay among the four components of a healthy relationship. To balance this component there needs to be clear communication and negotiation as well as explicit expectations, and an understanding of what it means for each partner to maintain certain aspects of his/her identity or to preserve certain activities or relationships. Depending on what the activities are or who the relationships are with, the decision to maintain these may be more or less acceptable to the partner. But before a lot of communication is required on this topic, self-inventories are a good idea. Each partner really needs to understand what these activities and relationships (e.g., time with friends, coworkers, family, etc.) mean to him or her and how dissatisfied s/he would be without or with less of each.

Once it is clear to each partner how much of a priority each of these are, communicating about what it means to the partner begins the dialogue. Again attributions are crucial to the negotiation process, as it is often what the partner believes it means that is more important than how many guys’ nights occur. Likewise, once it is clear why the freedom bothers the partner, there may be practical tradeoffs that can be made in order to satisfy both parties. Maybe two guys’ nights are acceptable, as long as that partner takes care of breakfast on the weekends.

Couples therapy is a process of identifying areas of dissatisfaction, understanding the function of each problematic behavior, and recognizing what strengths can be built upon, and what behaviors may be missing that can be added. With those targets in mind, it can be an exciting process. Of course, there are many apparent barriers that present themselves- but with careful self-inventories, an understanding of the meanings that are being made, and communication and negotiation many of these can be overcome, and some of those that can’t be, can be accepted, leading to greater personal and relationship satisfaction.

couples therapy

Couples Therapy – Relationships helped by Science

Couples Therapy isn’t for the faint of heart

People resist couples therapy for many reasons. The very nature of a romantic relationship conjures images and ideals that are in stark contrast to a those commonly associated with the scientifically trained clinician.  You may ask yourself, “How can these practical, even mechanically sounding tools and techniques  improve my capacity for love?  And I’m supposed to share intimate details of my relationship with this clinically-minded stranger?”  Some of our earliest memories of romantic relationships likely reflect those all too ideal versions only found in Disney movies or television series with a target audience consisting mainly of young teens.  The plots found in these productions did not tend to feature characters faced with financial stressors, nighttime feedings, or waning sexual desire; these modern realities may be demanding something we weren’t expecting.

Couples Therapy on Television

Many contemporary television shows have begun to pull back the curtain on substantive relationship issues, but they are most often infused with profuse humor, in order to satisfy and not spoil the viewer’s palate.  Who among us wants to embrace the reality that even the most well intentioned loving mature adults may not be well equipped to protect or maintain this fundamental relationship rooted in love? And even if we accept that we need help, who or what does help look like? Media’s representations of therapy and even couples therapy often involve non-directive therapists who respond to pleas for help and understanding by dodging the question, via redirection.

Client: “Doctor what does it all mean and/or what should I do?”

Therapist: “What do you think it means or what do you think you should do?”

The last thing many of us are looking for when confused and frustrated is for the person whom we are paying for help to turn our question back on us.

How many times have you seen a television therapist respond to a client’s question in that way? Of course there can be wisdom in promoting independence and confidence in a client’s decision-making, by allowing him or her to draw conclusions, take action, and experience the consequences. At the same time, effective therapy is often going to provide concrete strategies for a client to implement, and specific tools to help make the decisions in the first place, e.g., learning to reduce anxiety about the decision making process and outcome, tolerating the inherent uncertainty in all choices, and efficiently weighing the pros/cons of different strategies.

One of the most entertaining depictions of a couple failing to receive the help they need in couples therapy takes place in the movie, The Ref (1994). Dr. Wong (played by BD Wong) is a wonderful caricature of a couples therapist.

Dr. Wong illustrates how poor clinical judgment can make even useful strategies a catalyst for frustration and hostility in a couples therapy session. It is ironic that this couple enters therapy for emotional soothing and practical help, and leaves more distant and distressed. Fortunately this is a movie and the exaggerations are humorous. Unfortunately, many couples have experienced or expect to experience couples therapy at best as something ineffective, and at worst something that might make things worse. Here is an excerpt of dialogue from a couples session from the film. Lloyd is played by Kevin Spacey and his wife, Caroline, is played by Judy Davis.

Marriage Counselor: This next exercise will help you with listening. One of you will speak, while the other just……listens.
Wife: Me. I had this crazy dream.
Lloyd: Do we have to do dreams?
Caroline: I was at this fancy restaurant having lunch… and the waiter brought me my entree. It was a salad. It was Lloyd’s head on a plate of spinach…with his penis sticking out of his ear. And I said, ‘I didn’t order this.” And the waiter said, “You must try it. It’s a delicacy. But don’t eat the penis, it’s just garnish.” Marriage Counselor: Mmm. Lloyd, what do you think about the dream? Lloyd: I think she should stop telling it at dinner parties to all our friends. I mean, dreams should be private, don’t you think?
Marriage Counselor: I’m not here to judge or to take sides. I will say communication is healthy.
Lloyd: Healthy? Telling people she dreams of me being castrated “Florentined” is healthy?
Marriage Counselor: Are there any sexual problems in the marriage? Caroline: Well…the truth is, um, we haven’t had sex in quite awhile. [Clears Throat] And before that, it wasn’t all that, um… Oh, what’s the word? Noteworthy.
Marriage Counselor: Mm-hmm.
Caroline: By our twelfth anniversary, we’d gotten into a pretty stale routine, couple of kisses, a couple of nipple twists. It would be over in the time it takes to make cappuccino. I know because I timed it once. I mean, it’s no wonder I had an affair.
Lloyd: How could you tell him all that so casually, like you were asking him for a glass of water?
Caroline: Actually, may I have a glass of water?
Lloyd: Why don’t you have oral sex too, and I’ll go wait in the car?
Marriage Counselor: Lloyd, how do you feel about Caroline’s affair? Caroline: He just wants me to wear a red “A” on my chest and sleep in the basement.
Lloyd: Is that so unreasonable?
Caroline: Everything’s either black or white with him. You know, he doesn’t… he doesn’t see where he’s responsible. And I mean, it just didn’t mean anything to me. It shouldn’t even be counted as an affair. [Sighs]
Lloyd: I think we need a ruling on this.

The husband makes a final (sarcastic) request for the therapist to actively say or do something tangible. We are left with the clear picture that marriage counseling would never resolve the issues in this relationship. The couple apparently has repeatedly presented the therapist with examples of missteps, passive-aggressive (or outright aggressive) acts in their relationship, while his neutrality and seemingly non-directive approach have left them more frustrated, isolated, and dissatisfied. In fact, what we the audience come to believe, is that they really need a referee, not a couples therapist. And in this portrayal, the unlikely, but eventually effective candidate is a hot-tempered, straight shooting, burglar played by Dennis Leary- the ref. So, does the scientific evidence support what we see of couples therapy on television and in the movies? Does couples therapy ever work? Do marriage counselors really improve relationships by remaining impartial, not explaining what things may mean, and refraining from recommending what to do?

Does Couples Therapy Work?

Deciding to see a couples therapist can be a big decision. It takes significant time, money, and often times emotional resources. In addition, it often requires one partner to cajole or convince the other to enlist, which at a minimum can strain the relationship temporarily. Is it worth it?

For decades, couples therapy has been the subject of rigorous studies, which include randomized controlled trials (RCTs). In these studies, couples are randomly assigned to different arms of the experiment. They may receive one type of couples therapy or another, or even be assigned to a wait-list control, where they wait to receive treatment later. In the meantime, wait-list control couples provide data for what couples likely experience without treatment.

First, the evidence indicates that a large percentage of couples significantly improve in couples therapy. In many of these studies, improvement was shown to be both statistically significant and clinically significant. Statistically significant means that we can be reasonably confident that the improvement found was due to the treatment and not chance, i.e., the couples assigned to the therapy group just happened to improve.  Statistical significance means we can be highly confident our results would be the same if we conducted the experiment again on a similar group of couples, and randomly assigned half of them to couples therapy and the other half to a wait-list group.

Statistical significance is important. We certainly want to make sure that differences aren’t just due to the chance that particular groups of couples were assigned to one group or another. But for someone considering couples therapy, there is another crucial question: “How big is that improvement and what would it look like in my life?” A statistical difference could indicate for example that differences at the end of the study in therapy group couples, compared to those wait-listed, were the result of the treatment and not just chance. But just because there is a difference between the groups does not mean the difference is big or meaningful. We could be sure for instance that taking a fever reducing pill is the cause for the difference in body temperature between a treatment group and wait-list control, but if the difference was 1/10th of a degree, then we may see little value in taking the pill.

Clinically significant change indicates that the amount of improvement is sizable and would have a real world impact. So when making practical recommendations based on RCTs, it is important for these treatment studies to include clinical significance, as well as statistically significant findings. Although costs/side effects for psychotherapy are not typically on the scale of those for medications, e.g., diarrhea, palpitations, and occasionally death, they do exist, as is the case with almost any treatment.  If there are children, childcare may have to be arranged, out-of-pocket expenses may not be reimbursed, and many distressed couples struggle with finding time in their schedules. There is also often effort and time required to do work between sessions, so for couples therapy to be worth it, we want to know that the improvements are clinically significant.

One study indicates that 70% of couples receiving a specific therapy show clinically significant improvement. Another indicates that on average 80% of those in couples therapy are better off at the end of treatment than those not receiving couples therapy. This raises another important question: “If couples are doing better at the end of treatment, do their improvements remain, decrease, or even increase over time?” This question is addressed with readministering measures at a follow-up time period. There is good news for couples therapy on that front as well.

Approximately 50% of couples have been shown to maintain the improvements five years after treatment. These are some of the numbers that can help when making a decision about couples therapy. While the presentation of these data here was framed somewhat positively, it is clear that many couples won’t improve by the end of treatment, and about half of those who improved by the end of treatment may sink back into old patterns within five years. Therefore, psychologists have more work to do in the improvement of existing treatments or the development of new ones, and the aforementioned costs have to be weighed against realistic expectations for improvement.

Some Couples May Beat Odds in Therapy

In addition, couples that are motivated and are consistently practicing the skills acquired in couples therapy are far more likely to improve and maintain those gains over the years. The studies cited typically include a fixed number of sessions, and it is possible that a larger dose of sessions, occasional booster sessions, or if desired, ongoing couples therapy may result in maintaining the improvements or even increase the magnitude of those improvements.

There is ample evidence that many couples can benefit from meeting with a skilled couples therapist. At the same time, there are many who may not. It is important to realistically weigh the costs and benefits of both couples therapy and the consequences of the status quo. There are considerable costs on either side. It is also important to recognize that some clinicians may be a better fit and therefore be more effective for a particular couple. Therefore, advocating for yourself, when selecting a clinician and during sessions is crucial.  Asking the therapist what theory and techniques they apply in couples therapy, and how much training they have received in that area are examples of appropriate questions that can help filter clinicians with whom you are unlikely to be compatible.  Many clinicians explain that they have an eclectic therapy approach. I strongly recommend that if a clinician indicates he/she is eclectic, i.e., uses many techniques that clients ask him/her to explain one theory and set of techniques that he/she intends to implement in working with you. A confident clinician will be happy to spend a couple of minutes providing an overview of the model and skills that clients would use in couples therapy. Receiving clear answers to these kinds of questions often increases a couples comfort and confidence with the therapist and the model of psychotherapy. That comfort and confidence in both the couples therapist and model of psychotherapy often translate into increased client motivation, a stronger therapeutic bond with the therapist, and better outcomes for the couple. So if you decide the pros outweigh the cons for seeing a couples therapist, do not to be faint of heart across the board- be bold and ask questions of the therapist, your partner, and yourself-experiment with the tools and new skills you learn with your partner in session and at home… chances are it will be worth it. If you need couples therapy from a cognitive behavioral therapist, you can schedule sessions of couples therapy at New York Behavioral Health.

male eating disorder

Male Eating Disorders

Dangers of Beauty

Beautiful people everywhere…what new club or exotic resort destination can boast this tag line? Your kitchen before the second sip of coffee. Whether we are skimming a magazine, surfing the web, or flipping channels, images of thin women and muscular men without much body fat, are likely to bombard our psyches. While the majority of Americans have increased their waist sizes, the aesthetic ideals promoted by swimsuit and organic health shake ads alike are leaner than ever before.

Men and Eating Disorders

Body image issues surrounding our weight or body shape are very common. And there are huge industries bolstered by our obsession with becoming or staying thin, “fighting” aging and becoming more muscular. For decades women in the United States have increasingly suffered with eating disorder symptoms. Younger and younger females are presenting with severe symptoms, and many men and boys are also receiving diagnoses and treatment for eating disorders. Without question, women have suffered in greater numbers from eating disorders than men. Yet it has been important in recent years for treatment providers to begin to recognize the growing need for awareness of the increasing number of men suffering from these issues. In addition to more men developing eating disorders, there are other hurdles for men regarding eating disorders.

Anorexia Nervosa and Men

Many clinicians are not socialized in their training to assess for eating disorder symptoms in men. Even more striking are gender based diagnosis problems like amenorrhea, being listed as a symptom of Anorexia Nervosa. Clearly men are not ever going to lose their menstrual cycles. Not only does this complicate a diagnosis- it skews the way clinicians see potential sufferers. And as we can imagine it shapes how men who suffer may see their own problems- as something not masculine.

Male Shame

Shame and embarrassment accompany many mental health issues, and eating disorders are no exception. But, these distressing emotions may be even more frequent and intense for men suffering from an eating disorder. While the norms have been changing, eating disorders are still not something that many men people admire have admitted to having. Without any cultural models of someone we respect admitting they suffered and recovered, it makes it more difficult for men to come to terms with the problem and get help.

Combined Obstacles to Treatment

So we have a man who is likely confused, ashamed, and embarrassed with his suffering. Men are already at baseline less likely to share feelings or ask for help from a mental health professional, and that makes diagnosis less likely. Even if an accurate diagnosis and the motivation exist, men often still struggle to find treatment providers. There are obvious reasons, but the majority of eating disorder specialists have had much more experience treating women. Likewise many outpatient groups and even residential eating disorder treatment centers are not equipped to treat men.

Causes of Increase in Male Eating Disorder Diagnoses

It is unclear how much of the increase in male eating disorders is about improvements in clinician diagnosis, increased willingness of men to share symptoms, or changes in the culture that have increased the actual prevalence of symptoms. Hopefully professionals will become more attuned to looking for signs and asking men important questions that reduce embarrassment and shame, and eventually build the trust necessary to express the suffering that is a hallmark of eating disorders. While it is unclear what is causative, there does seem to be a correlation between how men have been depicted in magazines and the increase in eating disorders. Men pictured with their shirts off in magazines increased 11 times from the 1950s to the 1990s. It isn’t clear whether these images are causative or reflective, but it is clear that men’s behaviors have certainly changed over time and that has resulted in changes in their physiques and the numbers diagnosed with eating disorders.

Eating Disorder Research

My hope is that Eating Disorder research will continue to get the funding it needs, and that includes evaluating public policy and educational programs. Changes requiring models to be above a Body Mass Index (BMI) in some European countries are an interesting proposal. If these and other policy changes could be implemented long-term and if evaluations of their impact are significant, it could be a feasible method for preventing the development of the number of eating disorders we are seeing now.

Effective Eating Disorder Treatment

Unfortunately, in terms of treatment, Anorexia Nervosa is still very difficult to treat. But it is critical that anyone experiencing symptoms seek treatment. The Maudsley Family Based treatment approach has some of the best results. Although the clinical and research communities have a long way to go, people with an Anorexia Nervosa diagnosis are well advised to engage a professional for treatment. On a more optimistic note, the scientific literature demonstrates that Bulimia Nervosa and Binge Eating Disorder (BED) are very responsive to treatment. Cognitive Behavior Therapy (CBT) has been effective at treating both of these eating disorders. So if anyone believes she/he may be experiencing distress around eating behaviors and body image issues, I strongly encourage them to contact a qualified psychologist, mental health counselor, social worker, or medical professional with experience using empirically supported treatments for eating disorders.

Despite the obstacles for anyone, male or female, suffering with an eating disorder, there are good reasons for optimism. Aside from the good efficacy rates for Bulimia Nervosa and Binge Eating Disorder, more and more clinicians are being sensitized to the problem. This has been reflected in a few residential treatment centers designing programs that are appropriate for men, and societal attention to the impact our overvaluation of beauty may be having on body image and eating behaviors. There are also a number of research labs investigating integrating different treatment modalities in hopes of finding a more effective treatment for Anorexia Nervosa. Dissemination of cognitive behavioral therapies (CBT) and behavioral therapies to greater numbers of clinicians, who in the past may have hesitated from treating patients, or who may have been using techniques that are not helpful. So greater numbers of sufferers should have access to properly trained therapists. The first step is opening up to the possibility that the suffering may be treatable- and then asking for help.