Tag Archives: psychology

Internet Gaming Disorder? Is that a thing?

Yes, it’s a thing.

Are you (or someone you love) hooked on internet gaming?

An excellent recent article on parenting in Real Simple, “Parenting Against the Internet,” cited a statistic that the average adolescent male spends 20 hours a week playing internet games, and the average adolescent female spends 10 hours a week.

The internet can be great: I can look up all sorts of research, read the news, check the weather, contact family and friends around the world, find obscure used books in a mom-and-pop used book store somewhere across the country…

But for some people, the something good turns into a real problem. The American Psychiatric Association, in its 2013 update on diagnoses, the DSM-5, named Internet Gaming Disorder as a “condition for further study,” rather than an official diagnosis with its own billing code. Tune in within a few years; no doubt, that will change.

Twenty hours a week is a lot of time to spend doing something that teaches little, if any, useful knowledge; isolates a person from contact with real people and real life; is sedentary; and creates a world that is not real but full of very real gratification in terms of the brain’s dopamine system. That’s the average; that means for some people, there’s little or none and for some, it’s the equivalent of a full-time job, absorbing time, energy and mental space that could be dedicated to learning real-life skills, creativity, and other parts of life. Please don’t bother emailing me with examples of games where prosocial behavior is rewarded or you have to know useful stuff to be successful; I know. I also know that at some point it’s unhealthy to live in an artificial land of make-believe, instead of taking that pro-social behavior and useful knowledge and using it to make the world, and yourself, better.

What are the warning signs of this disorder that warrants further expert study? Persistent preoccupation; withdrawal symptoms such as irritability when the games are taken away; tolerance (more time playing games as time goes by); unsuccessful attempts to control the amount of time playing (for example, promising to cut back now that school has begun and sliding right back into excess); losing interest in other activities; continued excessive use of games in spite of problems in relationships, job, school, etc.; lying about how much time is spent playing; using games to deal with other problems (the game is a drug to feel better at this point); jeopardizing or already lost significant relationship, job, educational or career opportunities because of involvement in playing internet games (American Psychiatric Association, 2013). Note that these are games – gambling on the internet is already an official diagnosis when carried too far.

Most people can easily see the degree to which these signs are awfully similar to what we would use to assess a problem with alcohol or drugs: preoccupied with drinking? Cranky or shaky when they can’t get their “fix?” Unable to cut back; getting behind in life in all sorts of areas; lying about how much is used…so why are parents apparently turning a blind eye to how much time their kids spend in this world?

Some theories:

  1. Some parents are as active in gaming as their children and have convinced themselves that those excessive hours are better than other things their child might do. Well, yeah; I suppose you could also argue that it’s better for your child to get drunk than to inject heroin, but that doesn’t make getting drunk a desirable behavior.
  2. Some parents are unaware. They do not realize what their kids are doing in their rooms, on their phones, half the night, or when they’re supposedly doing homework, or when they are in a college classroom, not paying attention.
  3. Some parents think it will be outgrown…although the social skills deficits these young addicts have will often interfere with their ability to successfully navigate college, trade schools and work.

Of course, it’s not just teens. There are adults who sometimes work full time, or part-time, and spent 30+ hours gaming each week. They tend to have marital problems, job problems, or both. Perhaps they have neither a relationship nor a job, but do have angry parents who want very much to be empty-nesters, any decade now.

Don’t think this applies to your child, or to you? Try cutting it off for a week. A week’s not that long. No exceptions. Notice what happens. If you’re afraid to even bring it up because you “don’t want to deal with it,” you have just told yourself something very powerful, and somewhat frightening, about your confidence as a parent and your child’s relationship with gaming.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

 

Surprise! Today is mostly the same as yesterday…

Surprise! For most of us, today is mostly the same as yesterday!

Huh?

Well, maybe I am letting a pinch of my grew-up-in-Jersey show, with an unhealthy indulgence in sarcasm…but I have a point.

Why are so many people surprised when every day, so much is the same?

Why do some sources tell us the “average American woman” tries on four or five outfits before leaving for work? Is it really possible this hypothetical average woman is perpetually surprised by the obligation to wear something besides yoga pants and a slept-in t-shirt? Imagine: “D’oh! Get dressed again???? What the…?” It’s much more likely that what-to-wear becomes, under pressure, an emotional decision (what do I feel like wearing) instead of a practical one. The cool, calm decision on Sunday (what makes sense based on the demands of each day of the week) turns into a workday morning emotion-fest for people who get caught up in “I feel fat” or “I look terrible.”

It’s not just about prepping for the non-surprising workday.

Why is anyone over the age of twelve stymied by the multiplication of dishes in the sink, the need to do laundry, or the fact that garbage cans get full? Worse yet, why are so many couples arguing, night after night, about “what to do about dinner,” as if the need to eat sometime between finishing lunch and going to bed caught them unawares?

I try not to be surprised by the every-day. Maybe I am flattering myself by mincing words here: I am dismayed that Darcy the twelve-year-old cat has once again thrown up in the middle of a wood floor. I am, regrettably, not surprised.

The school year is beginning here in West-Central Florida, and so families all over are waking up to unpleasant (non)surprises: pack lunches? Matching socks? Complying with uniform rules? What??? I am right there with you, folks, amazed that it is once again time to get into the autumn routine.

For me, that includes packing a week’s worth of lunches and ironing a week’s worth of clothes on the weekend. Crazy, right? Until you imagine it taking two minutes to get dressed for work and a few seconds to grab a lunch out of the fridge, instead of trying to figure out what to wear, heat up the iron or touch up shoes, wash fruit and veggies, etc., while the work day morning clock’s ticking. I have it figured out: less than 30 minutes total for all clothes- and lunch-prep on Sunday or cope with 15 minutes or more five times a week. I am saving myself, at minimum, 45 minutes

Emotions are what get in the way for families bickering about “what to do about dinner,” or “how are we going to get the laundry/kitchen/pet duties done.” People are tired, they are hungry, they are stressed out from the day. Tired, hungry, stressed people are not as good at negotiating and decision-making, whether at home or work. Instead of wishing you could come home, magically downshift to a Zen-like mindful state and engage in creative cookery and Pinterest-worthy home maintenance, why not just plan to deal with reality?

The reality is, you will be tired, you will be stressed, and you will wish you had something easy, tasty and nutritious. You will not want to spend a half-week’s worth of grocery money on takeout because the dinner hour caught you by surprise.

The 1990s bestsellers by Elaine St. James (Simplify Your Life, Living the Simple Life, etc.) included very down-to-earth, helpful tips: have a weekly menu that rarely varies. It keeps life simple. That doesn’t mean you can’t have wonderful, complicated meals, but it does mean that you can also plan for: Ugh, it’s been a 14-hour day door-to-door and that homemade soup from the freezer/half a lasagna/whatever ready to go and bag of salad are going to taste really, really good…in about five minutes, instead of spending a half-hour bickering, grumbling, and absent-mindedly eating a half-bag of chips while you try to figure out what to do.

Slices of the culture are having a virtual love affair with simplifying, decluttering, etc. How about decluttering and simplifying the routines of life, the predictable little tasks that are the same each day, so you have more time and mental energy for the things you’d rather do?

 

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Reports, Commands and Rules

Many years ago, on the first day of class in the graduate-level course on Abnormal Psychology, our instructor held up the then-current version of the DSM (Diagnostic and Statistical Manual of Mental Disorders) and said,

“Always remember…you never know what flick is playing in someone else’s head.”

Words of wisdom: much goes awry because we forget that simple fact.

Honestly, don’t you ever wonder if some people are actually going out of their way to deliberately misinterpret what is said?

Have you never sat in slack-jawed wonder at the psychological gymnastics required to wrest a particular interpretation from something that meant nothing of the kind, as you witnessed someone gallop away, flush with a gross (and possibly deliberate) misunderstanding?

Sometimes, there may be bad intentions, or at least the intention, all along, to make some point, whether or not it makes any sense in context. We see this often in every level of politics. Commentator Smith had a well-rehearsed point to be made during the allotted few minutes on-air and by golly, Smith is going to find a way to interject it even if it makes no sense in context. Smith hopes that the point thus calculatingly made is so clever, so memorable, that it will be the “take-away” point for most listeners, even though, within the transcript, it seems arbitrary at best.

Among the well-intentioned, the problem may sometimes be a lack of clarity…more often, I think, it is a lack of clarification.

In family therapy and family systems theory, we refer to a metacommunication concept called “Report and Command.” The “report” is what someone actually says. The “command” is the meaning of that statement to them. It is the hidden expectation. In a final exam question for a family therapy course, I give the following example:

Matthew states, “Susan never makes my favorite meal anymore.” From a metacommunication perspective, “Susan never makes my favorite meal anymore,” is the report. The command portion might be:

  1. “I feel hurt because she doesn’t care to do this for me anymore.”
  2. “…And she should make my favorite meal.”
  3. “because she knows I’m supposed to watch my cholesterol.”
  4. There is no command in this communication

Students are expected to pick an answer and defend it briefly. There are multiple “right” answers. It is telling that, given the statement, “Susan never makes my favorite meal anymore,” more than half the students regularly assume that the command – the hidden meaning – is b, “And she should…” rather than the plaintive option, a, or even the matter-of-fact and somewhat complimentary c. The choice of b, of going negative, tells them, and me, a lot about how they make assumptions about what people might mean, and points out the risk of assuming rather than clarifying the deeper meaning of even seemingly mundane remarks. Here, then, if Matthew is passively expressing hurt at his wife’s apparent disinterest in nurturing him, and Susan instead “hears” a chauvinistic, boorish demand that she slave over a hot stove, well, I may have an appointment open, week from Tuesday, at 6 PM.

Another recent example: a friend observed a parent telling a child engrossed in a video game that the child’s sporting event was to begin in 10 minutes. To only the parent’s surprise, this barely nudged a response from the child. The parent actually said, “Hey, your race starts in 10 minutes.” The parent believes he communicated, “Hey, dude, we gotta get going NOW so you can be in position for the race in less than 10 minutes.” Dad made a vague observation about time that meant nothing to a child and the child took it literally: Dad is updating me on the passage of time. I leave to your imagination the subsequent exercise in frustration for Daddy and his swimmer.

Some people claim they don’t have a lot of expectations. Nonsense. Of course they do. They expect the lights to go on when they flip a switch, though for the most part they know not how it happens. They expect politicians to magically create more jobs and higher wages. They expect their spouse to read their mind when they make that little throat-clearing noise and bulge their eyeballs at dinner with extended family or friends. They expect their loved ones to know what they might want for their birthday. We all have lots of other day-to-day subtle expectations, without which we couldn’t get through the business of living. There really isn’t time in a day to treat every iota of experience as a new and undiscovered country. Some things have to be on autopilot (which implies expectations, however buried they may be).

If you are happily married, you expect your spouse to come home; you expect compassion; you expect at least well-feigned interest in much of what you say. You probably have a reasonable expectation that certain tasks will be done and that you will be warned before in-laws or ne’er-do-well friends, down on their luck, take up residence on the couch. If, to your surprise, perpetually unreliable Cousin Pete has been invited for an extended and slovenly stay, you might reasonably say to your spouse, through gritted teeth in a whisper in the kitchen, “I had no idea your Cousin Peter was coming to visit,” (report) with the unsaid (command), “…and I am perfectly right to expect that you would have asked before letting him set foot in our house.” “But honey,” your spouse might say, “Pete’s family.”

Ah, the family card. Now we move from Reports and Commands to Rules.

Everyone has rules. Some rules are overt: my husband has asserted that I am not permitted to give up chocolate for Lent. This is one of a few rules in our house. Have I mentioned his strong survival instinct?

Most rules are not even verbalized; they are taken for granted, as if a law of nature. In the example of your spouse’s unwelcome cousin Pete, “family are allowed to be here without either of us consulting the other,” is apparently the inviter’s rule. You might be thinking, “Yeah, well, maybe a nice family member but not stinky, rude, mooching Cousin Pete,” or, “for dinner, maybe, but to sleep on my couch for some indefinite period of time, no!,” but, you see, that is an entirely different rule.

A lot of clashes arise because people have not clarified their expectations and their rules, both to themselves and to others; and because they speak in terms that they believe are perfectly clear when actually they are not clear at all. Next time you find yourself in a gross misunderstanding with someone you love, perhaps it would be worth revisiting whether you actually communicated what you thought in the privacy of your head…and to ask more questions about what someone means before you assume that what you heard is what they intended you to understand.

 

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

 

Wrestling with OCD

If you have suffered with Obsessive Compulsive Disorder (OCD), or know someone who has, you are probably familiar with those distressing, intrusive thoughts that create so much anxiety. Traditional psychoanalysis used to focus on the content of those thoughts and seek to uncover the deep, buried wounds and wishes that led to these strange, seemingly alien notions. Thus the woman who was obsessed with the fear that her child would get hurt walking to school might be analyzed and advised that she seems to have a deep resentment against the child and all the responsibilities of motherhood and the worry is really an expression of an unconscious wish to be rid of the child. Talk about a guilt trip…!

Modern research and practice in treating OCD tends more towards the notion that everyone’s brain generates random and sometimes pretty crazy-sounding thoughts. Thus, the treatment is much less about wrestling with the particular content of the OCD thoughts and more about learning to compassionately notice that thought happening among all the other thoughts firing off like popcorn in the typical brain, use strategies to calm down the anxious physical reaction to the thought and refocus, gently and purposefully, on what one would rather think about at that moment in time. It stops becoming “Don’t think about X,” (try that: right now, I forbid you to think about pizza. Ha – how long did it take to imagine a pizza?). Instead, it becomes, “Yup, there’s that thought about X…and now I will take a deep breath and refocus on what I was doing/what’s going on right here and now.”

This is what mindfulness, stress management and cognitive-behavioral therapy can do, together, to help with OCD. The brain changes in response to choosing these behaviors, and the degree of physical distress decreases throughout the whole body.

If you are suffering with OCD, this kind of very well-researched approach may be what you need. Please contact a professional in your area if you think this might be helpful for you.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Why is your child so unreasonable?

Kids! They’re so irrational! Unreasonable! They’re…well, kids.

Toddlers are usually not able to understand that the ideas in your head are different than the ideas in their head. Learning that other people don’t know/see/hear/think all the things you do is called developing a “theory of mind.” Before this, kids think everyone knows what they know. If you hide a toy with Joey while Sarah is out of the room, and invite Sarah back in, 3-year-old Joey will not understand how Sarah can not know where the toy is. Joey is still developing a theory of mind. You will know when your child has developed a theory of mind when he or she tries to lie. This usually happens relatively late in the preschool years. Until then, if they know what they want (and are regrettably incoherent) and you fail to understand and comply, they can only reasonably assume (from their perspective) that you are being mean on purpose. They know what they want – how can you NOT?

As children develop a theory of mind, they also develop other signs of brain maturity. One is the ability to “conserve.” This doesn’t mean the Greenpeace/Sierra Club type of conserving. It means that they understand that, whether you break it into four pieces or leave it whole, it’s the same puny graham cracker for snack. The golden days of breaking it in two so they think that there is now “more” are behind you.

As they develop their theory of mind and the ability to understand a bit more about the physical world, they stay very literal for a while, or what cognitive scientists call “concrete.” They are in the real world. This makes it difficult for them to consider multiple aspects of a problem at one time, and makes abstract concepts – like algebra – just about impossible. They might fixate on one aspect of a project or task despite your efforts to get them to consider other aspects. They might memorize things to make you happy, but until their brain reaches a certain point of development (and sooner doesn’t necessarily mean smarter, it just means sooner) algebra and other abstract concepts don’t really “click.”

While, for example, a 15-year-old can be on a debating team and argue in favor of a point with which he or she personally disagrees, a bright 7 or 8 year old would have a great deal of difficulty doing so. This is a function of brain maturation – a process that continues into the early 20s.

So…that’s why your child seems so unreasonable. It’s because their brain is a child’s brain – growing, amazing, absorbing information at lightning speeds. It’s our job to meet them where they are and go with them as they grow.

 

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

If you won the lottery…!

We all know the stats: that six months after a major windfall, such as the lottery jackpot, people are no happier than they were before they won. Most of us assure ourselves, WE would do better. WE would know how to manage that blessing in such a way as to increase the happiness of many people – including ourselves – on an ongoing basis. WE would be happier, not succumb to dopey decisions and would never blow up our lives with self-destructive, self-indulgent bad behavior.
Here’s a question: what would you do if you won the lottery, and why aren’t you doing some version of that already?
If you imagine you’d travel, see new places and try new cuisines, are you saving money for a trip and seeking free/cheap adventures in your own area, experimenting in the kitchen and otherwise exploring here at home?
If your job is a poor fit, are you meeting your intellectual and creative needs via outside pursuits, or investigating how to transition to something that’s a better fit, or are you just feeling “stuck”?
Most changes people imagine making after winning a lottery are really superficial and thus, much to their surprise, they show up in that new, changed life with the same “them,” with all their flaws, quirks, and preferences. That means that we all would tend to level out at whatever our prior level of contentment was, pre-jackpot. If you’re a happy person, you’ll keep on being happy…and if you’re cranky, well, you’ll just be a rich, miserable person to be around instead of a not-rich miserable person. Worried people will keep on worrying until they decide to learn how to change that – which doesn’t require a lottery jackpot.
You can be happier today. You can find a new adventure in your town this weekend. You can learn something exciting and be on the way to mastering a new skill this week. Alternately, you could sit around and wait to win the lottery. You get to pick.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC
© 2016
Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Too busy!

People brag about the strangest things.

Not getting enough sleep is one; are Americans in some sort of dysfunctional competition to see who can get by on the least possible sleep – regardless of the effect on their mental and physical health?

Another is being busy – so very, very busy – that one could not possibly do anything healthy, or creative, or refreshing in any way.

Is it real busy-ness? It’s hard to say, but I have my suspicions that it often comprises some combination of underestimating how much time is frittered away on time-wasters, taking on a lot of extra and unnecessary tasks, and, sometimes, more than a hint of pride. You know, the people who find out you actually read books in the evening or squeeze in a date night with your spouse and give that little smile and a hint of a sniff when they say, “Well, it must be nice…” Well, yes, actually, it is. Very nice.

Pride, or arrogance, aren’t necessarily obvious. Healthy humans have a normal, natural need to feel needed and wanted. This is a good, but the fear that somehow your absence will cause all of creation – or at least your workplace or the kitchen at home – to immediately crumble into dust is not good. Even Jesus and Moses sometimes sneaked off for some very necessary R&R, either to be alone with God or also with some of their most loved, trusted friends.

Some people are going through a stage of life that is very busy. People with school-aged kids who each  participate in one extra activity will indeed be temporarily overly busy, driving to practice or lessons. They check homework, look under the sofa for shin guards, and use their vacation time for pediatric appointments for yet another ear infection. This stage is transient. Even too-busy parents, though, often hide time-wasters into their day.

When someone asserts always being “too busy” to do things they claim they really want to do, then I suspect that perhaps they don’t actually want to do those things. It would be better to say, “Oh, no – last thing I want to do is be stuck in a gym five mornings a week,” then to dodge exercise by pretending they are just too, too busy. Once they are honest about the issue (apparently they would rather do something else than spend hours on the human version of a hamster wheel) they are free to figure out how to meet the essential need (enough exercise to stay healthy) and stop dodging reality with brag-worthy busy-ness.

It’s hard to give up the busy excuse to oneself. It might be a polite dodge to other people (but remember that “let your yes mean yes and your no mean no” admonition?) but it’s just pointless to lie to oneself.

 

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Military Mental Health

It seems as if daily we are told how shamefully the military handles the problem of psychological distress and emotional pain for our men and women in uniform. In May, the USA Today newspaper empire asserted that the “Pentagon [is] perpetuating stigmas that hang over treatment, study finds.” (Zoroya, USA Today, May 6, 2016). The military is criticized because it takes mental health issues seriously enough to reconsider security clearances…unnecessarily “stigmatizing” those who have sought treatment.

This supposed stigmatization merits careful consideration. These include the depth and breadth of existing mental health services for active duty personnel and veterans; the conflicted American mindset on mental illness and emotional distress; and the logical outcome of this strange ambivalence.

A person not in the military or close to military personnel, may reasonably be under the carefully groomed media misimpression that the emotional well-being of our soldiers, sailors, airmen and marines is some sort of vague afterthought. Perhaps the general public is unaware that military mental health officers (people who are qualified to be licensed solo practitioners in the civilian world) are found in forward operating bases, combat outposts, and other deployment settings, providing critical incident debriefings, assessments, counseling, and referrals for more comprehensive care. When young men in harm’s way are despondent over a wife’s philandering, or are heartbroken over missing their child’s birth, the mental health officer is there. When there are incoming mortars, the mental health officer is there. When someone’s reaction to the weekly required malaria medication is extreme (malaria meds cause short-lived anxiety in about 1 in 10 people, and for some of that 10%, paranoia kicks in briefly, too), the mental health officer is the one who can figure out what’s going on and have the physician provide an alternative medication for the soldier – saving a military career from dissolving due to what looks like psychosis but is a transient medication side effect. In short, when crises occur, the “doc” or “shrink” or “combat stress lady” (quotes from military personnel) is there.

It is understandable that most civilians are unaware of mental health clinics on military bases, where military personnel and their families can receive counseling. Besides basic counseling services, mental health personnel provide services such as outreach before, during and after deployment, support while preparing for new babies, parent training, marriage counseling, couples’ retreat weekends, substance abuse education, and more. All these are part of the routine in military mental health clinics. Mental health officers are also able to veto a transfer if any member of the transferring family’s health or mental health needs cannot be adequately met at the new location. So…if Mom is being transferred to Base “A” and that area doesn’t have the specialized services that one child in the family needs, the transfer is nixed – possibly by a licensed clinical social worker at Lieutenant rank. The 2nd Lt. just overrode the entire command structure, in the military that is decried for not taking mental health needs seriously.

Then there are the VA system and the Vet Centers. Vet Centers are cousins of the VA. Unlike the VA, Vet Centers require only a DD 214 to provide free individual, couple or family therapy. It doesn’t have to be service-related…but if the problem seems to be service-related after all, the Vet Center personnel can help facilitate connection to the VA proper. These, too, are staffed by people licensed in their respective states as solo practitioners. There are no “not good enough to make it in private settings” amateurs serving in mental health positions.

Finally, there is the difference between benefits (think, Tricare, which is insurance for post-military service) versus service-connected health care (think, the VA system). A lot of veterans get that confused, and any of us who have tried to deal with health insurance and making sense of what is/is not covered, copays and coinsurance, and in and out of network…well, it’s understandable that almost anyone would find it confusing. Fortunately, the VA system and Tricare have professionals who do a lot of work (and get yelled at a lot) in trying to help people understand their benefits/insurance/service-connected health care, and connect them to the right services.

There are mental health services for military personnel and veterans. There could certainly be more, and the services available could be better marketed. In addition…there are stigmas.

Those stigmata comprise one more disgraceful example of too many Americans wanting to have their cake and eat it, too.

The regrettable medicalization of mental health has resulted in the mythology – happily embraced by many in the medical, pharmaceutical and professional-helper fields, as well as by many in the general public – that all mental disorder diagnoses are brain diseases. For example, many professionals will assure you that depression is strictly medical in nature; a brain disease, incurable but treatable by manipulating brain chemistry. Likewise, anxiety is (supposedly) purely a physical issue. People collect Social Security Disability, disability from their employers’ insurance, and other benefits, based upon having some sort of lifelong brain disease (according to psychiatry).

There are plenty of people eager to buy into this. We hear depression is epidemic (what else could we call something that apparently affects at least 20% of women and 10% of men each year, based on prescriptions for drugs?). Well, here is a recipe for depression:

  1. Maintain a sedentary lifestyle
  2. Eat a lot of junk food and assiduously avoid adequate portions of healthy foods
  3. Smoke cigarettes and/or abuse illegal or prescription drugs
  4. Drink more than one drink daily (females) or two drinks daily (males), or more than your physician recommends, given your particular health profile.
  5. Cultivate poor sleep habits. Watch television before bed; heck, watch television in bed, or use your smart phone, or tablet, etc. at bedtime. Drink caffeine less than six hours before bed. Wait until night time to argue with your spouse. Have a “nightcap,” which is a short word for “the alcoholic drink that will let you fall asleep more quickly and then wake up at 2 AM and have difficulty going back to sleep.” Eat salty foods before bed to activate your dopamine system and feel a little hyper.
  6. Avoid exposure to natural daylight.
  7. Watch lots and lots of television, or streaming video, or play video games, or surf the internet. The more the better. Strive for the national average of 6 hours or more daily (non-work related).
  8. Spend lots of time on social media. In particular, notice how much your life stinks compared to other people’s (supposed) lives.
  9. Shop for recreation. Spend money you don’t have on things you don’t need and then keep being surprised when, no matter how fancy the clothes or pricy the electronics, you are still, well, you.
  10. Be selfish.
  11. Don’t apologize, and don’t say thank you.
  12. Think a lot about how much other people are unkind, selfish, lazy, and how generally you are not getting your fair share.

Yes, I just described what an awful lot of people do, and yes, if you do enough of these things, you will probably feel depressed. Yet, as can be seen, every single one of these behaviors is optional for most people. Perhaps someone has physical challenges that prevent them from being active, but otherwise, these all represent choices made, choices which could be changed. If you were to do these things, and feel sluggish, unhappy, uninterested in life, helpless to make things better, etc., and reported this to your doctor, you could easily be diagnosed with depression.

The label depression, of course, is itself suspect. Within the mental health field, we are well aware of a dirty little secret. This secret is carefully hidden by pharmaceutical companies from the unsuspecting, suffering, and happiness-seeking public. That is, the criteria for almost every mental disorder diagnosis is a checklist. Committees review the research, argue about what should and should not be on the various checklists, have professional feuds, and publish the criteria. People are then diagnosed based off a checklist of symptoms or complaints. Those categories are fuzzy – a complaint I hear regularly from graduate students who, perhaps naively, expect pure, clear science. As soon as one set of criteria is published, the process starts all over again. This is how it came to be that, in the current diagnostic manual for the American Psychiatric Association, there is no such thing as bereavement. If you are still moping around after two weeks because someone you love has died, the American Psychiatric Association, in its infinite wisdom, has decided you meet criteria for Major Depressive Disorder. That’s the same Major Depressive Disorder diagnosis that many forces are pushing us to believe is simply a brain disease that requires lifelong treatment. I am not being sarcastic or flippant; it’s their decision, not mine. I was Hospice-trained and, even absent that, I am human and understand that bereavement is a long and painful process, even for the resilient among us.

The decision to eliminate the “bereavement exclusion” was supposedly made, in part, to allow people to use health insurance to pay for grief counseling. (At least, that’s the gossip I hear in mental health circles.) In other words, you are despondent. Someone has died. You go to a counselor. They diagnose you with depression, which is supposedly a brain disease, because you meet checklist criteria. You are now labelled with what many people assert is a lifelong condition due to your sick brain. You will now be able to have insurance cover your counseling (after your deductible has been met, of course). The diagnosis of a major mental disorder will last forever – long after you have forgotten whether you paid a copay or full fee for a handful of sessions, or went to a support group in a church conference room that a therapist facilitated as a volunteer.

Depression is worth discussing as one of the most common diagnoses. Psychiatrists and other physicians provide prescriptions for antidepressants, for example, to about 15% of the adult population annually – and many assert that depression is just a disease, like any other disease, and you have to face that you will be sick and need medication for the rest of your life. If that is the case, then why criticize the Pentagon for being concerned about someone whom psychiatrists assert has a lifelong brain disease having their finger on a trigger, or button, or sensitive data? Why should one person with a particular diagnosis be placed on perpetual disability and another maintain top secret clearance? Which do the people complaining about how the military stigmatizes mental health want?

To be clear, this is not unique to the military. People seek counseling, are unwittingly diagnosed, and discover later that they are deemed mentally ill and a high risk for suicide; perhaps their life insurance rates increase, or their health care premiums increase, and when the premium bills come in, they can’t remember having any mental problems except that time they saw a counselor after their grandparent passed away. The labelling can happen without any mental health treatment at all; if your physician lists a mental disorder as a possible diagnosis (fatigue, depressed mood, and poor sleep being symptoms of lots of problems, psychological and physical) while ordering blood tests (for what turns out to be something medical), that possible mental disorder diagnosis is in your health record, now part of your profile, even if you turned out to be anemic, not depressed.

Even if you are diagnosed with depression, the diagnostic categories don’t adequately describe what is happening, and they should. It is reasonable to expect that professionals, viewing the diagnosis on a chart, immediately discern the difference between these types of experiences:

“I’m depressed and exhausted because I’m having hideous nightmares ever since my buddy was blown up and died in my arms” versus,

“I’m depressed and exhausted because the 5 years I spent doing meth have caught up with me and my brain has been damaged,” or,

“I’m depressed and exhausted (and right now no one, including me, realizes it’s because I am among the one in 10 women who suffer depression as a side effect of chemical birth control).”

Right now, the label doesn’t differentiate. As you dig into the chart, yes, it’s there – but the most superficial record just shows the diagnosis code.

So, let us not pretend that the military is some big, horrid bully for treating serious mental disorder diagnoses as a possible risk factor for clearance. As long as those in power – throughout the medical, insurance, pharmaceutical and government arenas – are manipulating the definition of mental illness, one can hardly blame the military for being overly solicitous about the mental health of our men and women in uniform.

The conundrum of diagnoses and the risk of damage to one’s life explain why some military personnel are suspicious about seeking mental health treatment. We ought not to assume ignorance when they instead go to chaplains (who may be precisely who is needed) for wise and useful guidance. Similarly, they may choose to be self-paying for marriage counseling, stress management or other issues…off the record and off the base, their privacy is as sacred as mental health treatment ever was, before psychiatry yielded to intrusive insurance, and, as the big player in the mental health field, dragged most mental health professionals with it.

 

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

The Cancellation

Another day, another call or email: a couple whose first appointment was scheduled for later this week has cancelled. They have “found a doctor who takes our insurance.” That would be fine but for one detail: the appointment was for marriage counseling.

This could create a dilemma for the doctor who “takes our insurance,” if the clients turn out to be shopping for marriage/relationship counseling. This is because unless one member of the couple is diagnosed with a mental disorder, and the treatment rendered in those conjoint appointments comprise empirically supported treatments for that disorder, it is probably not covered by their insurance, whether the doctor “takes it” or not. No doubt this will be part of the discussion during their first appointment, when they inform the doctor that the problem is not helping Partner A cope with depression or anxiety (or some other mental disorder diagnosis), but rather some sort of relationship problem. Now, if Partner A is depressed, and the treatment involves communication skills combined with cognitive-behavioral therapy, or another empirically supported form of therapy that can involve the spouse as a coach/partner in healing, that’s excellent and ethical practice; not so for relationship problems.

At least I found out in advance, sparing the mutual aggravation of patients who imagined somehow that their marriage counseling needs are someone else’s financial responsibility and of a psychotherapist who expects to be paid for services.

This sort of retraction prior to a first appointment happens sometimes in my practice. “I found someone who takes my insurance.” This, despite my spending 10-15 minutes on the phone before setting that appointment and providing this information about my practice. I don’t contract with health insurance companies: it’s clearly stated on my website, and I tell people during that first, free, fifteen-minute consult.

Why bother mentioning it? There are ethical issues at hand.

To be perfectly frank: health insurance is for health problems.

It ought not to be used to get a discounted rate, subsidized by every other person paying premiums to that health insurance company, for marriage counseling, or premarital counseling, or vocational counseling, or any other normal, problem-of-living, life phase process.

My website clearly states my position on health insurance: I don’t contract with insurers because the bulk of what I do is not billable. I do not want my work with couples to be tainted by ethically questionable gymnastics in which we justify treating the relationship because it will indirectly help with a mental disorder. I will not label children with a brain disease because their grownups are getting divorced and upsetting the children, resulting in a custody evaluator referring the children to me. I will not participate in diagnosing people when I am concerned it is not in their best interest – a position supported, as it happens, by the American Counseling Association.

So, no, I don’t “take” insurance. Insurance cards are not debit or credit cards, anyhow: there’s no “taking.” There’s submitting paperwork and hoping one is eventually paid, or being denied payment and then having to bill the client, who may have been discharged months ago.

I don’t diagnose people for the sake of billing. If a client meets criteria for a diagnosis, what we’re doing is aimed at treating the symptoms of that diagnosis and, after being provided information about the process, the client chooses to submit the information to his/her insurance company, I will provide the appropriate form for the client to try to be reimbursed.

I work with human beings who are having problems in their lives (provided they are in Florida, where I am dually licensed for mental health counseling, and marriage and family therapy), and who want life to be better. They want better relationships and a hopeful outlook; they wish to live with purpose and meaning.

Those are not mental disorders. They are signs of health and hope.

 

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

A little out of sync…

Intellectually gifted children are a challenge for grownups.

Their ability to learn and apply information may be far ahead of their peers but their emotional and motor skills may be completely normal (read: average and right on schedule). So your highly gifted six-year-old, who can visualize Johnny Depp’s pirate ship but whose little fingers can only manage 5-year-old’s motor skills, will be angry and frustrated to the point of tears over a boat that looks perfectly fine to you. Your gifted twelve year old will, with the emotional fragility of a middle-school-aged heart, grapple with the existential questions peers more often face in college.

This kind of asynchronous development is hard for the child, too…and will continue to be so, until adulthood. It’s easier for adults to find a few intellectual peers with whom to deeply connect. The more gifted the child, the harder this will be, simply because of the mathematical odds. Intellectual giftedness comprises only 2% of the population. Highly gifted persons are less than 1/1000 of the population; for them, the odds of finding someone on par, or, an even happier event, encountering someone sharper in intellectual terms, is slim. It’s important for grownups to be aware of the interior struggles gifted children face and provide opportunities for support, encouragement and sometimes some careful education on why they feel so different from other kids.

Add to this gifted kids’ tendency to need a little less sleep, be a little more bouncy, be in a hurry to learn and do, ask a lot of questions…or, conversely, be very quiet, observant and introverted, and the challenge for parents and teachers becomes clear.

Interested in learning more? There are a lot of resources out there: American Mensa and SENG are two excellent sources of information and support for the gifted child (or grownup) in your life.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.