Leakage in Violent Intentions and Why Professionals May Not See It

Psychiatrist Richard A. Friedman recently wrote an opinion piece for the New York Times about why professionals may not be able to identify those with violent intentions.  In it he states that mental health professionals predict or identify at a level no better than chance.  He also states what many of us in this field already know but the public largely does not; that is, only a few mental illnesses carry with them an increased risk for violence, such as schizophrenia, bipolar disorder and major depression.  And most people with mental health issues are not violent.  He notes that the role of substance abuse, which is much more prevalent that the disorders listed above, is often overlooked or not cited in specific cases.  Due to the media's portrayal of "shooter" incidents the public is developing a distorted view of these events which leads to faulty conclusions.  These include: "fixing" the mental health system will reduce these events, and it should be easier to identify killers because it's so easy to see after the fact.  There's also a related notion that keeping firearms out of the hands of the potentially violent should be an easier thing to do.

These conclusions are faulty for several reasons, not the least of which is the assumption that science is or should be able to help us identify killers.  While we are not without some applicable knowledge and skill, it has not advanced to the point where predictive power is very strong or even anywhere near that.  We assume that being in psychological care can reduce or eliminate risk in all cases.  While I certainly believe that many negative situations are avoided or contained by competently applied therapy, it is also true that anyone can mislead us if they choose.  We are not magicians.  And no, we can't read minds either.

The concept of "leakage" of violent intent is relevant here.  Studies of those who have chosen to harm others indicate they communicate their intent many times, and often long before the violence is carried out.  But how often does this leakage occur in the therapy session?  I submit to you that it is very rare, especially in cases in which the client knows they are being monitored by others who are worried.  The therapy hour is one of 168 hours in the week.  How hard would it be for any of us to maintain a mask for one hour compared to 167?  If you are intelligent enough, not very hard at all.  For the most part, the leakage occurs outside of the therapy hour, while the violent are moving and posting on social media among us.  It may happen in bits and pieces, or it may happen all at once, but it is us, the general public, that will see the lion's share of the messages.  Even if it is leaked in the therapy hour, there is currently no magic bullet, as it were, to swiftly contain and manage the potentially violent person.  As has been noted elsewhere, a mental health hold or commitment may last only hours or days.  Then what?

There are no simple answers to this problem.  Any solutions are likely to come from many quarters, including mental health systems (I use that phrase loosely because there is no actual "system" in this country), law enforcement, firearms statutes, families, and the general public.  But one element we all need, which the concept of leakage reveals, is a commonly taught survival tool of recognizing and reporting leakage.  It ought to be taught just as CPR is taught, and just the signs of heart attack and stroke are taught.  (We could do better even with those better understood conditions).  You cannot manage a threat until you know how to recognize it, and until you have a sound way of mustering support.  We are a long way off from having either.

  

Eliminating negative self-talk

     

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Your mental illness can be a very powerful voice in your head. It doesn’t literally have to be a voice, though sometimes it is. It is whatever is inside of you that tells you things that make your symptoms worse and hinder your recovery. It might be saying something like this:

• You are worthless.
• The world is dangerous.
• You don’t deserve love and attention.
• Others are laughing at you.
• Your body is flawed.
• There’s no point in trying.
• You have to engage in unhealthy behaviors.

It can be hard to challenge these thoughts because they are coming from within. They appear to be your truth. But just because it’s in your head doesn’t mean it’s actually you. These thoughts might actually be from someone else or they might be a result of psychopathology.

Thoughts can be left over from what others have said or implied by their actions. We all have those things someone said to us once that we believed and of which we never let go. I haven’t felt confident singing since my junior high choir teacher told me I couldn’t. I’ve also never looked at my body the same way since someone I once dated told me to lose weight. That doesn’t mean those things are true. I can probably sing well enough to not seriously embarrass myself. What
                                                                                     someone else thinks my body should look like is actually irrelevant. 

But at some point, these people held credibility for us. What they thought mattered because we gave them that power. With effort, we can take it back. Recognize that these original messages might have been off-hand and not really meant. Other times, people might have been deliberately cruel. There can even be some level of truth to what was said. What matters is how you choose to respond. I can tell myself that how I sound doesn’t really matter because I’m not a professional singer. I can also tell myself that my ex was just plain wrong for criticizing my body. Challenging these thoughts can be hard, but the more you do it, the more you believe it. It might take years, but that’s better than giving these people space in our heads.

Other negative thoughts are not the voices of others, but a result of a mental illness. No one knows how mental illnesses work. But they do affect our thoughts. Depression might tell us that life isn’t worth living. Obsessive-compulsive disorder can tell us to engage in ritualistic behavior to prevent bad things from happening. Anxiety tells us that it’s safer to be scared. 

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These thoughts are invasions in our heads. They are foreign to who we really are. That’s why we call their speakers illnesses. They do not belong in us any more than cancerous cells do. You have to believe that what your mental illness says is not what you actually are. You can choose who you are.

That is not an easy task. It takes a lot of effort and it won’t get better overnight. One thing you might want to do is incorporate affirmations into your life. You can read about how to do that here. You can also ask yourself if the thoughts actually make sense. By challenging them, you lessen their power. Even if you don’t believe the challenge, the fact that you are doing it means that you are at least willing to consider that the thoughts might not be true. That’s somewhere to start.

Sometimes, we can’t work through these thoughts on our own. If they are causing you distress or interfering with your life, talk to a therapist. They know strategies to help you change. It might be helpful if, between sessions, you write down all the negative self-talk you catch. Bring your list to therapy, as this will give your therapist an idea of where you’re at and how you can be helped.

You don’t have to be a victim to your own mind. Remember, considering that you might be wrong is the first step. Fill your life with positive things to give the negative thoughts some competition. Recognize that the harmful self-talk is not a part of who you truly are. You are a strong, capable person who can take back your mind from negativity, no matter how long it takes.

How do you reduce negative self-talk? Share your tips in the comments.

7 ways to support someone with an eating disorder

Eating disorders have the highest mortality rate of any mental illnesses. Because of this, it is extremely important to work towards recovery. It is easier to get better when friends and family are supportive. But eating disorders are complex both physically and psychologically, so it can be hard to know what to do and say – or what to not do and say. Here are some suggestions on how to be supportive of someone with an eating disorder.

1. Remember that eating disorders don’t discriminate. A person of any age, gender, race or size can have an eating disorder. They’re not all bone-thin, white teenage girls. There are several different kinds of eating disorders and it’s impossible to tell by a glance whether or not someone is struggling with one.

  

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2. Understand that it’s not just about being skinny. Eating disorders are complex. While societal pressure to be thin can be a factor, it’s not the only one. There are usually intricate emotional reasons behind the disorder. Risk factors that can influence the development of an eating disorder include having another mental illness, substance abuse, perfectionism, sexual abuse and being involved in activities focused on weight (sports, dance, modeling, etc.).

3. Focus on positive non-physical traits. Eating disorders are often accompanied by a lot of insecurity. It’s therefore important to help build self-esteem in areas not related to the body. Compliment your loved one for his kindness, intelligence, skills, etc. Encourage participation in hobbies and activities that she excels in.

4. Be a good listener. If you are consistently paying attention and responding appropriately to your loved one, he will find it easier to talk to you about difficult subjects. Don’t push the topic of eating disorders, but if it comes up, be supportive and gently encourage recovery. If she has brought up the topic, you can carefully try to follow up, but follow her lead.

5. Do things together that don’t involve food. Eating disorders can be very isolating. It’s important to still have a social life, but a lot of social activities are centered around food. This can be very difficult. Invite him to do things where food is not the focus. Instead of going out for ice cream, go to the arcade or a concert. She’ll feel a lot more comfortable.

6. Don’t make demands about recovery. You can’t force someone to change. Recovery can only happen at the pace that someone is able to work at, so you need to respect that. Not doing so can damage your relationship and make your loved one feel uncomfortable around you. Trust his treatment team to keep tabs on how he’s doing.

7. Get emergency help if needed. Forcing treatment on someone can be ineffective and potentially counterproductive, but sometimes intervention is necessary. If symptoms get severe enough, call 911 or take her to the emergency room. Fainting, seizures, an irregular pulse and other severe symptoms call for medical intervention.

How do you maintain relationships with someone who has an eating disorder? If you have one, what do you find helpful? Share your thoughts in the comments.

Mental Illness Can Have More Impact on Life Expectancy Than Smoking

According to researchers at Oxford University, mental illness has an effect on life expectancy that is equivalent or greater than smoking. A great deal of effort and spending has been invested into smoking cessation programs and smoking awareness campaigns. This new research should prompt the government, health care and social services to shift their focus in an effort to increase life expectancy for those living with mental illness.

Researchers reviewed 20 review papers from clinical studies that reported mortality risk among mental health problems, substance and alcohol abuse, dementia, autistic spectrum disorders, learning disability and childhood behavioral disorders. These studies included over 1.7 million individuals and over 250,000 deaths. They also used studies and reviews that reported life expectancy and risk of dying by suicide. All results were compared to data for heavy smoking.

According to their findings, “one in four people in the UK will experience some kind of mental health problem in the course of a year” while smokers consist of roughly 21% of British men and 19% of women. 

They discovered that all diagnoses studied had an increased mortality risk similar or greater than heavy smoking. Some of the estimated reductions in life expectancy were found to be as follows:

• Bipolar Disorder: 9 - 20 years
  
• Schizophrenia: 10 – 20 years
  
• Drug and Alcohol Abuse: 9 - 24 years
  
• Recurrent Depression: 7 - 11 years
  
• Heavy smoking: 8 - 10 years

Dr. Seena Fazel of the Department of Psychiatry at Oxford University said: "We found that many mental health diagnoses are associated with a drop in life expectancy as great as that associated with smoking 20 or more cigarettes a day."
Despite the fact that this study did not mention the prevalence of smoking among persons with mental illness, the results are still devastating.

There may be many reasons for this phenomenon. For example:

• Psychiatric patients and those with drug and/or alcohol dependence can be more likely to engage in high-risk behaviours.
  
• Physical health problems may not be taken seriously and treated properly due to the stigma attached to their mental illness.
  
• Many mental illnesses can create physical health problems and/or worsen pre-existing ones.
  
• People with serious mental illness may not access healthcare effectively.
  
• The de-medicalization of mental illness may increase the likelihood that physical health problems go untreated or neglected.
  

Life expectancy may increase if only we could make mental health a priority as we have with smoking. In addition to funding and advancing research on mental illness, we should improve health and social services to ensure that persons with mental illness have better access to health care, suitable employment and supports in their community.

Many mental illnesses reduce life expectancy more than heavy smoking

© www.mentalhealthblog.com

13 theoretical orientations (and what that means)

This post is part of an organized reader request series. Stop by at the beginning of each month to make your requests on the designated post. This topic was suggested by reader Julie.

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There are as many different types of therapies as there are therapists. Maybe even more. Everyone has their own style and finds particular techniques or ideas to be helpful. Even so, there are general categories of therapy. These are called theoretical orientations.

A theoretical orientation is a theory about what causes mental illness and what can be done to heal it. In graduate school, future therapists are exposed to a variety of these and find what works best for them. There isn’t one that’s inherently better than another; research has shown that theoretical orientation doesn’t significantly affect therapy outcomes. 

But some therapies will work better for some people. When looking for a therapist, you can ask about his theoretical orientation in order to assess whether he might be helpful to you. You can also ask your current therapist about hers, as it might help you understand your treatment better. Here are 13 of the more common ones.

Cognitive-behavioral therapy (CBT)

This type of therapy focuses on beliefs and behaviors. With your therapist, you look at your thoughts, feelings and actions and look for maladaptive patterns. You might receive homework to track these things. They can then be worked on using specific techniques. CBT is commonly used to treat anxiety and depression.

Humanistic therapy

This orientation posits that people naturally strive for self-actualization. It encourages self-exploration and creativity. It emphasizes that everyone can be the center of their own healing. You will look at your values and help you find your inner wisdom. The focus is on positive adaptive traits rather than pathology.

Existential therapy

In this type of therapy, pathology is seen as stemming from internal conflicts with the givens of existence. These include death, freedom and its accompanying responsibility, isolation and meaningless. The present and future is focused on more than the past. The goal is to find out how to fully live.

Psychoanalysis

This therapy was developed by Sigmund Freud, but has been built on ever since. It believes that early childhood significantly impacts ones development and that we are driven by unconscious, irrational drives. Unconscious material causes us distress, which can be handled by bringing the material to consciousness. Sessions occur multiple times a week.

Psychodynamic therapy

Psychodynamic therapy is closely related to psychoanalysis, but is less intensive and focuses more on the therapeutic relationship. Psychodynamic therapy still addresses unconscious material and internal conflicts. It acknowledges maladaptive behavior and seeks to find its root. By bringing it to light, resolution can be achieved. 

Gestalt therapy

In Gestalt therapy, the focus is on being able to fully experience each moment. It also acknowledges the interconnectedness of everyone and everything. Relationships, including that with the therapist, therefore become important. It emphasizes personal responsibility and teaches one to have a higher level of awareness.

Feminist therapy

This therapy acknowledges the difficulties one might face due to sex, gender, race, ethnicity, religion, sexuality, level of ability, age and other traits that influence one’s position in society. By recognizing these forces, one can find ways to become more empowered. A lot of emphasis is placed on the therapist and client working together as equals.

Relational therapy

Relational therapy stipulates that reality is found in relationships. A relational therapist believes that a client’s problems stem from his relationships. Psychopathology comes from disconnection or dysfunction in one’s relationships. There is, naturally, a lot of focus on the therapeutic relationship, which can serve as a corrective experience.

Family systems therapy

This type of therapy will look at families and relationships as a unit and aims to treat it. The goal is to improve relationships and the family as a whole. It takes note of different patterns in the family and offers new alternatives. It is usually practiced by bringing in the entire family, but might also be used in individual therapy. 

Solution focused brief therapy (SFBT)

SFBT is a very structured and goal-oriented approach to treatment. It doesn’t delve into what the problem is and try to analyze it, but rather focuses on what the solutions are. By looking at times when the problem isn’t present or is less severe, successful practices can be identified and utilized in the future. 

Dialectical behavioral therapy (DBT)

DBT isn’t exactly a theoretical orientation, but it is a specific type of therapy. It is usually done as a group, but therapists will pull from it in individual work, too. The focuses of DBT are mindfulness, interpersonal effectiveness, emotional regulation and distress tolerance. It was created to treat borderline personality disorder, but has proven useful for other conditions, too.

Expressive therapies

Expressive therapies are a group of therapies that use creative expression to promote healing. This might include using art making, music, dance, drama, writing and recreational activities. The focus is on the process on creation. It is often used in conjunction with psychotherapy, but can also be used as the primary treatment when appropriate.

Eclectic therapy

Eclectic therapists take elements of different theoretical orientations and put them together in an individualized way. This could, for instance, mean combining the structured techniques of CBT with a good look at existential concerns in order to address feminist issues. A large number of therapists identify themselves as eclectic, so feel free to ask which modalities are an influence.

What types of therapy have you tried? What did or didn’t you find helpful? Share your experience in the comments.

Diagnosis spotlight: narcissistic personality disorder

Everyone knows someone who might be described as arrogant, self-absorbed or vain. When these traits are taken to an extreme, they can become pathological. In narcissistic personality disorder (NPD), self-centeredness overtakes a person and can hurt ones functioning, success and relationships with others. 

 

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In someone with NPD, there is a certain grandiosity and a need for admiration. This is further complicated by a lack of empathy. With NPD, it is expected that one is treated as special and valuable while other people might not even be on the radar. This can manifest in several ways.

According to the DSM-5 (the manual used to diagnose mental illness), people with NPD have an exaggerated sense of self-importance. This might manifest through overstating accomplishments or expecting recognition of superiority without the achievements to match. There can also be fantasies of unlimited success, power, brilliance, beauty, or ideal love. He might see himself as special or unique and therefore only able to be understood by or willing to associate with other people deemed special. There can also be an excessive need for admiration.

NPD might lead someone to take advantage of others. This can be done due to an unwillingness to recognize the feelings or needs of others. Someone with NPD might also be very envious or believe that others are envious of her. There is commonly displays of arrogant behaviors or attitudes.

No one knows exactly how NPD develops. It might be a combination of biology, temperament and early social interactions. It is believed that it can develop as a result of parenting that focuses too much on the child’s specialness. This might be done to increase the parents' own self-esteem. On the other hand, it is possible for it to develop as a response to a childhood of neglect and abuse.

When properly managed, people with NPD actually have some highly adaptive traits. They might have high self-confidence, allowing them to try new things. Their self-esteem can encourage positive risk-taking. NPD can make someone very charming, which can be socially advantageous when used responsibly. There is a lot of leadership potential that can be tapped into in a healthy way.

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Left unregulated, however, NPD can take over lives and lead to a lot of social problems. Friends and family might get worn down by the self-centeredness and lack of empathy, making it difficult to build and retain meaningful relationships. Professional relationships can also be disrupted due to shows of entitlement and an unwillingness to collaborate. At its most destructive end, people with NPD can become abusive. They are able to make their victims feel like they are at fault. 

People with NPD rarely seek treatment. They fail to see how they are being destructive to themselves and those around them. It is not uncommon for NPD to go untreated while those in his life end up seeking help for themselves. When treatment is sought, it is usually only at the insistence of loved ones.

NPD can be hard to treat. Treatment generally means psychotherapy, as there is no medication for NPD. The course of therapy might focus on changing beliefs and behaviors that are destructive. They might be taught to be more empathetic and learn how to use their talents and resources to help others. This might not change feelings such as entitlement, but in practical terms, it leads to a more functional life.

Specific symptoms, such as anger and impulsivity, can be worked on as well. In general, one might look for the areas in which NPD is causing the most problems and focus on those. For instance, if a business owner cannot retain employees because of the way he treats them, therapy might focus on respect and valuing the contributions of others. Group and couples therapy can also be beneficial, as it allows those with NPD to explore relationships and how they relate to others. 

Treatment can be difficult for those with NPD. It challenges their world views and asks for a lot in terms of change. It is usually a long-term process. This might be especially bothersome if the person with NPD does not believe she has a problem. Loved ones can be helpful by responding positively to the person with NPD seeking treatment and can offer praise and support as changes are gradually made. It can be a rough path, but the improvements in relationships are worth the effort.

5 ways nature can heal

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Nature has been helping people heal long before the inventions of therapy and medication. Humans were developed to survive without any modern conveniences, so it only makes sense that the natural world holds things that can help us in recovering. 

Consider what nature can do for you, even if you don’t want to leave the house. Inspired by the (hopefully) nice spring weather, here are five suggestions for how nature can help in your healing process.

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1. Sounds and scents

Nature can be very soothing and calming. It’s simple to bring nature inside through your senses. If you are lucky, you live somewhere you can simply open your window to hear and smell a forest or brook. But for the rest of us, turning on some nature sounds and lighting a flower-scented candle will have to do the trick. 

There are websites that let you blend and customize different sounds, such as this one. It is also said that certain scents will alter your mood, filling you with calmness, energy or concentration. Here is an example of a list of how certain scents might benefit you. Google will give you plenty more.

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2. Gardening

While some of us hate weeding (guilty), some people find gardening to be a soothing and stress-relieving hobby. It gives you the satisfaction of seeing your hard work bloom, which can do wonders for your confidence and self-efficacy. 

Even city-dwellers holed up in apartments can reap the benefits of caring for plants. A flower box can be used to make a beautiful display or to be used to grow herbs and small vegetables. For those who are interested in growing their own food in cities, look up urban gardening. It’s a real thing.

  

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3. Food and supplements

What you eat determines a large part of your health. It is, after all, what makes up your body. Good nutrition in general is beneficial to physical and mental health, but specific foods can serve individual purposes. Supposedly, blueberries should make you less stressed while walnuts make you happier.

In addition to providing food, nature also gives us plants and herbs that hold healing properties. The scientific backing on these varies, so do your research. But from what I’ve heard, some places use St. John’s wort as a first line of treatment for depression, preceding anti-depressants. But if you do want to try a supplement, talk to your doctor. Some can interfere with medications or make certain health conditions worse.

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4. Pets

The creatures we share this world with can become healing as friends, or even part of the family. My cat can tell when I am anxious or depressed and will cuddle up with me extra much. Having a pet also gives you a daily responsibility, forcing you to have interaction and get out of bed.

Sometimes, people have specially trained service or therapy animals. Dogs, for instance, can be trained to help with PTSD symptoms. I have also heard of ones that will bring your medication to you if you are bedridden, so it’s pretty incredible what animals can do.

  

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5. Spending time outdoors

Then, of course, there is simply going out into nature. Take advantage of whatever is nearby – forests, mountains, beaches or city parks. If you want more variety, plan vacations and road trips around the environments you’d like to spend more time in.

While outside, do activities that you enjoy. There’s more to do than hikes or walks. Some options include riding bikes, swimming, picnics, sketching or painting, picking flowers, snow activities, bird watching, playing children’s games and just sitting down and enjoying your surroundings.  Sometimes a breath of fresh air is exactly what’s needed to feel better.

What gifts of nature do you use in your recovery? Exchange ideas in the comments.