I’ve found myself reflecting on risks, taking steps of faith, and jumping into the unknown. I work in a field that inherently asks individuals to constantly take risks, to make oneself known, and to allow vulnerability. Theodore Roosevelt said it best: “It is not the critic who counts; not the man [or woman] who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man [or woman] who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly…who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly.” Research seems to indicate that taking risks or stepping into the unknown encourages anxiety and excitement, fear and anticipation. Somehow, the uncertainty, risk, and emotional exposure can leave one feeling enlivened and eager with the promise of possibility. As frightening as risk and vulnerability may be, it’s also the birthplace of love, authenticity, and meaning. As we play and work and live – both personally and professionally, the combination of blessings and challenges in life can leave you with the experience of living more fully.
The practical and psychological challenges of adjusting to the American culture is no more apparent than in the populations of 1st and 2nd generations of immigrants in the United States today. California, and especially Southern California, is a frequent destination for the immigrant population. As a local psychologist who often works with this particular population, I was interviewed by an international Chinese Television station. To view that interview, go to the following link:
One of the things that make us uniquely human, Summers (2013) states, is our ability to use metaphor. Within the context of psychotherapy, particularly because of the deep exploration of self it provides, the use of metaphor is a frequent consequence. If this opening up of creativity and the use of metaphor is uniquely human, how might constant interfacing with technology and mobile devices disparage this process?
Summers states that psychotherapy is a process between two people who engage each other for the express purpose of transforming and expanding the subjectivity of one party. The patient begins to understand herself more deeply. Subsequently, one of the hopes we have as therapists is that the transformative power of this very dynamic generalizes to other relationships and situations for our patients. The insights one gains in psychotherapy can begin to change relationships OUTSIDE of therapy. But if our patients live in a world of tethered technology, of potential disconnected-ness, doesn’t this circumvent the very changes we’re hoping to effect?
When considering the developmental arc of growth in the human being, the child is helped to master negative feelings by parental responses to the pain and the offering of a different viewpoint. Simply put, when a child is comforted and soothed, rather than dismissed, a child is left feeling valued and healthy self worth grows. As a result, the optimal conditions for the child are both mutual and self-regulation. The child learns to regulate his own emotional responses to life challenges. Children need the responses of primary caregivers to learn how to master their own feelings in order to learn how to self regulate. But what happens when mobile devices become so embedded in and between human interactions? Will our absence with each other serve to circumvent our learning to self regulate, to feel comforted by another’s response?
Summers makes the statement that concentrating on the patient in psychotherapy, with all his/her complexities, is a mode of engaging human experience that makes psychotherapy inquiry unique and powerful. This singular focus on the experience of the other person, might it be thwarted by constant interaction with “others” that are only experienced through email, text, or Facebook? Doesn’t communication, when it primarily occurs through technological means, inherently create a wall of intimacy whereby the participants cannot intimately engage with one another?
This might sound a bit simplistic. The longer I’ve been a psychologist, the more I feel like the main goal of psychotherapy is not only assisting clients in gaining insight about themselves, but helping them learn to tolerate their God-given feelings, and thereby growing in their ability for intimacy and vulnerability. This seems to occur the most powerfully in-between people and WITH each other. While technology is not inherently evil, my fear is that our world of tethered technology provides a ready made defensive and avoidance of the very conditions that help us feel like humans. Instead of conversation over dinner together, we feel tempted to check our mobile devices. Instead of noticing each other’s facial expressions, and thereby allowing for connectedness, we gradually become more and more distracted from each other. Instead of starting conversations with others in parks, coffee shops, gyms, or the grocery checkout line, we play games on our phones, listen to music with earphones, or check our Facebook page. In essence, we lose our ability for human relatedness.
It is precisely in the interaction with another that the self grows and flourishes. When cyberspace is used as a means of forming relationships, it withdraws the nutrients people need for the growth of self and therefore impedes self-development. While most endorse the importance of conversation, few ponder the hard truth that dialogue is what makes us human and without the ability to converse, people are in danger of losing their very humanity. Cut off from the world of meaningful human conversation, the individual is left in a space that remains empty and static. The very same individual, in attempt to fill that void, will fill this void with the stimulation of technology, a strategy that only serves to leave the person even more removed from human relationships.
A powerful example of this shift in thinking is the finding that attitudes toward robots have shifted over the course of the past 20 years (Turkle, 2011). In the early years of robots, children tended to have doubts that robots could substitute for the human interaction they clearly preferred. But 20 years later, children were not so sure. Once robots could speak and express caring responses, American youth became less sure that robots were poor substitutes for the human touch. Now both children and adults are much more likely to believe robots can meet the needs of elderly persons. The importance of this shift, according to Turkle, is not so much the robots’ capabilities but in the transformation in the way young people see humans.
Research suggests that technological advances have had a significant influence on the way children and adolescents regard themselves and others. In some of Turkle’s early work (2004), many MIT and Harvard computer specialists tended to see their minds as computers, information processing organs, machines housed inside their bodies. At that time, such a mechanistic view of human being was found primarily among those who built computer systems. Today, however, this ideology has spread beyond those who work in information processing.
In perhaps the most troubling example of our shift in attitude, research is now indicating that technology has increasingly become a companion. There was a computer program designed at MIT in the 1970’s, called ELIZA, which engaged in dialogue in the style of a psychotherapist. A user could type a thought and ELIZA reflected back in language that offered support or asked for clarification. To “My father is making me angry,” the program might respond, “Tell me more about your father.” Subjects went from benign statements/questions like “How are you?” to “My girlfriend left me” within four or five interchanges. Four decades later, after the first version of ELIZA, artificial intelligence known as “bots” present themselves as companions to the millions who play computer games on the Internet. It has come to seem natural to “converse” with bots on a variety of matters, from routine to romantic. Participants take the small step from having one’s “life” saved by a bot met in a virtual world to feeling affection toward it. A poignant and disturbing example of this shift in attitude was capture in the recent film, “Her,” starring Joaquin Phoenix. (For those who haven’t seen it, I highly recommend it!)
A natural outcome of this attitudinal shift is the contemplation of “Computer Psychotherapy.” In the late 1970’s, there was considerable reticence about computer psychotherapy, but soon after, opinions shifted. The arc of this story does not reflect new abilities that machines to understand people, but people’s changing ideas about psychotherapy and the workings of our own minds, both seen in mechanistic terms. Thirty years ago, psychotherapy or psychoanalysis, was seen as a context for coming to see the story of your life in new terms. This happened through gaining insight and developing a relationship with a therapist who provided a safe place. Today, many see psychotherapy less as an investigation of the meaning of our lives and more as an exercise to achieve behavioral change or work on brain chemistry. There is now increasing research that shows a greater willingness to enter into a relationship with a machine if people think it will help them feel better. This attitudinal shift risks many things – our souls, our humanity, our sense of self.
Robotics and connectivity call each other up in tentative symbiosis. The mobile device signals we receive tell us we’re together. Networked, we’re supposed to feel like we’re together but I have begun to wonder if our expectations of each other are so lessened that we can feel utterly alone (Summers, 2013). And there is the risk that we come to see others as objects to be accessed. In this new regime, a train station, café, or park is no longer a communal space but a place of social collection. People come together but do not speak to each other. Why is this? It is those on their mobile device who mark themselves as absent. Sometimes people signal their departure by putting a phone to their ear. But it also happens in subtle ways – a glance down at a mobile device during dinner or a meeting. A place used to comprise a physical place and the people within it. What is a place if those who are physically present have their attention on the absent? Once we remove ourselves from the flow of physical, messy, untidy life, we become less willing to get out there and take a chance. When media is always there, waiting to be wanted, people lose a sense of choosing to communicate. How often do people now break up over text, rather than in person? And how many intimate “conversations” now take place over email, rather than in person? Research portrays Americans as increasingly insecure, isolated, and lonely. We work more hours than ever before and many have left behind the religious and civic organizations that once bound us together. (Turkle, 2014)
While for some, social networking and dating service websites have become a means to an end, for many people it has become the PRIMARY means for social interaction. Approximately 100 million people use Facebook in the US (Turkle, 2011). The average user has 130 “friends,” sends out 8 requests each month for new friends, visits the site 40 times every month for an average of 23 minutes per visit, and creates 90 pieces of content per month. As a whole, 30 billion pieces of content are shared every month leading to 770 billion page views in a typical month. In a few years, online communication has gone from a casual way of conversing to a primary method of social contact and interaction. “Being connected” used to mean an emotional bond but now refers to available communication technology. Turkle’s research found that the average adolescent fretted over their profile on Facebook, wanting to present an acceptable façade. Ages 13 to 18 were once the years of experimenting with identifications, they are now the years of profile writing, which Summers argues, is façade creating. These well-constructed facades would not be such a cause of concern if they were seen as acting. But these online personas are taken seriously.
Another thing I’ve found myself reflecting upon is that today’s instant cyberspace connections provide a ready defense against emotional vulnerability. One of the most dramatic findings is that this protectiveness has resulted in the inability to converse among many of today’s youth (Turkle, 2011). High school sophomore subjects readily admitted they avoid direct human interaction through the safety of the Internet. For instance, texting is preferred because it allows greater control over the communication and less opportunity to feel rejected. Research findings show young people are using the Internet to stay away from the anxieties and vulnerabilities of direct emotional encounter. On the Internet one can ask someone for a date or break off a relationship without having to look into the eyes of the other or even hear their response. Internet communication has become a readily available means for maintaining the aloof, defensive stance adopted by many adolescents to defend against the vulnerability of emotional contact with others. Cyberspace communications tend to be brief, superficial, and do not require spontaneous responses. As a result, it provides a ready means to circumvent the anxieties embedded in interaction. One does not have to confront the spontaneous feelings of either intimacy or conflict when hiding behind the barrier of Internet space.
We love our new technologies of connection. They have made parents and children feel more secure and have revolutionized business, education, scholarship, and medicine. They have changed how we date and how we travel. The global reach of connectivity can make the most isolated outpost a center of learning and economic activity. One would be hard pressed to not to find families out for dinner, each one glancing on their mobile device.
The contemporary technological world reflects a monumental shift in daily living. The home computer embedded technology into daily living to a far greater degree than anything before. But even then, a person must be in the location of the desktop to use it. Today’s technological world is differentiated from the other ages by its mobility and omnipresence. iPhone, Blackberry, iPads, and Android cell phones are a constant companion. It is this tethering to gadgets that makes the current technological society unique. Text messaging and social networking go on continually – during meetings, while on the phone, writing, doing homework, shopping, waiting in line, or listening to a lecture. Implicit in this constant connectivity is the idea that we increase productivity, a value of the highest order in the post-industrial world. Implicit also is how grandiose it makes us feel; that is, the wonders of mobile technology stimulate the idea of a feeling of exceptional power, an almost inhuman sense of oneself. However, is there a price we pay? In the early days of cell phones it was considered rude to answer a call in the middle of a conversation but within a few years, it’s now considered commonplace and acceptable. Technology not only intercedes between people, but it also takes priority.
In a discussion of the price we may pay for tethered technology, Turkle (2011) found that the impact of omnipresent technology on daily life left many white-collar workers expressing the feeling of suffocation at the expectation that they should be continually available. Business is done on weekends and evenings; and the expectation of continual availability is not uncommon. In essence, mobile technology has blurred the lines between work and home life. And speed has become the highest priority. The constant connectivity also comes with it a constant fear of falling behind, of failing to keep pace. As a society, we have adopted the principle that all should be done as fast as resources allow. When technology accelerates a process, the new speed becomes the new standard. Piaget, the famous developmental psychologist, was known for saying that once Americans discover a developmental process, the American will then ask, “can it be done faster?” Cyberspace has set a standard for speed that enslaves many people to the devices that were supposed to free them.
Research is also now revealing another price we pay for constant connectivity. Research is now finding that young people are doing homework while attending to Facebook, shopping, music, online games, texts, and videos. The omnipresence of mobile technology has led to a pervasive distractibility. Young people have difficulty maintaining concentration on a single activity. There’s a commonly held myth that by learning to manage a variety of task simultaneously, today’s youth are getting better at multi-tasking without the danger of any loss of performance. Research is actually showing the opposite; that is, in multitasking all tasks end up being performed at a subpar level. The reality is that doing several tasks at once serves to degrade performance on each one.
Another danger of our current age of mobile technology is the absent self. Texting and instant messaging are no longer primarily practical activities; they have become a way of life. It has become a venue for gossip and social conversation; and a popular source of seeking romantic partners. Research has found that from a means of quick communication to achieve quick goals, the Internet has become the way adolescents contact and relate to each other. As a result, today’s adolescents seem to feel unsure of what experiences even are outside of cyberspace communication. Today’s manner of continual, and for some almost nonstop, Internet contact, adolescents commonly lack the ability to be alone and reflect on their states of mind. When feeling lonely, the adolescent uses texts and the instant messaging of brief telegraphic communications to feel connected. This “contact” may take the sting out of loneliness but he/she is not engaged with the other. He gains neither the satisfaction of solitude, nor the enrichment of human connection. In other words, he is alone together. (Ideas were also taken from Frank Summers in "The Psychoanalytic Vision, 2103)
It's always nice to see further and continued confirmation of the biological benefits of psychotherapy. For a more thorough explanation of recent medical findings, go to the following link for an interesting read!
If you go to Walmart’s website, it says the following in very bright and prominent letters - “Faster is Better: How We Are Optimizing Walmart.com.” AT&T boasts its “The Nation’s Fastest & Most Reliable 4G LTE Network”
In the October 14, 2013 issue of Time Magazine, there was an article titled “Six Second Stars,” written by Laura Stampler. In this short article, she spotlights a new social network called “Vine” (owned by Twitter) in which members are allowed to upload 6-second video clips. In her article, Ms. Stampler asks and answers the following question - “what’s fueling the app’s popularity? The answer is Vine’s restrictions, say [its] users. One of its recent famous users, Megalis, states, “I have a horrendous attention span, so six seconds was perfect.”
Cushman, in Constructing the Self, Constructing America, spends a great deal of time elucidating the values embedded in US commercials and relays the fact that they embody a certain social milieu. Studying our commercials is a great source of information about that which we care. In Habits of the Heart, Bellah et al, say the following, “While television does not preach, it nevertheless presents a picture of reality that influences us more than an overt message…[commercials], which convey the idea that human aspirations for liberty, pleasure, accomplishment and status can be fulfilled in the realm of consumption.”
Mercedes Benz commercials emphasize speed and luxury; many products use the phrase “more for less – as in 60% more for x number of dollars”; I-phones and Android technology make the world immediately accessible. With a couple of swipes across the screen, we can read about the news in India, Europe…, we can even set our DVR so as to watch a show later, enabling us to fast forward through every single commercial so we watch only the show itself. Many television shows and movies finish their arc within 30 minutes to two hours, leaving viewers with the satisfied feeling that life has been figured out. The storyline was completed. We are a society addicted to speed, accuracy, and efficiency. Embedded in the very fabric of our being is the idea that we can acquire quicker results for less money, less time, and less inconvenience to ourselves.
I don’t think it’s controversial to say that psychological, emotional, and spiritual transformation is often not that way.
The effort to articulate the unsayable and the awareness of the psychotherapist's own experience of the patient are designed to bring forth meaning and motivation that have not previously been known to either party. This is very difficult to measure and it takes TIME! My fear is that a consistent application of efficiency may not recognize the reality of any of this. The psychoanalytic worldview offers a science of pausing, knowing, and reflecting and is based on the belief that human experience can only be understood by engagement with it and that engagement cannot be completely assessed by the methods of efficiency. Jack Kornfield, in Mindfulness and the Brain, makes the following statement. “Intentionally paying attention allows things to reveal themselves.” He goes on to say that it is actually in the pausing, quieting oneself, and practicing mindfulness that one begins to cultivate traits associated with well being - a practice that's the very opposite of our culture's milieu.
By now most of us know something about the concept of mindfulness. Well, mindfulness has definitely gone global! It made the cover of Time Magazine in January 2014 in an article entitled: “The Mindful Revolution: The science of finding focus in a stressed-out, multitasking culture.” Reading the article reminded me of the powerful implication of neuroplasticity, something I’ve studied recently, particularly as it bears on my work with patients. Drs. Allan Schore and Daniel Siegel have made the most powerful links between the brain and the mind, and between neuroscience and psychotherapy. According to Dan Siegel (Siegel and Kornfield, 2010), there is clear scientific evidence that tell us specific circuits of the brain can be activated by focusing out attention. In turn, how you activate those specific circuits, under certain conditions, has actually been found to change the underlying structure of the brain. This is called Neuroplasticity. Siegel goes on to state that the focus of attention is the “scalpel that lets you remold the structure of the brain.” Where you focus attention activates the neurons in the particular circuits that correlate with that activity, meaning they fire together. Neurons that fire together, wire together. Focused, careful, massed concentration seems to work the best. If you’re going to do 20 hours of practice, better to do it all during a weekend retreat than over the course of six months. If you’re going to be in psychotherapy, you might want to go twice a day for a month then once a week for a year. Psychoanalysis had it right, Dan Siegel says, because reflective practice can create massed and focused attention on particular areas of oneself. In particular, mindfulness involves the process of paying attention to your body, and then back to your affect, to allowing your mind to wander, catching that, and moving back to the moment. When we follow this flow of activity, it creates an integrated state of neural firing because where you focus your attention creates a state of activation. With the repeated creation of an intentional state of awareness over time, particularly an integrated state of neural firing, the brain changes so that you develop a trait, which is what emerges when the architecture of the brain changes. Those traits are an amazing list of traits, according to Dan Siegel. What you find is that the practice of mindful awareness harnesses the social circuitry of the brain, which overlaps with the regulatory circuitry of the brain. So the traits you begin to experience are stress reduction, improved immune function, enhanced capacity for empathy and compassion, ability to balance one’s emotions, and insight. Siegel also says the following - if you have a psychology that doesn’t have a contemplative dimension, it means you can only be with the active, busy, and engaged mind and there are whole dimensions of your mind and of being human that you’re missing. What research is proving is that we can encourage people to reflectively observe the flow of information, both the busy mind and the contemplative mind, and when this occurs, you can learn to regulate it, and most importantly, modify it. These are wonderful reminders for the work of psychotherapy. Research is proving that the end result is a positive change to one’s emotional, physical and spiritual conditions. Amidst the frenetic pace of most of our lives, it is a good reminder to intentionally create space for reflective and contemplative pausing because to do so is to change the very architecture of our brain!
In a recent New York Times Op-Ed, Brandon Gaudiano, a clinical psychologist and assistant professor at the Alpert Medical School at Brown University, makes the following statement. “But psychotherapy’s problems come as much from within as from without. Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which — like some old-fashioned Freudian therapies — should be abandoned.”
Jonathan Shedler, in a landmark paper published in the American Psychologist in October of 2009, states that effect sizes for psychodynamic psychotherapy are as large as those reported by other therapies. In fact, he makes a bold statement, “the perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings.” Shedler acknowledges that there may be a lingering distaste in the mental health professions for past psychoanalytic arrogance and authority. In decades past, he says, American psychoanalysis was dominated by a hierarchical medical establishment that denied training to non-MDs and adopted a dismissive posture toward research. This did not win friends and influence people, he writes. When empirical findings emerged that supported non-psychodynamic treatments, many educational establishments greeted this with excitement and were eager to spread the word. When evidence supported psychodynamic concepts and treatments, it was often overlooked.
Psychoanalyst Frank Summers provides an interesting discussion on this in his recent book, The Psychoanalytic Vision: The Experiencing Subject, Transcendence, and the Therapeutic Process. He writes, “Psychoanalytic insights into human experience have been attacked as invalidated speculations…” In fact, “psychology texts are unanimous in dismissing psychoanalytic ideas as empirically unverified (Munn et al, 1969; Morgan et al., 1985; Kalat, 2007).
Summers goes onto state that the dismissal of analytic theory is not based on research findings but on the fact that psychoanalysis fails to fit into the dominant objectivist ideology of the social science culture. The natural sciences have enjoyed great benefit with the objectivist method and is based on a certain stance. This stance is reflected well by a statement by E.L. Thorndike in 1918: “Whatever exists, exists in some amount, and whatever exists in some amount can be measured.” Summers’ point is that this is a certain concept of reality that tends to believe that only the measurable exits. Hence, psychology texts define the field as the study not of the psyche, but of the behavior of living organisms. An introductory psychology textbook by Morgan et al., 2005, states the following, “Behavior, rather than mind, thoughts, and feelings, is the subject of psychology because it alone can be observed, recorded, and studied.” Summers’ point is this – the application of objectivist space to humans is a theoretical prejudice that ignores the distinctively human quality of being in the world. Psychic states, while one can make attempts to understand and quantify, are difficult to measure. Approaching the complexity of the human being with a purely empirical approach misses so much of the very subject matter in question. With the ACA’s supposed emphasis on outcome measures, and the tying to financial incentives to those outcomes, it’s easy to assume that a psychodynamic sensibility will be squeezed out. Not everything that is, is measurable and if our healthcare system is continually leaning toward legitimizing only that which is measurable, the psychoanalytic worldview becomes countercultural.
Mental health costs are actually a very small portion of total healthcare spending and will continue to grow more slowly than other costs, due in part to the continuing impact of managed behavioral healthcare organizations (MBHO’s). Mental health spending was $33 billion in 1986 and $100 billion in 2003. The total cost of mental illness and substance abuse – including treatment costs, law enforcement costs, mortality, and decreased productivity – has been estimated to be $190 billion per year (NAMI, 2013). With these figures in mind, experts predict the following trends. First of all, mental health spending is projected to reach $203 billion by 2014 but will account for a progressively smaller share of overall health spending, dropping from 7.5% in 1986 to 6.2% in 2003, and to only 5.9% in 2014 (Levit et al., 2008). Secondly, the share of spending for psychologists, counselors, and social workers for 2014 will remain at the 2003 rate of only 8% of all mental health spending, which is down from 9% in 1986. Ironically enough, fees for psychotherapy are only .047% of all healthcare expenditure dollars. Thus, a third trend projected is that spending for mental healthcare provided by physicians will increase from 11% in 1986 to 16% in 2014, with 70% of those services performed by psychiatrists. And finally, it is estimated that prescription medications, which were only 7% of mental health expenditures in 1986, will rise to 30% by 2014.
One also cannot discuss national expenditures for mental health services without mentioning how the development and marketing of antidepressant medications has impacted the practice of psychotherapy. From 1998 to 2007, the percentage of individuals in the general population receiving outpatient psychotherapy decreased from 15.9% to 10.5%. There was also a reduction in the percentage receiving a combination of psychotherapy and medication, decreasing from 40% to 32.1% (Olfson & Marcus, 2010). In contrast, the percentage of individuals prescribed medications alone increased from 44.1% to 57.4%. Health insurance plans, which typically cover psychotropic medications while significantly limiting coverage for psychotherapy, have been a major factor contributing to the treatment of larger numbers of individuals with mild to moderate disorders in primary care environments, as compared with specialty care environments (Olfson & Marcus, 2010). This is a fancy way of saying that people now tend to talk to their primary care physician about psychological symptoms or to inquire about psychotropic medication, rather than seek out a psychologist or psychiatrist in private practice. These numbers also suggest that individuals tend to reach for the anti-depressant BEFORE it occurs to them to find a psychotherapist, especially because their insurance company probably covers the visit to the family doctor, rather than a visit to a private practice psychologist.
I’d like to offer a glimpse into the current landscape set before us, and what the Affordable Care Act (ACA), in part, is trying to address. If you’re like me, seeing numbers can be helpful. And despite my fears and hesitations about the ACA, these numbers and figures help me understand some of the rationale behind the ACA and provide some empathy for its attempts to address a serious problem. What about to share are a lot of numbers. Don’t get lost! There is a purpose behind them and if you can stay with them, I think you’ll find yourself more informed.
Healthcare Spending in the US reached $2.6 trillion in 2010, which is 17.6% of our gross domestic product (GDP). It’s expected to rise to $4.7 trillion or 19.8% of GDP by 2020. These rising costs are due in part to the impact of major coverage expansions in 2014 and beyond, as a result of the ACA and projected Medicare enrollment growth. By 2020, estimates suggest the government will pay 49% of all healthcare costs (Keehan et al., 2011). In 2009, only 1% of the US population accounted for 63.6% of all healthcare spending. A different half of the population accounted for only 2.9% of all spending (Cohen & Yu, 2012). Due to these numbers, there is a growing awareness that medical and mental-health problems are often linked. Patients with diabetes and heart disease have twice the rate of anxiety and depression as the general population, which in turn makes it harder to make healthy changes like losing weight. Hence, a key to bending this cost curve is development of care systems that target that part of the population accounting for the greatest costs.
Here’s another interesting fact, approximately 25% of primary care patients have one or more disorders – mostly anxiety, depression, or substance abuse, according to a recent JAMA study. Time pressed primary care doctors typically hand such patients a referral to a mental health specialist, but only 60% of these patients followed through, according to a 2002 study in Seattle conducted by the University of Washington. In contrast, in an integrated practice, doctors can do a “warm handoff” instead, personally introducing patients to a therapist on site. By integrated, the experts mean a clinic or hospital that houses a wide variety of providers, including ones for mental health. Many studies have shown that integrated care can reduce patients’ depression and cut costs. One University of Washington study of 1,800 patients found that providing a year of integrated care cost $600 a patient but saved an average of $4,000 in lower medical bills over the next four years. It is with this in mind that patient centered medical homes and Accountable Care Organizations (ACO’s) have been piloted and tested for persons with chronic illness, including serious and persistent mental illness (Grumbach & Grundy, 2010) A perfect example of an ACO is the Kaiser Hospital system here in California, which is a group of hospitals, physicians, and other providers who share responsibility for the cost and quality of care for a defined patient population. What experts seem to be saying is that significant savings are possible but ACO’s require intensive collaboration and investment to support care management and exchange of sensitive performance data. What are being included in these ACO’s are psychologists and mental health clinicians. However, one has to keep in mind that the kind of work psychologists are doing in ACO’s is very different than the work done in private practice offices. Psychologists who work in the ACO setting are doing important work but the pace is frenetic, sessions typically last 15 to 20 minutes, and group therapy is common. Patients are commonly seen only 3 – 5 times and provided problem solving skills, relaxation techniques, or psycho-education. As you can see, there is a tension represented here. An ACO’s design is attempting to target more patients who have psychological issues because to do so will actually result in more savings over the long haul. And if more people are going to be insured, because of the ACO, then you can see why hospitals want to include more psychologists in house. However, like I just mentioned, the kind of treatment provided in the hospital is of a very different kind than provided in the private practice model.
For a brief, but effective look at encouraging psychotherapy, feel free to view the following short videoclip!
I’ve been reflecting much on death and dying recently. I seem to have encountered the concept frequently via personal and professional contacts. A couple of months ago, I was given the opportunity to say goodbye to a beloved professor from my doctorate program. After fighting metastasized cancer for 14 years, this woman was officially given two to three weeks to live. Along with approximately 40 other students from my program, I was given the honor of sitting in her presence for two hours, expressing to her my deep gratitude for her life and love. It was one of the most moving experiences of my life. Despite the fact that this woman has been “dying” for 14 years, she’s one of the most “alive” human beings I’ve ever known. Rich in psychological depth and spiritual understanding, this lady has changed the lives of many. I’ve pondered the lessons this woman’s life and death may have for me.
I don’t believe there’s any topic more anxiety ridden than the idea of death or loss. In fact, the basic premise of Ernest Becker, in The Denial of Death, is that human civilization is ultimately an elaborate, symbolic defense mechanism against the knowledge of our mortality. One need only turn on the television for a few minutes before encountering various topics promising some form of elongated life. Multivitamins, face cream that stops aging, and plastic surgery, to just name a few. We humans seem to struggle mightily with the idea of death, of loss, of terminations, or of endings. We balk at them and cry at them. We avoid them, but then we dream about them. Depending on the type of death (or loss), we may become depressed, overwhelmed, avoidant, or fearful. We also might fight bitterness, anger, and loathing, as a result of the loss we’ve been dealt.
In the days since meeting with this beloved professor, I’ve found myself reflecting on several thoughts. First, she was unafraid and showed no bitterness. Confident of her spiritual standing and grateful for the years she lived, this lady exhibited a peaceful acceptance. It was remarkable. Simultaneously, she was also refreshingly honest, stating that saying goodbye to her two children and her husband was going to be “the most difficult things [she] has ever done.” She paused, and then added, “but the pain and hurt is worth it…because it means I became attached. I only hurt this deeply because I have loved deeply.”
I don’t think that it’s ever too soon to think about the meaning of one’s life. Sitting with death, deeply and honestly, has a way of focusing our energies and cleaning our senses. It invites us to think about our relationships, how we spend our time, and how we treat others. Each of you is doing something with your life. Whether it’s buying groceries, sipping coffee, or spending time with those whom you love, I urge you to do it wholeheartedly and with great kindness, knowing that you’re engaging in life, encouraging others to live more fully, and changing the world in the process.
Happy people don’t hide from emotions but instead tend to acknowledge that life is full of disappointments and are willing to address them. Feelings of anger can be effectively utilized to stand up for oneself or in becoming more assertive. Feelings of guilt can be used to motivate oneself toward behavioral change. This mental flexibility between pleasure and pain, the ability to shift one’s behavior to match a situation, is known as psychological flexibility and results in greater wellbeing! Columbia University psychologist George Bonnano found that in the aftermath of 9/11, the most psychologically flexible people living in New York City during the attacks bounced back more quickly than their less adaptable counterparts. Specifically, Dr. Bonnano found that those individuals who were angry at times but could also conceal their emotions when necessary enjoyed greater psychological and physical health in the months and years after 9/11. Opportunities for flexible responding are frequent. Perhaps a colleague appeared rude and demeaning. Instead of letting your hurt and anger simmer quietly, accept your feelings as a signal, which allows you to employ other strategies for reacting. These include compassion. Perhaps the colleague is experiencing an emotionally difficult time. Another strategy includes mindful listening – being curious about what might be occurring in the life of this colleague that has nothing to do with you. Similar to training for a marathon, learning the skill of emotional discomfort is a task that’s learned over time. So instead of pouring yourself a glass of wine next time you get into an argument with your spouse or family member, try simply tolerating the emotion for a few minutes. Before you know it, your ability to tolerate daily negative emotions will expand.
It’s easy to assume that when we encounter difficulties, it’s the presence and empathy of a good friend that assists one in journeying through the pain. Whether we get passed up for a promotion, find ourselves in conflict with a family member, or encounter a loss of some sort, it’s the presence of a good friend, or of benevolent social support, during those times that makes all the difference in the world, right? Interestingly enough, recent research from psychologist, Shelly Gable (USC in Santa Barbara), has found that the happiest people are the ones who are present when things go right for others – and whose joys and wins are regularly celebrated by friends, as well. Dr. Gable also found that when romantic partners did not make a big deal out of each other’s successes, the couple is more likely to break up. As it turns out, when couples celebrate each other’s accomplishments, they’re more likely to be satisfied and committed to their relationship. But aside from intimate relationships, why would it be conducive to be genuinely happy for a friend’s success, even in an area in which you yourself may struggle? (For example, your friend gets the promotion after you’ve been turned down numerous times!) The process of discussing positive events with a responsive listener actually changes the memory of the event. So after telling you about it, your friend will recall that night as even more positive that it was. And more importantly, the next time your friend encounters a difficulty, he/she will recall your positive support. So while it may be kind to send a card to your friend when he/she was dumped, you’ll both achieve more satisfaction out of the flowers you send her when she gets that promotion or when he graduates with his medical degree. Happier people are those individuals who actively celebrate others’ successes.
Research appears to suggest that satisfied people are less likely to be analytical and detail-oriented! University of New South Wales psychologist, Joseph Forgas, found that happy people tend to be less skeptical than others, uncritically open toward strangers, and can be vulnerable to lies and deceit. When negotiating the finer points of a complicated and social world of colleagues, dates, and friends, it certainly seems adaptable, and even advisable, to pay attention to the finer details. Yet, research seems to suggest that too much attention to detail can interfere with basic daily functioning. Psychologist Karen Harkness, from Queen’s University, found that individuals in a depressed mood were more likely to notice minute changes in facial expressions. Meanwhile, happy people tended to overlook these small changes in others’ faces. A flash of annoyance, a sarcastic grin, a rising of the eyebrow – were all fluctuations that happy people seemed to overlook more easily. While in a bad mood, we tend to notice the tiniest shifts and can’t seem to disengage from an argument. The happiest people seem to have a natural protection against getting sucked in by the pull of those little details. For example, a nice analogy might be the effect of water on a duck – it slides right off! Another way to put it, perhaps, is “not sweating the small stuff.” Don’t get me wrong, paying attention to details is helpful, but too much focus on minutiae can be exhausting and debilitating. The happiest people accept that striving for perfection is a loser’s bet and are willing to let small offenses go by the wayside.
“Truly happy people seem to have an intuitive grasp of the fact that sustained happiness is not just about doing things that you like. It also requires growth and adventuring beyond the boundaries of your comfort zone.” (Kashdan & Diener, Psychology Today, Aug 2013) Simply put, happy people are curious. In a 2007 study done by Kashdan and Michael Steger, participants were monitored for 21 days on their daily activities and how they felt. Those who felt curious on any given day also felt the most satisfaction and engaged in happiness-inducing activities. Interestingly enough, curiosity is at its base an anxious state. It’s a state of not knowing and is largely about exploration. Studies seem to suggest that curious people accept the notion that while being uncomfortable and vulnerable is not an easy path, it can also provide a means of becoming stronger and wiser. In fact, the study performed by Kashdan and Steger suggests that curious people invest in activities that cause them discomfort but the result is often a higher psychological peak. So, from time to time, it seems that it’s worth engaging in an experience that is novel, intricate, uncertain, and even upsetting.
In an article in the August submission of Psychology Today, authors Kashdan and Biswas-Diener attempt to tackle the question of happiness. Interestingly enough, the question of happiness is not uniquely an American ideology. Psychologists Ed Diener of the University of Illinois at Urbana and Shigehiro Oishi of the University of Virginia studied more than 10,000 participants from 48 countries. They discovered that individuals from all over the world rated happiness as being more important than other personal outcomes, such as having meaning in life, becoming rich, and getting into heaven. The article mentions that true happiness is probably better described as a sense of peace or contentment. It also includes cognitive reflections, a state of mind, and as such, can be intentional and strategic. And not surprisingly, certain choices you make throughout the day can push you toward increased well-being – or not. Happy people, it turns out, engage in some counterintuitive habits that seem downright unhappy! So stay tuned for a collection of findings that researchers have found increase a sense of well-being!