A memoir by the mother of a teenage girl with anorexia, written with her daughter's consent. (Her daughter is given the pseudonym "Kitty.")

There are a number of memoirs by people with anorexia (by far the best-written is Wasted by Marya Hornbacher, which is worth reading for the prose quality alone), but fewer by their loved ones. But a child with an eating disorder affects and is affected by the whole family.

This book attracted some really angry negative reviews, many of which took very vehement exception to Brown's refusal to take the blame for her daughter's illness, and for her saying that her family became temporarily dysfunctional due to the stress of it, but was doing basically okay before and after. I have no idea whether that's true or not, since all I can go by is the book itself. But I was struck by how pissed off a subsection of readers were at a mother saying, "This wasn't my fault" and "I think my family has good relationships," and how sure they were that this couldn't possibly be the case--that if a child has a mental illness, the mother and her family must be to blame.

Brown thinks the culprit is a combination of genetic predisposition and social pressure. She leans more heavily on the former as a factor in anorexia in general than I personally would, and if her account is correct, it does sound like that played more of a part in her daughter's case than it usually does. From her perspective, anorexia descended on her daughter like the demon in The Exorcist; while Brown herself had some mild issues with eating and weight that could have also affected her daughter, they're the sort of issues that probably 90% of white American moms have, and 90% of all daughters aren't anorexic. She might be in total denial about terrible problems within the family... but she might not be. Being a "good enough" family isn't a magic shield against mental illness.

As a memoir, it's gripping and well-written, and makes a convincing case for the family-based (Maudsley) approach to treating anorexia. (That approach also has very convincing evidence behind it.) But it's the response to it that fascinates me. Like I said, maybe the reviewers are right that she's lying or in denial. Brown does sound a little defensive. But who wouldn't sound defensive if she's constantly getting blamed for the illness that nearly killed her daughter? Could any mother have told her story without being blamed?

Americans are very apt to blame the victim. In every respect. And that goes one million if they're female. Were you raped? It's your fault for going on a date/wearing that dress/trusting your uncle/not buying a state of the art home security system. Do you have anorexia? You're vain/weak-willed/selfish/not really sick. Does your child have anorexia? You're a bad mother.

Brown's unknowable truthfulness or accuracy aside, there is nothing more infuriating to a big section of America than a woman who says, "It wasn't my fault."

Brave Girl Eating: A Family's Struggle with Anorexia
Barbara Ehrenreich rips toxic positivity a well-deserved new one in this much-needed but unfortunately poorly organized book surveying the origins, bizarre applications, and downside of the American obsession with positive thinking.

The first chapter is about how her diagnosis with breast cancer lands her in a strange new world of enforced positivity and a weird, mutant, and extremely pink version of feminist femininity.

She clearly traces the journey from breast cancer being an unspeakable and hidden doom to how genuinely needed efforts to get it more funding and make it seem less of a shameful death sentence went off-kilter in some very strange ways. For instance, support groups (needed; very helpful to many women) get so obsessed with the idea that positivity is essential to survival that they refuse to allow women to express any negative emotions, especially anger, for fear that they will literally kill them; one of Ehrenreich's ends up ostracizing a dying woman for being angry and depressed.

As Ehrenreich points out, actual research on the effect of positive thinking on illness outcomes is complicated at best. Just to start with, many studies don't actually say what people think they say, and "positive thinking" is extremely hard to measure. And then there's the whole issue of correlation vs. causation: the patients who were more positive might have felt more positive because their illness was less severe, they had better medical support, etc, while the more negative patients might have had worse symptoms, couldn't tolerate the treatment, etc. So it might not be that positive thinking causes better outcomes, but rather that people who were going to have better outcomes anyway are more likely to be positive. And so forth.

And even if positive thinking really does make it that fraction more likely that you'll live longer (even the best-crafted studies don't show large differences), can positivity be forced? If it works at all (it may not) does it work if it's forced, or does it have to be sincere? Does telling people they need to smile or they'll die produce the sincere happiness that's supposedly needed. Or is it more healthy to feel and express the emotions you sincerely feel, even if they're not positive?

And how come, out of all the illness-based positivity hammering, it comes down hardest on a disease primarily affecting women? Could it be that "smile, smile, smile, look on the bright side, use the opportunity to bond with your loved ones, and whatever you do, don't be angry" is a message that American women get anyway?

Ehrenreich's righteous fury burns through this chapter, fueling a killer takedown of bad science, not-actually-feminism, and cruelty disguised as kindness. It was brilliant and if she'd written the whole book on that, it would have been stunning. Also, there is definitely enough material for a book's worth.

The rest of the book unfortunately leaves the subject of breast cancer and, in most cases, illness behind to first explore a possible root cause of the whole positivity movement in the US, then devote a chapter each to various idiotic and rage-making applications. It was interesting but didn't live up to the beginning. Unless I missed it, the US is really overdue for a current version of something like Susan Sontag's Illness as Metaphor and AIDS and Its Metaphors

Bright-sided: How the Relentless Promotion of Positive Thinking Has Undermined America
Morrison’s book is a textbook for mental health clinicians. It is exactly what it says on the tin. It’s easy reading and could be read by a layperson with some knowledge of psychology. He lays out a number of important principles. I’ll just note a few that I find particularly useful.

In my own practice, I don’t often find diagnosis challenging in the sense of “What official diagnosis could this person possibly have?” (It has to do with where I work. Most of our clients were recently traumatized or court-mandated, so their issues tend to be pretty obvious - PTSD, depression, anxiety, life stress, etc.)

But the principles are still useful. For instance, I often have clients who match the criteria for multiple disorders. It is not at all uncommon for one person to fit the criteria for PTSD, generalized anxiety disorder, major depression or dysthymia, agoraphobia, panic disorder, and social anxiety. Which one is the most important? Is one causing all the rest? Which should I treat first? Which treatment is best for this person, given that they could in theory benefit from treatments for all the disorders? Is there one treatment that would cover several?

Also, sometimes the initial diagnosis is wrong or incomplete, and they need additional or different treatment. For instance, the client comes in with a clear-cut case of PTSD. But maybe they’re also non-neurotypical and have never been diagnosed. Or they were bulimic before and didn’t tell me about it. Etc.

Prioritization by safety hierarchy.

Since tests and investigation take time, you need to immediately check into some things, and leave others for later investigation. First, check for issues which are potentially life-threatening but treatable and likely to have a good outcome; last, check for issues which are not immediately life-threatening, hard to treat, and not likely to have a good outcome. In the middle, look for things in between. For instance:

1. Suicidality, major depression, bipolar disorder, medical illness. All potentially very dangerous, all potentially very treatable.

2. Panic disorder, OCD. (Very treatable but not immediately dangerous.)

Substance abuse without suicidality. (Potentially very dangerous, but difficult to treat; practically speaking, you can put a hold on the person who is threatening suicide, but you can't put a hold on a heroin addict just because you worry that they might accidentally OD.)

4. Personality disorders, dementia (if the person has caretaker and isn’t in danger of wandering into traffic or some such). Not easily treatable; may be life-threatening (Alzheimer’s) but immediate intervention won’t change that.

History beats current appearance

If you’re talking to someone who was raped last month, they will usually appear to have major depression, generalized anxiety, etc. Find out if they ever had any of those symptoms before.

Someone with a history of depression or anxiety is a better candidate for a psychiatric referral than someone who was fine pre-trauma. If someone was depressed before, treating their PTSD may not cure their depression, so they should be getting a med consult ASAP. (They are also much more likely to be open to the possibility of taking medication.)

If they have no previous history of depression and are not suicidal, sending them to a psychiatrist is not a priority; by the time they found an anti-depressant that worked for them, their depression may have resolved anyway because it wasn't true depression; it was a depressed mood caused by trauma. Treat the PTSD, and the depression goes away. Also, these people frequently don't want to take meds. (In those cases, I bring it up again if their PTSD seems to be resolving but they have persistent symptoms of some kind that are not improving with talk therapy. I point out that they may just need a little extra help in this one area, since we've tried our best with non-medical means and, unlike their other issues, it's not going away.)

And along similar lines:

Be cautious about diagnosing mental illnesses in people actively abusing substances when they do not have a known previous history of mental illness. Especially if they appear to be psychotic.

Maybe they’re schizophrenic. Maybe they’re bipolar. Maybe they’re depressed. But it is really hard to tell if they’re also snorting coke and drinking a bottle of whiskey every day. Very likely they do have some mental illness, but which one? Defer diagnosis and refer for specialized treatment (unless you’re the specialist.)

Get a family history

This is useful in so many ways. For instance, if you have a client balking at medication, knowing that their father was a drug addict may open up a conversation about exactly what their concern is – maybe they don’t know that SSRIs are not addictive. On a more obvious note, if there’s a long family history of depression, that makes depression a more likely diagnosis. Many mental illnesses run in families. (Typically, both genetic and learned factors are in play.)

Look for horses before you look for zebras

The teenage girl who seems anxious and pulls at her hair might have trichotillomania (the compulsion to pull out her hair.) But I’d check for anxiety, depression, trauma, neuro-atypicality, or even OCD first. (I'd start by asking her what the hair-pulling is about.)

Keep an open mind

Don’t just assume that previous diagnoses are correct. That includes your previous diagnosis. That also goes for family history. The “alcoholic grandfather” may have been self-medicating something.

Consider medical causes, including environmental ones

I once correctly diagnosed a client’s “panic attacks” as caffeine withdrawal. Morrison once thought he was suffering from a panic attack (he was in combat at the time, so very understandable) but it was actually an electrolyte imbalance – he’d forgotten to take his salt tablets. Once he took them and drank some water, his symptoms vanished.

Clients with chest pains need to see a medical doctor to rule out heart problems if they haven't already, even when you’re 100% sure it’s panic/anxiety. Depressed, low-energy, overweight clients and anxious, skinny, eye-bulging ones should get their thyroid checked. If there is any reason to think there may be a medical issue going on, send them to a doctor.

Always about ask medications a patient is taking, and ask again if they present with new symptoms with no clear cause. Specifically include OTC meds, herbal meds and supplements, and recreational drugs. Also ask if they’ve recently given something up.

Similarly, ask if they’ve been recently diagnosed with a medical condition. Many medical drugs and some medical conditions can have psychiatric side effects.

Clients presenting with a completely new condition in middle age with no clear cause (ie, not PTSD from a recent trauma) should be strongly considered for a medical cause. Mental illnesses (again, other than PTSD) tend to have a history, and middle-aged people are more likely to be physically sick than young people.

"Undiagnosed" is a perfectly legitimate label to use when you don't know what's going on, or don't have enough info to go on. Don't be embarrassed to use it.

The rest of the book is about diagnosing specific illnesses, such as “How to diagnose OCD.” It’s quite helpful (especially the diagnosis trees) but I thought the general principles above were more interesting for a general audience.

Diagnosis Made Easier, Second Edition: Principles and Techniques for Mental Health Clinicians
The Essential Jung. When people tell me Jungian stuff, I love it! And then I attempt actual Jung. Where are they even finding all those cool ideas? All I am seeing is (opening at random) Even though alchemy was essentially more materialistic in its procedures than the dogma, both of them remain at the second, anticipatory stage of the coniunctio, the union of the unio mentalis with the body.

And it's not just because I'm opening at random. When I was in school I started from the beginning. The effect was exactly the same as if I'd opened it at random. Has anyone here read Jung in German? Is this just a translation effect, or is he equally incomprehensible in the original? (And what if you do know German, but you don’t know Latin? WHY IS THE LATIN NEVER TRANSLATED?)

Owning Your Own Shadow, by Robert Johnson

First sentence: The shadow: what is this curious dark element that follows us like a saurian tail and pursues us so relentlessly in our psychological work?

This is not Johnson’s fault but I was irresistibly reminded of Ursula K. Le Guin’s The Language of the Night (one of my all-time favorite books, by the way) in which she mentions a terrible sf story she read as a child which concluded with “And so they returned to the saurian slime from whence they sprung!” She and her brother created the jingle,

The saurian slime from whence they sprung
Unwept, unhonored, and unsung.

No, okay, that is Johnson’s fault. That is a ridiculous sentence and it also deserves a mocking jingle. I know it’s a metaphor, but it is also an image. Please take a moment to picture a psychoanalyst being stalked by a disembodied lizard tail.

If you don’t know the concept of the shadow this book is a decent introduction to it, but you could do much better. Unimpressive.

Inner Work, by Robert Johnson. This is actually a pretty good book on working with dreams and imagination and the unconscious. I’m not keeping it because I get the principles and it’s not so well-written or uniquely insightful that I’d re-read. But if you’re interested, this will give you a lot of useful tools.

I don’t do a lot of dream work, either for myself or for my clients, but it comes up occasionally. (I do a lot of work with PTSD-related nightmares, but that’s a different thing. Those are not subtle.) When clients ask me what a dream means, I tell them that only the dreamer can know the meaning of the dream and ask them what they think it means. If they have no idea, I start asking what specific parts make them think of, if anything has a cultural meaning or how dreams are generally interpreted in their culture, etc. (“Is there anyone in your family who knows a lot about dreams?” Not uncommonly, there is.)

Treating Eating Disorders, ed. Werne. This is from 1996. I’d rather read something more recent. I think a lot of ideas in the field have changed since then.
In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness, by Peter Levine. This is the guy who invented somatic experiencing. I am sure it works when he does it. Lots of therapies work because they're done by charismatic, compassionate, insightful people who believe in what they're doing. (In fact, therapy in general works that way, even when using highly structured therapies like CBT for phobias.)

This book? USELESS. FACTUALLY INCORRECT. STUPID. He explains that he saw lions chase zebras on TV, and the zebras who escaped would shake and twitch, then recover and go about their lives without getting PTSD. HOW CAN YOU TELL? YOU WATCHED ANIMAL PLANET. YOU DID NOT FOLLOW UP WITH THE ZEBRAS. He concluded that animals don't get PTSD (FACTUALLY INCORRECT. Anyone who has ever seen an abused pet has seen PTSD in animals.) and that the reason is that they physically shake out the trauma. And so he created a treatment based on shaking out the trauma. I am being unfair and simplistic but only slightly. This dude was highly respected at my school, too. I'm sure someone will appreciate this book over there.

Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma (Norton Professional Books), by Babette Rothschild. Summary: vicarious traumatization is a thing. If you're a therapist, maintain boundaries, be aware if you're getting too affected by other people's pain, and practice self-care. There, now you don't have to read this book.

The Psychology of the Transference (Ark Paperbacks), by Carl Jung. From this we must conclude that the symbolism of the stories rests on a much more primitive mental structure than the alchemical quaternio and its psychological equivalent. I am not smart enough to read this book.

The Theory and Practice of Group Psychotherapy, Fifth Edition, by Irvin Yalom. This is a pretty great and classic work on a very specific type of group therapy that I HATE and never intend to do. ("I have difficulties relating to others, let's work these out experientially in a group focused exclusively on how the group interacts with each other." I'm sure this actually works very well when someone as skilled as Yalom is running it, but 1) it's not my thing, 2) it can very easily turn into a parody of itself in a very specific way, 3) I was permanently traumatized by a badly run group of this sort in college, which did become the parody, in which this exchange actually occurred:

Group Member A: "I notice that your foot is pointing in my direction. I wonder what you intend to convey by that."

Dude with Foot (hastily moves foot): "Er… No, my foot just happened to be there. I didn't even notice it was pointing at you."

Group Member A: "You sound defensive. Were you pointing it at me subconsciously, because you have some unexpressed anger at me?"

Dude with Foot (moves foot back): "No… but NOW I'm feeling angry!"

It's also a very expensive required text at Antioch. Someone else will benefit from this book, but I don't need it.

Fast Girls: Teenage Tribes And The Myth Of The Slut, by Emily White. This is actually a pretty good book on sexism, rape culture, how girls get labeled "sluts," how this is perpetuated by both girls and boys and society at large, and the effect this has on everyone. It's just that I get this, so I wouldn't need to re-read it, and it's not so brilliantly written that I'd keep it just for that.

Therapeutic Communication: Developing Professional Skills, by Herschel Knapp. If you don't find that therapeutic communication (validating, challenging, interpreting, etc) comes naturally to you or is something you learn by doing, this is an EXCELLENT book. I personally find that I learn it by doing or by listening to other therapists describe what they do in specific cases rather than in generalities.

Also, I find that responding instinctively/intuitively/spontaneously - even if it's something I technically shouldn't say - goes over better with clients than when I say the "correct" thing in a more artificial/non-spontaneous way. (There is a specific technique key to narrative therapy called "externalizing the problem" that for whatever reason feels really unnatural to me, and whenever I try it, my clients look at me like I have two heads. My own therapist does it with me, and it works great. I use a narrative philosophy and other narrative techniques, and just ignore externalization. You have to do what works for you.)

So for me, this was not a book I'd return to. It will help someone else, I'm sure.
But first, a brief health update. The relevant bit for this entry is that while my most recent experimental treatment (rifaximin) had no effect whatsoever, I am still feeling good enough from the combination of the semi-successful sleep experiment (it didn't permanently fix the problem, but it did improve it) and the previous successful experimental antibiotics that I am attempting to catch up on six months' worth of stuff I didn't due because I was too sick.

I have just begun experimental antibiotic treatment # 4: two of the same ones that worked before for a slightly longer period (14 rather than 10 days) and one at a higher dosage, minus the one that had horrible side effects. If it is a complete failure, that will at least suggest that the key factor was fucking tinidazole (or tinidazole combined with something).

Anyway, I am procrastinating starting with the easier long-delayed chores before working my way up to the harder stuff.

Problem: I have too goddamn many random books that I don't want and are cluttering up my apartment. One of today's tasks, chosen for being low-energy-required, amusing, and producing a visible and wanted change, is to get rid of a chunk of them.

Step 1: Sort unwanted books into three categories based on what I'm going to do with them.

Category 1: Psychological books that are outdated, not useful, etc. Some of these are quite expensive textbooks, but I don't have the time/energy to sell them or mail them to people who want them. Instead, since I am going to Antioch (old campus) anyway on Thursday, I will leave them in the student's lounge with a note saying to take them if you want them. Some student or students will be very grateful to save hundreds of dollars on required texts.

Category 2: General books I don't want. These will be delivered to the library. If the library doesn't want them, they go to the thrift store next to the library.

To help motivate me, I will record the books as I go along. This is the possibly amusing part. Please feel free to comment! That will also help motivate me. The next post will be updated daily with actual books.

My opinion on books meant to be helpful to the therapist, by the way, is that they are mostly useless. Or rather, that they are the wrong books. Want to treat combat veterans? Read memoirs by veterans. Those are about a billion times more helpful than textbooks. Want to apply Jungian principles to therapy? Read Robertson Davies' The Manticore. I doff my hat to anyone who gets anything out of reading Jung himself but a headache. Want to understand Carl Rogers? Watch videos of him in action. (His book is fine. It's just that the videos are SO MUCH BETTER.)

If anyone cares, when I am done I may do an overview of the short list of books that I did find helpful.
Reading for one of my trauma classes. I’m not summarizing the whole thing, just bits I found especially interesting.

Chapter One: Clinical Features of PTSD. Nothing new here.

Chapter Two: Cognitive and Behavioral Features of PTSD.

Amnesia. People rarely have global amnesia for traumatic events (not even knowing it happened or having no memories of any of it), unless they also had a head injury or other physical damage (ETA: or are children, or there were a whole series of similar events, of which only some are remembered. What doesn't happen often: a sober adult has something horrible happen to them, and later does not even recall that it ever happened.) But partial amnesia is extremely common. A typical example is “weapon focus,” in which a person might recall every detail of the gun but nothing about the attacker’s face.

Taylor suggests that this is caused by “attentional narrowing,” which is a common result of extreme arousal. The apparent amnesia is caused by hyperfocus on certain details and total ignoring of others, so the ignored details were never encoded into memory at all. (As opposed to being forgotten or being present but inaccessible.)

My note: be upfront with people about this – they may never be able to recall everything, and that’s okay. Total recall is not necessary to healing.

Guilt. Trauma survivors tend to have a number of incorrect beliefs about the trauma which cause them a lot of pain and suffering. Helping them identify and argue with these beliefs can be very helpful. Great breakdown of common false beliefs on p. 34-35. I’ll just list a few.

- Hindsight bias. “I should have (magically) known the drink was roofied.”

- Justification distortion. “What I did/did not do during the trauma was unjustified.”

- Responsibility distortion. “It was entirely my fault.”

- Wrongdoing distortion. “What I did during the trauma went against my morals and ethics.”

These come about for the following reasons (I only excerpt a few); unraveling them and making them explicit may be very helpful.

- Judging your actions not based on the reality of the situation, but against an ideal or fantasy that didn’t actually exist. “I should have disarmed and kicked the asses of the men who were holding me at gunpoint.”

- Blaming yourself for not acting on ideas you didn’t get until after the fact. “I should have memorized the license plate.”

- Overlooking actual benefits of actual actions. (ie, you got out alive, possibly because of what you actually did.)

- Focusing only on imaginary good outcomes of actions you didn’t take. “If I’d tried to disarm him, I definitely would have succeeded.”

- Not taking into account that when all options are bad, selecting the least bad is a highly moral choice.

- Not taking time and emotional factors into consideration – what you’d do if you had an hour to contemplate it in the peace of your own living room is different from what you do when you have seconds and a gun to your head.

Beliefs about Symptoms

- People with PTSD often think their symptoms mean they’re “going crazy.”

- They tend to interpret emotions or physiological responses as objective truth. “My heart is pounding and I’m frightened, therefore the situation is dangerous.”

- Physical/emotional arousal has become so entwined with negative feelings that they may avoid all arousal, including that caused by exercise or positive feelings. (Anxiety sensitivity.) Interoceptive exposure (inducing arousal in a safe, controlled manner) is good for this.

Clinician's Guide to PTSD: A Cognitive-Behavioral Approach
A book on hallucinations which are not caused by schizophrenia and other psychotic disorders. (It also doesn’t deal much with culturally normal hallucinations, which is too bad.) Hallucinations – sensory perceptions which occur during waking and are not based on consensus reality - are surprisingly common, and include many experiences which probably most people don’t think to define as hallucinatory.

While drifting off to sleep, with my eyes closed, I often see kaleidoscope-like geometric patterns, faces (often grotesque or witch-like), and occasionally swarming insects. They are not dreams, are not perceived as being part of reality or projected into the real visual field, and do not have emotional connotations. I always assumed they were caused by going from visual perception to blank darkness while drifting toward sleep: a sort of meditative optical illusion/visual imagination.

They are called hypnogogic hallucinations and are extremely common, and the particular things I see are commonly seen, along with other stereotyped visuals. (“Stereotyped” as in common to people who experience the phenomenon, as opposed to “unique.”) They are caused, in simple terms, by the visual centers of the brain “idling” before sleep.

Hypnopompic hallucinations are less common, and are more vivid, often briefly perceived as real, often frightening illusions which occur upon waking from sleep. I've had those too, thankfully only a few times; mine were quite unpleasant, full-sensory illusions of being entombed in stone. They were not nightmares, though; I could also see my real surroundings. Once someone in the room with me verified that I had my eyes wide open and could track movement and respond to voices.

I have also sometimes, while wide awake, heard my name being called, when no one is there or when nobody called it. This is also extremely common. People in dangerous situations often hear voices giving helpful commands or suggestions; grieving people often see or hear their loved ones. These phenomena are common and “normal.”

I wish Sacks had analyzed those situations more in neurological terms, because I find that fascinating. The main theory he suggests, regarding auditory hallucinations in general, is that they’re a glitch caused by the brain failing to recognize its own thoughts. Another possibility is that people become consciously aware of the non-verbal stream of consciousness beneath their articulated thoughts, and perceive it as coming from the outside.

Sacks covers a number of hallucinatory experiences caused by neurological conditions, such as Charles Bonnet Syndrome, in which blind people hallucinate certain types of sights. Also, in a fairly funny chapter, his own youthful drug use.

The non-psychotic hallucinations are typically either never experienced as “real,” or are easily believed to be unreal once someone explains that they aren’t real, or are understood to not be real once they’re over. This is quite different from psychotic disorder-type hallucinations, which are often believed to be real, even when they end. (A person with PTSD may hallucinate, but they typically either always know the hallucination isn’t real, or, as in the case with flashbacks, figure it out in retrospect.) Regarding culturally normal hallucinations like ghosts, people may believe that they did literally see a spirit, but they also regard it as a spirit – a visitor from another realm. That’s a different experience from literally believing that Abraham Lincoln is living in your guest bedroom. (To avoid wank, let’s assume that I am only discussing those perceptions of spirits, God, etc, when they really are hallucinated and not objectively real.)

Hallucinations without accompanying delusions don’t usually cause major life problems for people. They are not “crazy,” though they might worry that they are. Delusions seem to be what cause the life problems.

The book is well-written and intriguing, as one would expect from Sacks, but more descriptive than analytical. Some types of hallucinations, particularly visual ones with a clear-cut neurological basis such as migraine auras, are explained in neurological terms, but others are simply described. The descriptions are quite evocative and the material is fascinating, but I would have liked more neurological speculation, especially on why certain situations or conditions create certain types of hallucinations, like fever deliriums causing distorted perceptions of size, which are almost invariably perceived as unpleasant or threatening.

I also wish he’d covered auditory hallucinations in more depth. At times he speculated on historical figures who might have heard voices. The problem is, many people write about the simple perception of their own thoughts in voice-like terms, so it’s very hard to tell whether someone literally meant they heard a voice, or only that their thoughts were so vivid that they seemed voice-like. It seems entirely possible, too, that two different people might have a neurologically identical experience, but one might attribute it to an outside voice and one to distinctive inner thoughts.

Please discuss your own experiences of and theories on hallucinations, if you wish.

Hallucinations
Classic work on cognitive therapy by one of its founders. Parts are technical, but overall it’s straightforward, easy to read, and a good introduction.

The basic idea of cognitive therapy (CT) is that a lot of anxiety is caused by thoughts. Typically, these are negative, irrational, automatic thoughts which go on at a low level of consciousness – not unconsciousness, but a sort of background chatter which you may not be aware of, but can easily call into awareness if you pay attention. Stuff like, “She hates me,” “I’m a loser,” “They won’t hire me,” etc.

These thoughts are what cause or precipitate anxiety, depression, and panic attacks; if you become aware of the thoughts, then you can challenge them and teach yourself to think them less. You will then be less depressed, anxious, and panicky. (Mindfulness-based CT suggests that all CT works not by literally changing your thoughts, but by changing your relationship to your thoughts. I think both are a factor, but I’m with the mindfulness camp that the relationship aspect is more significant.)

That’s the basic theory. I’ll highlight details I thought were especially interesting.

Read more... )

Cognitive Therapy and the Emotional Disorders
Recced by [personal profile] rydra_wong. Great rec, thanks!

Excellent, clearly written, honest memoir about the mind-body connection. My description is going to sound straightforward, but you really have to read the book to get what I got out of it. I've read a fair amount of memoirs and nonfiction about physical disability, mind-body issues, and even the type of paralysis Sanford has, and thought I understood much of what he discusses, at least on an intellectual level. After reading this book, I feel like I have a far, far better and more visceral understanding.

At age thirteen, Sanford was in a car accident which killed his father and sister, and paralyzed him from the chest down. He goes through puberty while still recovering from his injuries, which was fairly traumatic all by itself, and grows up seemingly doing fine, but inwardly suffering from being disconnected from his body. Well-meaning doctors told him that the sensations he had in the paralyzed parts were meaningless "phantom pains," and Sanford learned to dissociate himself from his body as a survival mechanism, to be able to endure otherwise unbearable pain.

Later in life, he begins studying yoga and learns that his entire body is still a part of him, and he does still have a perception of it and feelings from it. I already knew that people with spinal injuries do still have sensations below the point where the nerves are severed, but they're, essentially, transferred by indirect means and may be felt in other parts of the body or in different ways. Sanford explains not only what this actually feels like, but how important it is not only physically, but emotionally and even spiritually.

He is now a yoga teacher.

Fantastic book. Read it if you have any interest whatsoever in the subject matter, and by that I mean mind-body issues, not just physical disability or yoga.

Note that while Sanford doesn't get into tons of graphic details, there are fairly harrowing descriptions of injuries, medical procedures, and pain. The one that got to me the most was when he broke his neck a second time after the car crash, by tipping out of his wheelchair, and someone insisted on moving him despite his protests.

Waking: A Memoir of Trauma and Transcendence
A clear, well-written, informative, easy-reading book for the layperson on the history and current conceptions of autism, and what that means for people with autism. Grinker has an autistic daughter, and includes his own experiences with her to illuminate larger issues. He primarily writes about the US, but has two chapters with snapshots of the situation in South Korea and India.

I particularly liked the lengthy section in which he makes his case that autism is not increasing, but seems to be because we are more aware of it. I don't have time to lay out his detailed explanations of how he came to each of his conclusions, but the reasons for the perceived increase are as follows:

- It is only comparatively recently that autism, like many other mental and developmental disorders, has become understood as a unique phenomena rather than lumped in with every other disorder else as "mad" or "simple" or some such. That is, autism has always existed, but was not called "autism."

- Parents and researchers agitated for more awareness of autism. Once people became aware, they started noticing it more: laypeople recognized kids with autism, and doctors became able to diagnose it. Previously, the same kids would have been labeled mentally retarded or schizophrenic or something other than autistic.

- Due to improved services for autistic kids, pressure arose to diagnose kids with autism rather than with some other diagnosis which entitled them to less or inferior services. Hence, kids who previously would have been labeled mentally retarded are now labeled autistic. (Autism is also less stigmatized than mental retardation.) For the same reason, kids who have less severe problems, who previously would not have been diagnosed at all but would have struggled and been called weird, stupid, or lazy, now tend to get an autism diagnosis so they can get help.

- A misprint in an early edition of the diagnostic manual DSM-IV - "or" instead of "and" - led to many kids qualifying for an autism diagnosis who otherwise wouldn't have gotten it. (Basically, it should have been "must have this symptom AND this symptom," but it was printed as "must have this symptom OR this symptom."

Unstrange Minds: Remapping the World of Autism
Craziness also runs in the family. I can trace manic depression back several generations. We have episodes of hearing voices, delusions, hyper-religiosity, and periods of not being able to eat or sleep. These episodes are remarkably similar across generations and between individuals. It's like an apocalyptic disintegration sequence that might be useful if the world really is ending, but if the world is not ending, you just end up in a nuthouse. If we're lucky enough to get better, we have to deal with people who seem unaware of our heroism and who treat us as if we are just mentally ill.

This is Mark Vonnegut's second memoir. (Kurt Vonnegut's son.) The first one explains how he had a psychotic break while a young man living on a commune. Due to the circumstances, everyone at the commune just thought he'd become spiritually advanced. Eventually, his parents stepped in to rescue him. It concluded with the note that he was diagnosed with schizophrenia but apparently "recovered," which is unusual, especially given that it all went down in the 1960s. I had wondered if he'd been misdiagnosed.

His second memoir picks up many years later. He became a successful doctor... who periodically had psychotic breaks, to go with his drinking problem and falling-apart family life. But it's not primarily a story about pain and problems, but about one man's particular life. Every life has problems. Usually they don't involve being put in a straightjacket every ten years or so. But that's Mark Vonnegut's particular issue, or one of them, anyway, and he treats it very much in the manner of "everyone's got problems."

The memoir is at least as much about being a doctor as it is about having a mental illness of a somewhat mysterious nature. (He gets diagnosed with bipolar disorder later, but that might not be it either. Whatever he has, it's atypical.) It's also about life, and art, and being a misfit in a screwed-up society, and also about being his father's son (Chapter title: "There is Nothing Quite So Final As A Dead Father"). And accidentally poisoning himself with his shiny new hobby of mushroom hunting.

It's all over the place and hard to describe, but enormously funny, enjoyable, quotable, and wise. Its humane, humorous, epigrammatic tone reminded me a bit of James Herriot, and I love James Herriot. Unless you're really squicked by medical stuff or triggered by mental illness, this is the sort of book I'd recommend to just about anyone.

Just Like Someone Without Mental Illness Only More So: A Memoir
It took me 124 pages to become so annoyed that I decided to live-blog this book. Given that it is written by a hippie named Richard Alpert who changed his name to Ram Dass after becoming the follower of a guru named Maharajji, my annoyance was quite predictable.

Page 124: Ram Dass disapproves of an old woman who says that she will never forgive her dead parents. He condescendingly states that she is only hurting herself, and her refusal to forgive her parents (who, for all he knows, might have not just been unsatisfactory but actively abusive) will keep her "tethered to this resentment forever."

BARRRRF. Forgiveness is an emotion; like any other emotion, it is neutral in itself, subjective, and not something that can be commanded by others. Nor, often, is it something that can be commanded by oneself.

Forgiveness is not necessary to mental health or peace of mind. If it comes naturally, it can be very healing. But the recognition that some wrongs are unforgivable, and that victims don't need to forgive perpetrators, can also be very healing.

Who is he to judge? Did he experience that woman's pain? BAAARF, I say!

The book, which I have to read for a workshop on aging, consists of vomitous platitudes interspersed with some true but obvious statements about aging and acceptance.

Summary: We all get old. American society is prejudiced against aging and old people. We may not automatically like the changes that come with aging. But we should accept them and try to embrace them. If you don't accept and embrace, you are willfully being unhappy. If you do accept and embrace, you will be blissfully enfolded in spiritual peace. The Soul lives forever. God exists. I know this because I am the disciple of Maharajji, my totally awesome guru, who embodies all wonderfulness and Godly qualities. If he told me to drink Koolaid, I would accept and embrace.

Obviously, he's correct that many issues of aging are really issues of ageism. But some things do suck. It's one thing to talk about accepting and embracing wrinkles, and another to talk about accepting and embracing Alzheimer's disease. (I especially disliked his statement, not scientifically supported so far as I'm aware, that people with Alzheimer's who become paranoid, depressed, violent, or afraid are having previous, unresolved psychological issues surface.)

He seems judgmental and blaming toward people who feel anger or fear or depression and don't quickly move on to peaceful acceptance, and toward people who see anything as inherently negative or bad.

It's one thing to counsel people to look for moments of hope and happiness in their lives, even if they're in a generally bad situation. It's a totally different thing to counsel people to see a situation which they think is bad as actually being good. The first is healthy and reasonable. The second is denying people their honest feelings, and telling them they're wrong to feel the way they feel.

It's fine if people eventually, in their own time and way, come to the decision that something they originally thought was bad is actually good, or at least okay. But it's creepy, manipulative, and cultlike to tell them they have to think that.

Cut for discussion of death and dying.

Read more... )

Still Here: Embracing Aging, Changing, and Dying

Annoyingly, I have to read ANOTHER book by Ram Dass in a totally different class this quarter! WHY.

ETA: Went out before finishing book. He is now quoting some woman who channels "a disembodied being named Emmanuel." Not enough BLECCH in the world.
Brief notes on books I read a while back but never got around to writing up.

A Taste of China: The Definitive Guide to Regional Cooking (Pavilion Classic Cookery), by Ken Hom. An evocative, hunger-inducing travelogue/memoir/cookbook/food history by a Chinese-American author. A bit of a period piece now, but much of it is historical anyway, and it's well worth reading if you have an interest in the topic.

The Gift of Fear, by Gavin de Becker. The classic nonfiction book on the value of intuition: specifically, that fear - especially women's fear of men - is often based on having subconsciously picked up subtle signals of very real danger. I've re-read this book a couple times before, and it continues to be valuable: honest, easy to read, thoughtful, and very usable. One thing I'd forgotten was that de Becker himself was a survivor of childhood abuse and trauma, and is writing not only from his experience as a security expert but from his experience as a scared little kid.

This would make an excellent paired reading with Malcolm Gladwell's Blink: The Power of Thinking Without Thinking, which is also about how intuition works, but approached from completely different angles. Both books discuss false intuition based on prejudice or pre-conceived ideas versus true intuition based on the situation at hand, and how to tell the difference. Gladwell's book is more sociological, and de Becker's is more of a how-to.

Let's Take the Long Way Home: A Memoir of Friendship. It's an old story: I had a friend and we shared everything, and then she died and we shared that, too.

Probably the best memoir I've read all year. I read it when it first came out, and then re-read it several months later. Though Knapp's death frames the memoir, it's not primarily about that, but about the intimate, twin-like friendship between two women. Writers Gail Caldwell and Caroline Knapp bonded over their careers, their alcoholism and sobriety, and most of all, their beloved dogs. The structure is complex but seamless. Caldwell traces her own life story and how it paralleled and diverged from Knapp's, weaves it back into the story of their friendship, and then continues her story without Knapp, but always with her memory. It's extremely well-written, intense, and engaging, and reminded me quite a bit of another favorite memoir of mine... Caroline Knapp's Drinking: A Love Story.

It also reminded me of Ann Patchett's Truth & Beauty: A Friendship, another intense and well-written memoir about female friendship, in this case with troubled author and cancer survivor Lucy Grealy. Though Let's Take the Long Way Home, despite Knapp's early death, is a lot less tragic, since Caroline Knapp sounds like she had a lot more happiness and satisfaction in her life than poor Lucy Grealy ever did. It's also got way more dogs. In fact, it has enough dog content that I would especially recommend it to anyone who loves dogs. it contains dog death by old age, but is much more about what it's like to live with and love and train dogs.

You can click on the author tags to get reviews of the books I mentioned in comparison.
A practical, easy-reading guide to some common issues and obstacles faced by a beginning therapist. This makes a good companion to Yalom’s The Gift of Therapy, which could be described the same way but which has little overlap in content.

What I liked best about Cozolino’s book is his emphasis on the idea that no one is perfect when they start out, everyone feels like an imposter, and that mistakes are inevitable but not the end of the world. While Yalom discusses his own mistakes, they tend not to be embarrassing or stupid ones. Cozolino, to my relief, recounts some truly ridiculous errors of his own. My favorite was how when he was just beginning private practice, an earthquake hit in the middle of a session. Cozolino was so locked into his role as the “unflappable analyst” that he didn’t react at all.

Finally, his client said, “Um… Isn’t that an earthquake?”

Cozolino replied, “How does that make you feel?”

In retrospect, of course, he realized that he had acted like a robot, and also that he might have made his client feel that his own completely normal reaction was wrong.

The book has a nice balance between emphasizing being yourself and not getting so anxious that you become a robot, and pointing out ways to avoid making common errors. A few suggestions:

- Keep what you say as concise as possible. Clients tune out long monologues. Try to get to the heart of what you’re trying to say.

- Put emergency numbers on speed dial. Schedule any potentially dangerous (to self or others) clients for when your supervisor or other backup is present. Discuss emergency procedures with your supervisors before there’s an emergency.

- Stay calm. You don’t have to feel your client’s emotions. Provide hope, and provide structure. It can be helpful to boil down multiple problems into some central core issue, to make them feel less overwhelming and hopeless.

- Don’t try to reason people out of delusions. Cozolino has a great story here in which he tries to prove to a psychotic client that she is not pregnant with a kitten. When he attempts to enlist the other members of her group in this effort, he instead inspires her to persuade them of the truth of her delusion. They end up planning a kitten shower, to which Cozolino is browbeaten into contributing a litter box.

- Always get specifics, especially in the areas of child discipline, sexual behavior, alcohol and drug use, past diagnoses, and cultural and religious beliefs. “One drink” may mean “one glass of wine.” It may also mean “one liter of vodka.” “Spanking” may mean one swat across the butt. It may also mean “a blow to the head with a piece of wood.”

- If something tragic or traumatic happens to you, it’s better to cancel than to come in distracted and upset.

- Don’t voice an interpretation the first time it occurs to you. Sit with it and see if more supporting evidence turns up. Also, don’t get too attached to interpretations. It’s OK if clients reject them.

- Be aware that much of your fees in private practice will be eaten by office rent.

Incidentally, there’s a meme going around: “Pick up the nearest book to you. Turn to page 45. The first sentence describes your sex life in 2012.”

Using this book, I got: "In addition to a growing sense of confidence, it also helps to have crisis-situation action plans prepared in advance." Actually, this describes my sex life to date.

The Making of a Therapist: A Practical Guide for the Inner Journey
Another school book, this one for Personality 1.

A manual for accessing one’s unconscious via dreams and “active imagination.” Johnson is a Jungian and discusses archetypes, but emphasizes that most dream symbolism is highly personal. Whether one believes that dreams are literal messages from the unconscious, or that one’s interpretation of the largely random matter of dreams is a method for accessing unexplored areas of the psyche, if one has any interest in exploring dreams and the unconscious, Johnson’s methods seem likely to be helpful.

He outlines detailed steps for dream interpretation, as follows:

Associations: Write down all the associations for each element of the dream, one at a time, not censoring oneself. That is, if the dream involves a blue car, all the associations for “blue.” Then all the associations for “car.” Etc.

Dynamics: Connect the images and associations with one’s inner life. Which associations seem intuitively valid? What in one’s inner life might relate to them? He suggests that real people in dreams typically don’t represent the actual people, but characteristics one associates with them.

Interpretations: Search for the central message that seems to be communicated.

Rituals: Do a small but concrete ritual action to cement the meaning of the dream and its message.

He also explains and gives steps for “active imagination.” Basically, this is doing somewhat directed daydreaming while writing down the daydream as it occurs. This sounds potentially interesting, and I will try it. (There’s way too much involved to try to summarize it here, but the book is easily available in the US, if you’re curious.)

Caveat: some mild gender stereotyping, and romanticizing of the past and non-western cultures.

Last night I dreamed that Anthony Bourdain and I were strolling around an indoor-outdoor food court somewhere in Asia, sampling and discussing all the food. We each tried a lamb skewer with different seasonings, his tandoori, mine spice-rubbed, then took a bite of the one we didn't get. He deemed mine "tough but good." I also recall ramen, donburi, and some very fancy wagashi.

Inner Work: Using Dreams and Active Imagination for Personal Growth
Summary: Lots of parents were the victims of child abuse and parents who crushed and denied their feelings; they then abuse, or deny and crush the feelings of their own children. It takes lots of therapy to overcome this. Many patients come in claiming that their childhoods were just fine, but after a bunch of sessions, they realize that actually, their childhood feelings were denied and crushed.

Moms! The first few weeks of infancy are crucial, and if you aren’t perfectly sensitive and loving (while you’re sleep-deprived, exhausted, and overwhelmed) you will cause enormous trauma to your child, which will persist throughout their entire life unless they do intensive therapy.

My feelings: Meh. I agree with what she says when it comes to actual abuse, of course. But a lot of what she talks about sounds a lot more like “failure to be perfectly sensitive and caring 24-7.” I bet Miller hates the idea of “good enough parenting,” but it came to my mind a lot while reading. It takes a lot to make me to think, “You’re being awfully hard on parents,” but I did. Not to mention, “Parents could often stand to be more sensitive, but kids are probably not going to be OMG traumatized for life because their parents let them have bites of ice cream but wouldn’t buy them their own cones,” and “Stop insisting that people are in denial just because they aren’t saying what you think is the truth.”

The Drama of the Gifted Child: The Search for the True Self
This was one of my class textbooks and is written for psychology students, but it’s easily accessible to the layperson. If you’re a writer and are thinking about writing a character who’s a therapist or psychiatrist, this book will give you all you need to know about diagnosing mental illness in America. (It’s based on the diagnoses in the DSM-IV.)

In easy-to-follow logic and clear prose, Morrison lays out the steps for diagnosing a patient with a mental illness, or concluding that they’re not mentally ill. He has his own hobbyhorses, most notably his fondness for somatoform disorders, but other than that, the way he thinks is the standard way that diagnosticians think. My caveat is that he doesn’t get into cultural/social factors at all. Otherwise, this is a very good basic text.

Diagnosis Made Easier
Getting a jump on some school reading for next quarter.

I have only just started this, but... is it just me, or is she annoyingly prone to assuming that everyone experiences similar things in the same way and has the same reactions, and so insisting that anyone who says they feel differently from what she expects is denying or repressing the ONE TRUTH?

Drama of the Gifted Child
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