A Quokka Dreeds its Weird

A dense and academic but enlightening book about what it says on the can; I got through it by skipping all the Foucault and other philosophy, along with some of the math.

(In general, I take the position that any paragraph involving certain types of non-standard word usage is skippable. For instance (not actual example AS FAR AS I KNOW) Re-Membering Herstory: Men Con/Descending to Women.)

Addiction by Design is an in-depth look at how machine gambling, like video poker, is designed and regulated, how it affects gamblers, and what gamblers get out of it.

The parts about game and casino design are infuriating and sad; the details are fascinating and new, but the overall thrust is unsurprising. Huge amounts of money, market research, and brainpower are spent to make the machines and the environment around them addictive and deceptive, and to keep gamblers going until all their money is gone. Machine gaming is not regulated in any meaningful way. Habitual machine gamblers in Las Vegas often lose all their money, and find it very difficult to quit because gambling machines are literally everywhere, including in grocery stores.

What gamblers get from machine gambling is the surprising part. They're not gambling in the vain hope of winning lots of money, which is what I always assumed. (The vain hope of hitting it big does seem to be a big factor in non-machine gambling.) The machine gamblers are gambling for its own sake. Their hope of winning isn't for money per se, but because money will enable them to play longer. People who end up at Gamblers Anonymous often gamble for twelve hours straight, not stopping to eat or drink or, in some cases, even to use the bathroom.

According to this book, and it's intensively researched, gambling machines are better understood as dissociation machines. Gamblers play to enter "the zone," in which they lose themselves and enter a dissociative state in which they forget not only their problems, but their very selves. It's a highly addictive state, though like many addictions it quickly stops being actually enjoyable.

Casino designers know exactly why the machine gamblers are there, and employ an astounding amount of money and cleverness to encourage and enable their dissociation addiction. Everything from the game design itself to the casino layout to the machine placement to the chairs to the bathroom access is meticulously researched and optimized. In one case, a team of experts spent a month working on a single "bing!" sound to make it satisfying and comforting rather than annoying or distracting.

Unsurprisingly, the casino owners and designers focus on the design itself rather than on what they're doing to the gamblers, and wave off the addictive elements as the gamblers' own responsibility.

This is a depressing and infuriating book. It's not just how exploitative and predatory the whole thing is, but that so much time and effort and money and cleverness is poured into making something that preys on people and makes their lives worse.

For instance, they designed incredibly expensive and sophisticated comfortable, ergonomic chairs so people won't get uncomfortable while gambling for hours and hours. Why not design and provide those chairs to office workers, for whom they would actually make their lives better? Welcome to capitalism, where the office workers get cheap chairs that cause orthopedic problems that they have to pay to fix, if they even can with their inadequate paychecks and medical care, and the gamblers get perfect chairs to lull them into an addictive dissociative state that will ruin their lives.

Schüll notes that the gamblers' subjective experience of "the zone" sounds very similar to something you've probably heard of in a positive sense, which is "flow."

I find machine gambling very boring and have never found a video game more than mildly enjoyable, but I absolutely understand the appeal of repetitive tasks. I can weed or prune or do other repetitive garden tasks pretty much indefinitely, in a blissful state of losing myself in the task. I join with the garden in a way that sounds very similar to the way gamblers say they become the machine. I also love arranging things, like alphabetizing books or putting rocks in a border. I can also get in the zone via certain types of repetitive exercise, like lifting weights.

We tend to draw a hard line between dissociation (bad!) and flow (good!) but if you think of it as a state of absorption in a repetitive task to the point that you lose yourself and feel that you become the task, it's clearly something that a lot of humans experience and enjoy and and seek to experience over and over. If gardening was cleverly optimized by teams of experts, I might well slide from doing it for fun to doing it addictively.

In the chapter on treating machine gambling (insanely difficult when the gamblers are living in Las Vegas, where they can't escape it) it's noted that people tend to switch one addiction for another. I wondered if the machine gamblers specifically might be able to do some harm reduction by switching to home video gaming, which at least won't suck their money. You can play video poker at home just as a game, with no money involved. It wouldn't be in the casino environment, but it might serve as a kind of methadone for the casino's heroin.

via landingtree. Their review here.

You can read this without being spoiled for more than the first few episodes by not clicking on the cut tags. Cut tags are spoilery through S4 E7.

Dr. Bright is a therapist who treats atypicals (people with powers). They are not known to the general public, but a secret sinister organization, the AM, studies them.

At the start, she has four clients we follow. Caleb is a sweet teenage empath who's struggling to not get overwhelmed by other people's emotions and who has a sweet romance with another boy at his school, Adam, who is not atypical. Sam is a young woman who time-travels when she gets anxious. Chloe is a college-age woman who is an extremely strong receptive telepath.

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We learn early on that Dr. Bright has a secret agenda and wants to use her clients' powers for her own purposes. This is actually not my beef with the show or its portrayal of therapy. Obviously, it's unethical but the show knows it is and this is discussed a lot. Her clients learn what she's doing and why fairly early, and because she does have sympathetic motives they stick with her.

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Chloe, the telepath, I think is incapable of tuning out other people's thoughts. (This isn't 100% clear but it seems like it.) If she attends a therapy session, she can/will read Dr. Bright's mind. That means that she knows everything Dr. Bright knows, including everything Dr. Bright's other clients tell her. She routinely blurts out stuff other clients told Dr. Bright to different clients of Dr. Bright. Effectively, no one can have any secrets or privacy around Chloe, not just because she knows things, but because she will tell everything she knows to everyone.

(Dr. Bright's clients all end up meeting each other, which sets up its own set of ethical issues which I'll get to shortly.)

If I was Dr. Bright dealing with this genuinely fascinating problem in a therapy ethics, there are multiple possible ways to deal with this. The best way would be to only see Chloe over the phone. Another might be, since my clients all know each other anyway and know this is happening, to ask them, privately and individually and after discussing it, whether they consent to Chloe knowing everything they tell me. If even one person says no, then all of Chloe's sessions happen over the phone, permanently.

If I was the writer of this podcast, I would make clear is whether Chloe is literally incapable of shutting up about other people's secrets, whether she can but it's difficult for her for whatever reason, or whether she just doesn't want to or get why this upsets people.

Why this is happening makes a huge difference! Especially since Dr. Bright is literally there to help people control their powers. If Chloe is incapable of shutting up and her other clients don't consent to having her blurt out everything they tell Dr. Bright, then all her sessions need to happen by phone so she can't read Dr. Bright's mind. If it's difficult for her not to blurt, then Dr. Bright should be helping her with this. If she just doesn't think it's a problem and so refuses to stop, she should be booted as a client.

In the show, the why is not made clear but it seems like it's difficult for her not to blurt and she doesn't want to stop. (At one point she complains how haaaaard and saaaaad it is for her to be expected to keep other people's secrets.) Whatever the reason, everyone keeps telling Chloe not to blurt out their secrets to third parties and Dr. Bright keeps complaining that the whole situation is unethical, but no one ever boots Chloe out of their life or asks Dr. Bright to only see her by phone or do anything about it. Chloe is portrayed as a sweet cinnamon roll too good for this world, but in real life, she would be murdered so fast.

Any time someone brings up Chloe blurting out everything other clients told Dr. Bright to third parties, Chloe or someone else points out that Dr. Bright was also unethical. ONE PERSON BEING UNETHICAL DOES NOT MEAN IT'S OKAY FOR SOMEONE ELSE TO BE UNETHICAL. ALSO, CHLOE, SHUT THE FUCK UP BEFORE SOMEONE SHOVES YOU OFF A CLIFF.

This brings me to my biggest single problem with the show: almost everyone in it is from the Crab Nebula. (On FFA, "from the Crab Nebula" is shorthand for "person operating off of an incredibly strange set of assumptions about life/human beings/everything.") The particular quadrant of the Crab Nebula is, I think, young people on Tumblr.

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Almost everyone's values and ethics and reactions are skewed from how humans normally are, and they're all skewed in the same weird directions.

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People keep defending the evil lab with "but they do some good work," which is true, but WHO THE FUCK CARES WHEN THEY'RE ALSO IMPRISONING AND TORTURING PEOPLE WHO SOMETIMES DIE AS A RESULT? The evil lab people say they don't kill anyone on purpose and their experiments aren't meant to kill anyone, which appears to be true, but WHO CARES! They literally grab atypicals off the street, lock them up, and do experiments on them and sometimes they die! Not killing them on purpose doesn't make that better!

As of season four, everyone knows they still have atypicals locked up and experimented on, but no one is doing anything to break them loose and they're still half-heartedly defending the AM as "they do some bad things and some good things, it's complicated." NO IT ISN"T!

And that's not all! There is SO MUCH Crab Nebula reasoning!

A telepath constantly blurting out your secrets to third parties? Worth resignedly bitching about but not worth doing anything about.

A time-traveler using her ability to spy on the evil organization kidnapping, experimenting on, and sometimes killing atypicals? BAD. INVASION OF PRIVACY.

A therapist telling one of their clients something another client told them in therapy? Unethical enough to literally say "So much for ethics!" in a "Oh well, can't be helped" manner.

A violent sociopath is seriously injured when attempting to kidnap your friend? TERRIBLE. THE WORST.

Guiltily not caring if that sociopath dies? TERRIBLE. THE WORST. (No one ever wishes him dead without feeling guilty about wishing harm on another human being. I wish people harm all the time because they're harming other people, and I feel no guilt about it, and those aren't even people who threatened to murder someone I loved!)

Using the word "rape" or "sexual assault?" Apparently so horrifying that it can't be done, even when people are explicitly talking about it, such as exchanges like this:

Character A: "Did he... do anything to you? You know, when he kidnapped you and you spent all that time together, I mean I don't know his sexual orientation but, well...?"

Kidnapped Character: "No! Absolutely not! Nothing of the kind happened."

YOU CAN SAY SEXUAL ASSAULT, THESE ARE ADULT CHARACTERS ON AN ADULT SHOW DEALING WITH TRAUMA.

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There's this weird prudishness and naivete going on, which is especially weird given that the show deals very openly and explicitly about topics like trauma, mental illness, and sexual orientation. This juxtaposition feels very Tumblr teenager to me.

AND ALSO, when you have a situation where your clients end up all knowing each other and hanging out together, one's telepathic and two are empathic, and they don't have any real therapy options other than you, stop wringing your hands about the unethical lack of privacy and DO SOMETHING ABOUT IT.

It's actually a very interesting problem in therapeutic ethics. The most relevant ethical frameworks I can think of come from group therapy and situations in which dual relationships and clients knowing each other is unavoidable, such as being a therapist in a hospital or in a very small town where you're the only one.

The solution that comes to my mind is to get everyone's input, first individually and then (if they all want) in a group setting. You could decide that within the group, you don't have secrets, but you cannot reveal anything from within the group to anyone outside of the group.

And this is just touching the surface! There's so much more, like why the fuck Dr. Bright wouldn't tell a client that the organization she's involved with KIDNAPS AND EXPERIMENTS ON PEOPLE LIKE HER when there is literally no reason not to tell her other than that-- HER STATED REASON FOR NOT DISCLOSING THIS - is that the organization doesn't always do this and is sometimes helpful WHEN IT DOESN'T DECIDE TO KIDNAP AND EXPERIMENT ON YOU WHAT THE ACTUAL CRAB NEBULA FUCK.

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

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

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.

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

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.

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Cognitive Therapy and the Emotional Disorders

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

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.

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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.

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