Harville Hendrix and Helen LaKelly Hunt discuss why couples fight and how to replace negativity in a relationship with curiosity with Carol Donahoe, Rhinebeck program director at Omega.
Carol: How did you come to create Imago Relationship Therapy together? Did it happen because of your relationship or along with it?
Helen: On one of our first dates, Harville told me he wanted to write a book about why couples fight. He was exploring why couples who are drawn together and think they’re in love end up being each other’s worst enemies. We were both divorced, and I was mesmerized by the idea. The answer to this question is so important and significant for our well-being.
Harville: This was in 1977, and over the next couple of years I continued to do research and process my ideas with Helen. She has a background in psychology, so she was a great partner. I don’t think there was ever a decision to “do this together,” it just emerged out of our relationship. In 1979 we named it Imago Relationship Therapy, in 1982 we got married, and in 1988 Getting the Love You Want came out. Helen was busy working in the women’s movement and stewarding our family when I was away, but she was always part of Imago. S ometimes I’m not sure who came up with an idea. I will think it’s me and Helen will think it’s her and then we can know it probably came up in a conversation.
Helen: I was very happy not being overtly involved, but I’ve always felt like a partner.
Harville: Yes, it would have never happened without Helen and our conversations.
Carol: So why do couples fight?
Harville: When two people meet and fall in love, they idealize each other. They see each other as the person who will meet their needs. At first it seems true—people do all sorts of things they wouldn’t normally do because they’re trying to bond with someone, and we each end up with the impression that the other person is perfect and they’re going to do all we want them to do. But once a commitment is made—this often happens after a wedding—there is a desire to reclaim ourselves, to find some differentiation from the merger that happened during courtship, and we begin to act more like our true self. For example, when we’re dating, if you say vanilla is your favorite ice cream, I might eat vanilla ice cream, too, just to bond with you. But then we get married and you find out chocolate is really my favorite flavor and you wonder where the guy who liked vanilla went. It seems to you that I’m not the person you married, that I’m behaving differently or strangely, and you want that idealized person back, the one who was meeting all your needs.
Carol: Meanwhile, the same thing is happening with the other partner, right?
Harville: That’s right. Both parties are feeling disillusioned and entitled. Both people are trying to recover themselves and neither person wants the other to do that. Couples realize at that point that true intimacy is harder than they thought it might be, and the fear of this is what makes them fight.
Carol: This is the moment, then, that there is an opportunity for a couple to have a conscious relationship?
Helen: Yes. First, both partners have to realize that they each have wounds from childhood and that one of the purposes of marriage is to finish those childhood issues. We didn’t get our needs met by our original caretakers, and now is our chance to heal that. Second, it’s important to realize that incompatibility is grounds for marriage. Most people believe if you’re struggling in your marriage, you’re married to the wrong person. We are convinced that if there is struggle, growth is trying to happen, and it’s the perfect opportunity for a conscious relationship. At that point, both people need to move beyond the negativity and shift their focus from themselves to the space between. Couples experience a shift when they move from their own need for gratification and embrace the well-being of their partner and the whole relationship. At that point a whole psycho-spiritual transformation begins to take place.
Carol: Imago has helped millions of people, but it also helped your relationship as well. How did you come to experience your own work?
Helen: We struggled a lot in our marriage, especially when the fame came. We probably would have limped along with a so-so marriage because neither of us is a perfectionist, but we realized there was a split between how others expected us to be and how we were at home.
Harville: You were great; it was me that was the problem.
Helen: Yes, I probably thought it was you, but I had to learn it was me, too. So we used Imago therapy and through that process discovered another piece that transformed our relationship: we agreed to absolutely no negativity. It became the number one rule. It’s hard, but surprisingly transformative.
Carol: What if something seems negative to one person, but not the other?
Helen: If your partner thinks it’s negative, then it’s negative. Harville and I were both raised in a culture that values critical thinking. We were both schooled to look at what’s not there, to be critical. It was a good quality to have. But in a relationship, it can destroy any sense of safety.
Harville: You can’t have a great relationship unless it’s emotionally safe; it has to be predictable and reliable. You need to be able to count on the fact that, when you’re around your partner, you’re not going to get hurt or be criticized, put down, or shut out. When we first agreed to no negativity, we thought we needed to replace it with positivity. But that didn’t work. In the end, we replaced it with curiosity. If you’re curious about the other person, then it becomes exciting to learn about them and their inner world, and when they open up, you are able to be empathetic and they feel safe. Safety is essential to being able to connect, and when you’re connected you are joyful to be alive.
Carol: Helen, let’s say Harville did something that really annoyed you. How do you deal with it if you don’t want to be negative?
Helen: You use what we call in Imago “sender responsibility.” You figure out how to communicate what you’re feeling from your higher brain, from the highest degree of functioning, so there is a greater likelihood your partner will hear it. Use “I” language rather than “you.” Be selective with how much you bring up, so you don’t flood your partner. Speak in a calm tone to increase the chances that your partner will hear you and respond positively.
Carol: Imago has been around for several decades now and has made a difference in many, many lives. Omega is interested in how individual transformation in turn changes society for the better. Have you seen this with Imago?
Harville: Yes, we have, and we’re working on an exciting project to bring Imago to an even wider audience. We are stripping out the part of Imago that can be used to educate the public on how to be in a committed partnerships or marriage. We’re working with a group of relational experts—John Gottman , Dan Siegel, Michele Weiner-Davis, Ellyn Bader, and Marion Soloman—to launch a global wellness movement that focuses on all relationships. Our first initiative is Project Dallas, where over the next few years we’ll bring this technique to the general public using social media, traditional media, and trainings. The goal is to saturate the environment with the idea that healthy relationships make for a healthy society. We’ll be filming what we do and will ultimately turn it into a documenatary.
Helen: The idea behind this was that if you want a driver’s license, you have to take a course and pass a test. If you want a broker’s license you have to take a course and pass a test. Bu if you want a marriage license you simply have to pay a small fee; yet marriage is one of the most important commitments you will ever make in your life. We think most couples wait too long to get help, so we want to bring the simple practices of a conscious partnership into the mainstream. That way, people know how to be in a marriage before they enter one. We believe we have the technology to end divorce, if people can learn these principles of communication.
Harville: Yes, and Helen doesn’t mean just she and I think we can end divorce. All our partners in this endeavor feel the same. The point is there are a lot of couples who don’t need therapy. But there isn’t anyone that doesn’t need relationship education. Maybe 10-20% of the population had a happy enough childhood not to have a problematic marriage. But that means 80% of us are great candidates for relationship education. We’re going global with this and we think it’s going to change everything.
No one likes to be down but a new book, The Depths, argues that depression has real and helpful evolutionary benefits for humans and animals. But have the harms grown worse in modern society?
“The flesh is sad, and I’ve read all the books.” The famous opening of Mallarmé’s poem “Sea Breeze” is a sigh of resignation. Not even the knowledge gleaned from all the books in the world can loosen the grasp of human sadness.Of course reading all the books is impossible; merely reading the books on ways to find happiness would be a daunting prospect. Yet despite the countless titles promising infallible strategies for attaining happiness, depression is reaching epidemic proportions. More than 30 million adults in America now suffer from depression. The World Health Organization estimates that by 2030 depression will surpass cancer and heart disease to become the leading cause of worldwide disability and death.
Dominant models of depression tend to treat the condition as a defect or deficiency. Psychiatry emphasizes a deficiency in the brain, cognitive therapy sees the shortcoming in our thoughts, family or couples therapy focuses on defects in our relationships.
The deficiency approach regards depression as the malfunctioning of the human organism; it’s what happens when something is missing or flawed. In The Depths: The Evolutionary Origins of the Depression Epidemic, psychologist Jonathan Rottenberg presents a compelling inversion of conventional wisdom, arguing that depression is not only a natural response to certain conditions, it’s a state that often promotes our very survival.
One sign that depression is an adaptive behavioral response is its widespread presence in the animal kingdom. Depressed dogs and depressed humans both show decreased interest in food and sex, a drop in energy levels, sleep disruption, and lower levels of self-care and personal grooming. Though other species lack our capacity to signal these sensations in language, behavioral symptoms in animals mirror human experiences of depression with striking fidelity. We also share triggers of depression with other species: starvation, disease, and the death of a close relative can induce depressed behaviors in multiple species.
Anxiety that might have been useful in the context of alion huntcan easily become debilitating when triggered by asales presentation.
To see the adaptive benefits of depression, it helps to consider certain cruel but illuminating studies. In one, mice are hung upside down by their tails for six minutes while the intensity and duration of their struggle is measured. Initially they attempt to escape, but over time their efforts diminish. Rather than continuing to expend energy on an impossible goal, the mice reduce the risk of exhaustion and injury through partial or total immobility. Their moods system demobilizes effort in the face of an impossible task and thus increases the likelihood of survival.
In another test, mice or rats are repeatedly dropped into water. Their first response is to swim vigorously, but after multiple immersions they conserve energy by floating and making only minor motions to stay above water. If they swam just as strenuously on the tenth immersion as on the first, the risk of drowning would increase dramatically. More broadly, animals without an evolved mechanism to decrease effort in certain situations would be less likely to survive. Depression, Rottenberg argues, is precisely such a mechanism.
Experiments with human subjects tend to lack such stark brutality, but there are certain exceptions. Near the end of World War II, for instance, 36 conscientious objectors volunteered to be systematically starved for six months to help researchers develop strategies to treat the mass starvation the Allies expected to encounter in postwar Europe. For most of the men starvation caused more than just weight loss: it also induced many of the symptoms of significant depression. Animals that responded to famine or danger with exuberant moods that motivate exploration and expend energy would fare worse than those with a behavioral shutdown mechanism to conserve energy in environments of scarcity or hostility.
It’s easy to forget that humans have spent approximately 1000 times longer living and evolving as hunter-gatherers than in any other lifestyle. Starvation, disease, war, and predation were common threats for a majority of our evolutionary history. Even in less dire circumstances, however, mild depression can still confer benefits. A variety of studies indicate that low mood narrows and directs our attention to perceive threats and obstacles. It also helps conserve energy, facilitates disengagement from impossible goals, and improves our capacity to detect deception and to assess the degree of control we exercise over our environment. Some studies even suggest that low mood can improve skill in persuasive argument and sharpen memory.
Does this mean the psychologist enlightened by an understanding of these evolutionary benefits will greet the onset of depression in friends, family, and clients with appreciative acceptance? It’s useful to remember that many incredible adaptations have major attendant costs, and depression also follows this pattern. The evolution of larger human brains increased the risk of death in childbirth for mothers; upright walking helped our ancestors to spread across the globe, but it also causes major back problems.
Depression can be a useful response in particular conditions, but it can also be a debilitating condition that mars quality of life and even interferes with evolutionary goals of survival and reproduction. The behavioral mechanism that helps us disengage from impossible goals can become a generalized condition that inhibits the pursuit of any goals, even perfectly attainable ones. The symptoms of depression often last far longer than its initial causes; improved circumstances, in other words, do not always result in relief from symptoms.
In some cases it appears that depression is an adaptation that has long outlasted its utility. Rottenberg presents an instructive analogy with the freeze reflex of deer. Before headlights existed, freezing would help deer avoid detection by a predator. Now, however, the impulse to freeze when threatened often causes their death. Humans can also respond to perceived threats in maladaptive ways that decrease our well-being and even jeopardize survival. Anxiety that might have been useful in the context of a lion hunt can easily become debilitating when triggered by a sales presentation. Depression too can be both a valuable defense and a devastating vulnerability.
Though depression has origins deep in evolutionary history, contemporary factors may be increasing our susceptibility to the condition. Americans get less sleep and less exposure to sunlight than they did a century ago. Cultural expectations of wealth and happiness are also rising. In 2000, half of high school seniors wanted to pursue an advanced degree, a percentage that has doubled since 1970. Many American teens now consider fame or wealth reasonable life goals. Given that a major function of depression is to promote disengagement from impossible goals, it’s alarming to consider how a cultural acceptance of extravagant aspirations could be contributing to the depression epidemic.
Even that most fundamental American activity of pursuing happiness can become a self-defeating drive. Other species experience bad feelings, but humans are unique in their capacity to feel bad about feeling bad. Cultural stigmas surrounding depression certainly don’t help to alleviate this meta-level of suffering. Humans are also singular in the confidence we place in our powers of reason. But attempts to reason one’s way out of depression often backfire: the search for causes that explain a low mood often ends up identifying several new reasons to feel down.
Despite the dark subject of his book, Rottenberg’s search for the fundamental sources of depression is strangely consoling, even inspiring at points. By accounting for depression in evolutionary terms, he decisively discredits any lingering explanations of depression as a character flaw. He also achieves something equally powerful: a nuanced assessment of the ever-shifting advantages and costs of depression in various circumstances. Depression is not an experience anyone would choose, but this doesn’t mean that natural selection hasn’t favored the evolution of a condition that continues to harm and benefit us all in some way.
“Anger is an acid that can do more harm to the vessel in which it is stored than to anything on which it is poured.” — Mark Twain
You know what it feels like to hold a grudge. Your stomach churns. Your muscles tense. Your mind clouds with anger, resentment and maybe even notions of revenge. And the longer it goes, the darker your thoughts become.
Though that bitterness can be understandable — and even justifiable — it comes with a price.
Studies show that depression, anxiety, cardiovascular issues, immune system problems, sexual dysfunction and a higher risk of stroke are all connected to letting hostility fester. As Twain says, it’s an acid that harms your body.
But you can stop the damage with one simple act: forgiveness.
The act of forgiving — of truly letting go — creates a healthier body and mind. Research has found that when you forgive, you instantly reduce your blood pressure and lessen your destructive feelings. In the days and weeks that follow, you may experience:
fewer muscle aches and headaches
improved resistance to disease
closer personal relationships
less stress, anger, and depression (“the mental health problems associated with chronically holding grudges”)
“It’s not always easy, but if you think of what we want in life, we want to be healthy, we want to be at peace, we want to be loved,” says Everett Worthington, Professor of Psychology at Virginia Commonwealth University and a pioneer in forgiveness research. “If I forgive, it promotes all of those.”
What is Forgiveness?
According to Worthington, there are two kinds of forgiveness.
Decisional forgiveness is largely behavioral, and directed toward the person who has done us wrong: “We make a decision about how we’re going to act toward someone,” says Worthington.
It’s reconciliation, or an outward smoothing of a situation that can lead to a deeper forgiveness, but doesn’t always.
Emotional forgiveness, on the other hand, is what Worthington describes as “emotionally replacing negative emotions like resentment, anger, bitterness, and hostility, with other, positive emotions…like empathy and sympathy, and compassion, and maybe even love.”
It’s not revenge, reconciliation, or simply forgetting something has happened. It’s acknowledging your pain, and then letting it go. Your mental and physical well-being are affected, and even determined, by emotional forgiveness.
When it comes to personal relationships, emotional forgiveness is crucial to getting along, as well as each partner’s long-term health.
“If I’m forgiving of what my partner does to hurt me, then she is more likely to be forgiving of me,” says Worthington. In fact, one University of Miami study found that reciprocity was “strongly linked to well-being,” while another report published in the journal Personal Relationships discovered that “conciliatory behavior” actually lowered the blood pressure of both parties during arguments.
Your ability to forgive yourself is another factor in healthy relationships. “If someone’s holding a grudge against themselves,” says Worthington, “that tends to produce regret, remorse, sorrow, shame and guilt. So it’s a different set of emotions, but one that can take a toll.”
How Can I Forgive?
There’s no single path to forgiveness; it’s complex, personal, and differs for everyone. However, current research points toward three key steps that could help the process along:
1. Acknowledge what took place. Don’t deny the event. Go over the facts in your mind as impartially as possible.
2. Choose to forgive and commit to that forgiveness. Give up your grudge, and absolve your perpetrator for good. Resist the temptation to dwell.
3. Move on. Release the toxic emotions that crowd out feelings like gratitude and love, once and for all.
What if we find we can’t absolve someone? Ultimately, we must understand there are no benefits of holding on to anger. “I think we always should try to forgive. It’s not only good for us, but it’s a good thing to do,” says Worthington., “Ask yourself, ‘Why do I want to carry this grudge around?’”
Chronic insomnia is a serious problem for many people. According to the National Sleep Foundation, 22% of Americans experience insomnia every or almost every night. For people who have fibromyalgia or ME/CFS, that percentage is significantly higher. More than 75% of people diagnosed with FM and approximately 60% of those with ME/CFS have difficulty falling asleep, staying asleep and/or awakening from sleep feeling rested and refreshed.
Understanding the Problem
In order to understand why FM and ME/CFS patients have such a hard time getting quality sleep, it is first necessary to understand what happens during a normal sleep cycle. Although you may think of sleep as a time of rest, your body is actually quite busy doing some of its most important work, like repairing cells, secreting certain hormones into the blood, and consolidating memories. It is also thought that the immune system turns on during deep sleep to combat illness.
When we sleep, our body cycles through five stages:
Stage 1: Light sleep – the time between being fully awake and entering sleep
Stage 2: Onset of sleep
Stages 3 and 4: Deepest, most restorative sleep
Stage 5: REM (rapid eye movement): Brain is active and dreams occur
A complete sleep cycle takes about 90 to 110 minutes and is repeated four to six times per night, with the initial REM period occurring about 70 to 90 minutes after falling asleep. The first sleep cycles each night consist of relatively short REM periods and long periods of deep sleep. As the night progresses, REM sleep periods increase in length while deep sleep decreases. By morning, most people spend nearly all of their sleep time in stages 1, 2, and REM.(1)
However, if you have FM and/or ME/CFS your body is probably not making it through the complete sleep cycle without interruption.
A 2008 sleep study compared 26 ME/CFS patients (12 with coexisting FM) with 26 healthy controls. The researchers found that the ME/CFS patients had significantly reduced total sleep time, reduced sleep efficiency, and shorter bouts of sleep than healthy controls. They concluded that the sleep differences seen between the ME/CFS patients and healthy controls were primarily due to a decrease in the length of periods of uninterrupted sleep.(2)
In 1975 Dr. Harvey Moldofsky first discovered that FM patients had an “internal arousal mechanism” that interrupted their stage 4 deep sleep(3), and multiple studies since then have confirmed his findings. This interruption of deep sleep by sudden bursts of awake-like brain activity is now called the alpha-EEG anomaly.
A Danish review of research done on pain and sleep, with special reference to fibromyalgia, reported that most studies found the alpha-EEG anomaly to be very prevalent in FM patients.(4)
A 2013 study comparing ME/CFS patients to healthy controls found that the ME/CFS patients had significant changes in heart rate variability measures during sleep. The researchers also found evidence that the reduced sleep efficiency and reduced total sleep time of ME/CFS patients might be caused by increased sympathetic nervous system activity during non-REM sleep stages.(5)
1. Herbal Sleep Support
Ziziphus Spinosa – the most prescribed medicinal herb for sleep and relaxation support in China and throughout Asia.
Corydalus – historically employed in traditional Chinese and Native American medicine to support relaxation and stress reduction.
Valerian – the most researched sleep-supporting herb in the world. No herb has proven to be more effective in clinical trials for providing effective support for improved sleep. One review identified 12 studies showing that valerian by itself or in combination with hops was associated with improvements in sleep latency (the time it takes to transition from full wakefulness to sleep) and quality of sleep.(6)
Passion Flower – provides support for stress, anxiety, and sleep. It is also has calming and restorative properties.
2. Digestive Support – Calming and supporting the digestive tract is an important first step in attaining restful, restorative sleep.
Lemon Balm – used to promote comfort, relaxation, and calm the digestive and nervous systems. It provides synergistic sleep support when combined with Valerian.
Ginger – a calming anti-inflammatory and digestive aid used to settle the stomach and promote peristalsis. It offers over 150 times the protein digesting power of papaya and contains at least 22 known anti-inflammatories and 12 antioxidants.
Peppermint – traditionally used as a relaxant, it calms the muscles of the stomach, helps reduce excessive gas production, improves the flow of bile used in fat digestion, and promotes proper elimination.
Hops – acts directly on the central nervous system to support the relaxation of smooth muscle tissue, improve central nervous system activity, and calm and soothe digestion.
3. Muscle and Nerve Support – Supporting muscle and nerve health is important for proper sleep.
ZMA™ – a great source of extremely bioavailable magnesium and zinc that supports sleep and healing by aiding in the transport of oxygen to nerve and muscle cells. Magnesium is the number one mineral deficiency in the United States, and zinc is the most important mineral for immune system function.
Magnesium Taurinate – a bioavailable yet gentle source of magnesium combined with the nervous-system-calming amino acid L-taurine.
4. Amino Acid Support – Amino acids are the building blocks of life and are critically important for nerve cell health as well as neurotransmitter and hormone production and balance.
GABA – the main calming amino acid in the central nervous system, this naturally produced substance helps to induce relaxation and sleep. It is also known for supporting healthy pituitary function as well as for its calming effect on over-stimulated neurons.
Melatonin – a natural hormone produced by the body that helps regulate other hormones and maintains the body’s circadian rhythm. It supports the body’s own production of the tranquilizing neurotransmitter serotonin, which plays a key role in healthy sleep patterns and mood. Recommended by more and more doctors as a safe and natural sleep enhancer, melatonin has become the most popular sleep-support compound in the natural food industry.
5-HTP – used by the body to make serotonin. Several small clinical trials have found it may provide significant support for fibromyalgia, sleep, mood, and migraines.
L-Theanine – a calming amino acid found in green tea that can increase levels of GABA (gamma-aminobutyric acid). Studies suggest it may reduce feelings of mental and physical stress and may produce feelings of relaxation. It is also thought to enhance immune function and boost levels of glutathione. L-Theanine increases the brain’s alpha wave activity, which is associated with deep relaxation.
Valerian and Hops: A 1998 German study comparing the use of a hops-valerian combination with a benzodiazepine drug found them to be comparable in effectiveness for improving sleep. The one big difference was that those taking the benzodiazepine experienced withdrawal symptoms when the stopped but those taking the hops-valerian did not. The investigators concluded that a hops-valerian combination was a “sensible alternative to benzodiazepine” for treating sleep problems.(7) Passion Flower: A 2011 Australian study of 41 participants who were given passion flower tea and a placebo, separated by a one-week ‘washout’ period, found that their sleep quality significantly improved when they used the passion flower as opposed to the placebo.(8) Melatonin, Magnesium and Zinc: Forty-three people with primary insomnia were given either a supplement consisting of melatonin, magnesium and zinc or a placebo one hour before bedtime for eight weeks in a 2011 Italian study. The group taking the supplement had significantly better scores on three different sleep-evaluation instruments, indicating that the treatment had a beneficial effect on the restorative value of sleep. The authors concluded that the nightly administration of melatonin, magnesium and zinc appeared to improve both the quality of sleep and the quality of life of the participants.(9) GABA and 5-HTP: In a 2010 study, 18 patients with sleep disorders were given either a preparation containing GABA and 5-HTP (hydroxytryptophan) or a placebo. The researchers reported that the differences between the two groups were significant, concluding that the GABA/5-HTP combination reduced the time to fall asleep, decreased sleep latency, increased the duration of sleep, and improved the quality of sleep.(10)
In the twenty years I have been advising parents, children, and their legal advisers in several hundred cases in Family Law matters, I have often been asked, “Why is it that children are so often ordered to have contact with, and even into the custody of, parents who have abused them and have perpetrated violence against their partners.”
The answer to this question is not simple and involves an examination of the requirements of Family Laws which stress the importance of children having both parents in their lives after parental separation, the dynamics of legal processes, and the often very clear gender biases of the principals involved in judicial processes.
But one of the most outstanding and consistent features of proceedings involving the care of children post-separation are the conduct and behaviors which can be identified as clearly fitting the definitions of psychopathy/sociopathy.
The major personality traits of the psychopath are supremacy and narcissism. The afflicted individual must be in complete control of their environment and all persons who are a part of that environment or can serve the psychopath’s purposes in maintaining control.
The psychopath is capable of using both aggressive anger and passive anger with cunning and guile, to achieve their goals of exerting control. Examples of such contrary behaviors are the aggressive violence against intimate partners, with the frequent inherent abuse of children, designed to groom friends, relatives, and professionals into believing they are harmless and indeed very stable and friendly. If thwarted in attaining these goals, however, the passive can quickly turn into the aggressive.
In furtherance of these traits, the major tactics and ploys of the psychopath are:
1. Denial of wrongdoings in the face of clear evidence;
2. Refusal to take responsibility for behaviors and actions;
3. Minimization of the incident and consequences;
4. Blame being placed on others;
5. Misrepresentation, fabrication, embellishment and distortion of information and evidence;
6. Minimization of all information and evidence regarding wrongdoing;
7. Claims of victim status, alleging the victim was the aggressor;
8. Projection of their own actions and behavior onto the victim; e.g. she abuses/neglects the children/ she is an alcoholic or drug abuser.
This is based on the belief by the psychopath that attack is the best form of defense.
The grooming of friends, relatives, and professionals is very clear in many cases, and in particular some psychiatrists, psychologists and family evaluators/reporters have been hoodwinked by such tactics and ploys by the psychopathic individual. Their reports, of course favoring the psychopath, have very considerable influence on the Courts and their determinations. Very often clear evidence of intimate partner violence such as convictions, Domestic Violence Orders, Apprehended Violence Orders and Restraining Orders against the psychopathic aggressor and medical evidence of injuries suffered by the adult and child victims are ignored or dismissed as irrelevant by such professionals.
Such professionals now refer to such cases as `high conflict’ cases, when it is clear that they are situations of a violent aggressor/tormentor/persecutor and their victims. It is easy to see how the cases in Austria and America where young girls were imprisoned for many years by controlling individuals and regularly abused in several ways were undetected, when the aggressors/persecutors/tormentors were able to convince their family members, relatives and associates that they were reasonable, normal people.
The same often occurs in other cases of violence and murder where neighbors report that the accused murderer is a nice and friendly neighbor. They do not recognize the Jekyll and Hyde aspects of the psychopath’s ploys and tactics and of those they have effectively groomed in their beliefs.
The high conflict which usually occurs in such cases is most commonly engendered by the respective lawyers, conditioned by operating in an adversarial process and arena, whose own major goal is to ‘win’, whatever may be the justness and fairness of the result.
It is not difficult to see, therefore, how the psychopath is able to readily gain the sympathy and support of some of the professionals engaged in the Family Law system and for them to abandon and forfeit their professional objectivity and impartiality in such circumstances. In blaming others the psychopath will allege the former partner is mentally ill and in some cases the former partner may be suffering a Complex Post Traumatic Disorder after suffering years of physical, mental, and sexual abuse and violence. This is often misinterpreted and misdiagnosed as a Borderline Personality Disorder or similar psychiatric term. In effect it is a classic ‘blame the victim’ scenario.
The groomed professionals then enable the psychopath to achieve their primary objective, which is to maintain power and control over their victims, their former partner and children. It is an act of vengeance and spite but mostly it is to maintain the power and control and feelings of supremacy and narcissism. “I am faultless and flawless and in control of my whole environment” are the unvoiced cravings of the psychopath, and “I can continue to inflict my tortures on my victims with impunity” are the psychopath’s continuing behaviors.
The Family Law and their shared parenting provisions and its administration by the Family Courts have become ready enablers for the psychopath.
by Janis Leibold, assistant editor, Fibromyalgia Network
Posted: March 31, 2011
Sweet sleep is often elusive for people with fibromyalgia. Falling asleep, staying asleep, waking up unrefreshed, or experiencing daytime sleepiness are naturally sources of frustration. However, a treatment trial using an inexpensive supplement combo showed promising results for people with insomnia and this same approach may also be helpful for fibromyalgia.
An effective treatment for sleep can be challenging to find, particularly one that does not leave you feeling hung over in the morning. Medications may help by sedating you, but after you wake up, their effects may persist. Rather than a therapy that works by sedation, it would be better to find a treatment that actually improves the quality and restorative nature of your sleep. Of course, long-term safety is also a concern because the sleep disorder of fibromyalgia is most often persistent and chronic.
A research team in Italy tested a more natural route to treating insomnia.* Using only melatonin, zinc, and magnesium supplements, they enrolled a group of residents in a long-term care facility for the study.
Each of the three supplements selected are substances the body needs and uses every day. While there are no set quantities for melatonin use, science knows this naturally produced hormone in the brain is closely associated with sleep-wake cycles and diminishes in quantity as we age. Zinc and magnesium are both trace minerals that are needed by the body to make melatonin. In addition, zinc may improve mood, and magnesium is relaxing and calming. Combined, all three of these elements seem to strengthen each other’s properties and should lead to better quality of sleep.
Forty-three men and women with insomnia were carefully selected to participate. Since they were elderly, the researchers were meticulous in screening out people with dementia, depression, other sleep disorders, or those on any medication that might alter sleep.
Researchers administered a series of commonly used questionnaires for assessing sleep. In addition, everyone wore armband sensors that measured how much they slept and moved during the day and night. The greater the activity picked up by the sensors during the night, the more the disturbed sleep. The questionnaires were given before and after the eight-week study, while the armbands were worn for 72 hours before the study and the last two weeks of the week study.
Twenty-two participants were given 5 mg of melatonin, 225 mg of magnesium, and 11 mg of zinc in a pear sauce each night before bed for eight weeks. The dose of the magnesium and zinc is just shy of the standard recommended daily allowance as established by the U.S. Department of Agriculture.
The other 21 participants were part of the control group that received only the pear sauce. None of the participants knew whether they were in the test group or the placebo control group.
Patients in the test group reported a 45% improvement in their sleep quality, compared to the control group. In addition, benefits were reported in not only quality of sleep, but also mood, ease in getting to sleep, morning alertness, and overall feeling better during the day. The sensor on the armband also measured significant improvements in total sleep time and daytime movement. In contrast, control group members reported no differences in sleep or health at all. Overall, side effects were minimal and none of the participants in either group dropped out of the study.
“These study findings are of great relevance from a clinical point of view,” says Mariangela Rondanelli, Ph.D., of the University of Pavia, Italy, the study’s lead researcher. “The concept of quality of life is defined as perceived global achievement and satisfaction within a number of key domains, with special emphasis on well-being.” Rondanelli notes that a larger study will need to be done before more conclusions can be drawn.
While it may seem expected that melatonin could help with sleep, the other benefits may not be as clear, she says. “It is possible that better nighttime sleep quality made participants more alert during the day. Furthermore, improved mood and well-being may have positively influenced the subjective evaluation of daytime sleepiness in the participants.”
More information on supplements and health is reported in the article, “Covering the Bases on Nutrition,” that appears in the April 2011 issue of the Fibromyalgia Network Journal. A feature article “Setting the Clock Straight on Melatonin” is offered as a free bonus to those receiving the Journal. Join the Fibromyalgia Network to stay abreast with the latest in research, treatments, and coping tips.”
I’ve finally settled on a pre-talk regimen that enables me to avoid the weeks of anticipatory misery that the approach of a public-speaking engagement would otherwise produce.
Let’s say you’re sitting in an audience and I’m at the lectern. Here’s what I’ve likely done to prepare. Four hours or so ago, I took my first half milligram of Xanax. (I’ve learned that if I wait too long to take it, my fight-or-flight response kicks so far into overdrive that medication is not enough to yank it back.) Then, about an hour ago, I took my second half milligram of Xanax and perhaps 20 milligrams of Inderal. (I need the whole milligram of Xanax plus the Inderal, which is a blood-pressure medication, or beta-blocker, that dampens the response of the sympathetic nervous system, to keep my physiological responses to the anxious stimulus of standing in front of you—the sweating, trembling, nausea, burping, stomach cramps, and constriction in my throat and chest—from overwhelming me.) I likely washed those pills down with a shot of scotch or, more likely, vodka, the odor of which is less detectable on my breath. Even two Xanax and an Inderal are not enough to calm my racing thoughts and to keep my chest and throat from constricting to the point where I cannot speak; I need the alcohol to slow things down and to subdue the residual physiological eruptions that the drugs are inadequate to contain. In fact, I probably drank my second shot—yes, even though I might be speaking to you at, say, 9 in the morning—between 15 and 30 minutes ago, assuming the pre-talk proceedings allowed me a moment to sneak away for a quaff.
If the usual pattern has held, as I stand up here talking to you now, I’ve got some Xanax in one pocket (in case I felt the need to pop another one before being introduced) and a minibar-size bottle or two of vodka in the other. I have been known to take a discreet last-second swig while walking onstage—because even as I’m still experiencing the anxiety that makes me want to drink more, my inhibition has been lowered, and my judgment impaired, by the liquor and benzodiazepines I’ve already consumed. If I’ve managed to hit the sweet spot—that perfect combination of timing and dosage whereby the cognitive and psychomotor sedating effect of the drugs and alcohol balances out the physiological hyperarousal of the anxiety—then I’m probably doing okay up here: nervous but not miserable; a little fuzzy but still able to speak clearly; the anxiogenic effects of the situation (me, speaking in front of people) counteracted by the anxiolytic effects of what I’ve consumed. But if I’ve overshot on the medication—too much Xanax or liquor—I may seem to be loopy or slurring or otherwise impaired. And if I didn’t self-medicate enough? Well, then, either I’m sweating profusely, with my voice quavering weakly and my attention folding in upon itself, or, more likely, I ran offstage before I got this far. I mean that literally: I’ve frozen, mortifyingly, onstage at public lectures and presentations before, and on several occasions I have been compelled to bolt from the stage.
Yes, I know. My method of dealing with my public-speaking anxiety is not healthy. It’s dangerous. But it works. Only when I am sedated to near-stupefaction by a combination of benzodiazepines and alcohol do I feel (relatively) confident in my ability to speak in public effectively and without torment. As long as I know that I’ll have access to my Xanax and liquor, I’ll suffer only moderate anxiety for days before a speech, rather than sleepless dread for months.
I wish I could say that my anxiety is a recent development, or that it is limited to public speaking. It’s not. My wedding was accompanied by sweating so torrential that it soaked through my clothes and by shakes so severe that I had to lean on my bride at the altar, so as not to collapse. At the birth of our first child, the nurses had to briefly stop ministering to my wife, who was in the throes of labor, to attend to me as I turned pale and keeled over. I’ve abandoned dates; walked out of exams; and had breakdowns during job interviews, plane flights, train trips, and car rides, and simply walking down the street. On ordinary days, doing ordinary things—reading a book, lying in bed, talking on the phone, sitting in a meeting, playing tennis—I have thousands of times been stricken by a pervasive sense of existential dread and been beset by nausea, vertigo, shaking, and a panoply of other physical symptoms. In these instances, I have sometimes been convinced that death, or something somehow worse, was imminent.
Even when not actively afflicted by such acute episodes, I am buffeted by worry: about my health and my family members’ health; about finances; about work; about the rattle in my car and the dripping in my basement; about the encroachment of old age and the inevitability of death; about everything and nothing. Sometimes this worry gets transmuted into low-grade physical discomfort—stomachaches, headaches, dizziness, pains in my arms and legs—or a general malaise, as though I have mononucleosis or the flu. At various times, I have developed anxiety-induced difficulties breathing, swallowing, even walking; these difficulties then become obsessions, consuming all of my thinking.
I also suffer from a number of specific fears and phobias, in addition to my public-speaking phobia. To name a few: enclosed spaces (claustrophobia); heights (acrophobia); fainting (asthenophobia); being trapped far from home (a species of agoraphobia); germs (bacillophobia); cheese (turophobia); flying (aerophobia); vomiting (emetophobia); and, naturally, vomiting while flying (aeronausiphobia).
Anxiety has afflicted me all my life. When I was a child and my mother was attending law school at night, I spent evenings at home with a babysitter, abjectly terrified that my parents had died in a car crash or had abandoned me (the clinical term for this is separation anxiety); by age 7 I had worn grooves in the carpet of my bedroom with my relentless pacing, trying to will my parents to come home. During first grade, I spent nearly every afternoon for months in the school nurse’s office, sick with psychosomatic headaches, begging to go home; by third grade, stomachaches had replaced the headaches, but my daily trudge to the infirmary remained the same. During high school, I would purposely lose tennis and squash matches to escape the agony of anxiety that competitive situations would provoke in me. On the one—the only—date I had in high school, when the young lady leaned in for a kiss during a romantic moment (we were outside, gazing at constellations through her telescope), I was overcome by anxiety and had to pull away for fear that I would vomit. My embarrassment was such that I stopped returning her phone calls.
In short, I have, since the age of about 2, been a twitchy bundle of phobias, fears, and neuroses. And I have, since the age of 10, when I was first taken to a mental hospital for evaluation and then referred to a psychiatrist for treatment, tried in various ways to overcome my anxiety.
Here’s what I’ve tried: individual psychotherapy (three decades of it), family therapy, group therapy, cognitive-behavioral therapy, rational emotive behavior therapy, acceptance and commitment therapy, hypnosis, meditation, role-playing, interoceptive exposure therapy, in vivo exposure therapy, self-help workbooks, massage therapy, prayer, acupuncture, yoga, Stoic philosophy, and audiotapes I ordered off a late-night TV infomercial.
Also: beer, wine, gin, bourbon, vodka, and scotch.
Here’s what’s worked: nothing.
Actually, that’s not entirely true. Some drugs have helped a little, for finite periods of time. Thorazine (an antipsychotic that used to be referred to as a “major tranquilizer”) and imipramine (a tricyclic antidepressant) combined to help keep me out of the psychiatric hospital in the early 1980s, when I was in middle school and ravaged by anxiety. Desipramine, another tricyclic, got me through my early 20s. Paxil (a selective serotonin reuptake inhibitor, or SSRI) gave me about six months of significantly reduced anxiety in my late 20s before the fear broke through again. A double scotch plus a Xanax and a Dramamine can sometimes, when administered before takeoff, make flying tolerable. And two double scotches, when administered in quick enough succession, can obscure existential dread, making it seem fuzzier and further away.
But none of these treatments has fundamentally reduced the underlying anxiety that seems hardwired into my body and woven into my soul and that at times makes my life a misery.
My assortment of neuroses may be idiosyncratic, but my general condition is hardly unique. Anxiety and its associated disorders represent the most common form of officially classified mental illness in the United States today, more common even than depression and other mood disorders. According to the National Institute of Mental Health, some 40 million American adults, about one in six, are suffering from some kind of anxiety disorder at any given time; based on the most recent data from the Department of Health and Human Services, their treatment accounts for more than a quarter of all spending on mental-health care. Recent epidemiological data suggest that one in four of us can expect to be stricken by debilitating anxiety at some point in our lifetime. And it is debilitating: studies have compared the psychic and physical impairment tied to living with an anxiety disorder with the impairment tied to living with diabetes—both conditions are usually manageable, sometimes fatal, and always a pain to deal with. In 2012, Americans filled nearly 50 million prescriptions for just one antianxiety drug: alprazolam, the generic name for Xanax.
I’ve abandoned dates; walked out of exams; and had breakdowns during job interviews, on flights, and simply walking down the street.
And anxiety, of course, extends far beyond the population of the officially mentally ill. In a much-cited 1976 study, primary-care physicians reported that anxiety was one of the most frequent complaints driving patients to their offices—more frequent than the common cold. Almost everyone alive has at some point experienced the torments of anxiety—or of fear or of stress or of worry, which are distinct but related phenomena. (People who are unable to experience anxiety are, according to some theorists, more deeply pathological—and more dangerous to society—than those who experience it acutely or irrationally; they’re psychopaths.)
My life has, thankfully, lacked great tragedy or melodrama. I haven’t served any jail time. I haven’t been to rehab. I haven’t assaulted anyone or attempted suicide. I haven’t woken up naked in the middle of a field, sojourned in a crack house, or been fired from a job for erratic behavior. As psychopathologies go, mine has been—so far, most of the time, to outward appearances—quiet. Robert Downey Jr. will not be starring in the movie of my life. I am, as they say in the clinical literature, “high functioning” for someone with an anxiety disorder or other mental illness; I’m usually quite good at hiding it. This is a signature characteristic of the phobic personality: “the need and the ability,” as described in the self-help book Your Phobia, “to present a relatively placid, untroubled appearance to others, while suffering extreme distress on the inside.” To some people, I may seem calm. But if you could peer beneath the surface, you would see that I’m like a duck—paddling, paddling, paddling.
Stigma still attaches to mental illness. Anxiety is seen as weakness. In presenting my anxiety to the world by writing publicly about it, I’ve been told, I will be, in effect, “coming out.” The implication is that this will be liberating. We’ll see about that. But my hope is that readers who share this affliction, to whatever extent, will find some value in this account—not a cure for their anxiety, but perhaps some sense of the redemptive value of an often wretched condition, as well as evidence that they can cope and even thrive in spite of it. Most of all, I hope they—and by “they” I mean “many of you”—will find some solace in learning that they are not alone.
I struggle with emetophobia, a pathological fear of vomiting, but it’s been a while since I last vomited. More than a while, actually: as I type this, it’s been, to be precise, 35 years, two months, four days, 23 hours, and 34 minutes. Meaning that more than 83 percent of my days on Earth have transpired in the time since I last threw up, during the early evening of March 7, 1977, when I was 7 years old. I didn’t vomit in the 1980s. I didn’t vomit in the 1990s. I haven’t vomited in the new millennium. And needless to say, I hope to make it through the balance of my life without having that streak disrupted. (Naturally, I was reluctant even to type this paragraph, and particularly that last sentence, for fear of jinxing myself or inviting cosmic rebuke, and I am knocking on wood and offering up prayers to various gods and Fates as I write this.)
What this means is that I have spent, by rough calculation, at least 60 percent of my waking life thinking about and worrying about something that I have spent zero percent of the past three-plus decades doing. This is irrational.
And yet, an astonishing portion of my life is built around trying to evade vomiting and preparing for the eventuality that I might throw up. Some of my behavior is standard germophobic stuff: avoiding hospitals and public restrooms, giving wide berth to sick people, obsessively washing my hands, paying careful attention to the provenance of everything I eat.
But other behavior is more extreme, given the statistical unlikelihood of my vomiting at any given moment. I stash motion-sickness bags, purloined from airplanes, all over my home and office and car in case I’m suddenly overtaken by the need to vomit. I carry Pepto-Bismol and Dramamine and other antiemetic medications with me at all times. Like a general monitoring the enemy’s advance, I keep a detailed mental map of recorded incidences of norovirus (the most common strain of stomach virus) and other forms of gastroenteritis, using the Internet to track outbreaks in the United States and around the world. Such is the nature of my obsession that I can tell you at any given moment exactly which nursing homes in New Zealand, cruise ships in the Mediterranean, and elementary schools in Virginia are contending with outbreaks. Once, when I was lamenting to my father that there is no central clearinghouse for information about norovirus outbreaks the way there is for influenza, my wife interjected. “Yes, there is,” she said. We looked at her quizzically. “You,” she said.
An astonishing portion of my life is built around trying to evade vomiting and preparing for the eventuality that I might throw up.
For several years, in my mid-30s, I worked with a psychologist in Boston, Dr. M., who had a practice at one of the city’s academic medical centers. I had originally sought treatment for a number of phobias, but after several months of consultations, Dr. M. determined—as several other therapists, before and since, also have—that at the core of my other fears lay my fear of vomiting (for instance, I’m afraid of airplanes partly because I might get airsick), so she proposed we concentrate on that.
“Makes sense to me,” I concurred.
She explained that we would try to apply the principles of what’s known as exposure therapy toward extinguishing my emetophobia.
“There’s only one way to do that properly,” she said. “You need to confront the phobia head-on, to expose yourself to that which you fear the most.”
“We have to make you throw up.”
No. No way. Absolutely not.
She explained that a colleague had just successfully treated an emetophobe by giving her ipecac syrup, which induces vomiting. The patient, a female executive who had flown in from New York to be treated, had spent a week undergoing exposure therapy. Each day she would take ipecac administered by a nurse, vomit, and then process the experience with the therapist—“decatastrophizing” it, as the cognitive-behavioral therapists say. When she flew back to New York, Dr. M. reported, she was cured of her phobia.
I remained skeptical. Dr. M. gave me an article from an academic journal reporting on a clinical case of emetophobia successfully treated with this kind of exposure.
“This is just a single case,” I said. “It’s from 1979.”
“There have been lots of others,” she said, and reminded me again of her colleague’s patient.
“I can’t do it.”
“You don’t have to do anything you don’t want to do,” Dr. M. said. “I’ll never force you to do anything. But the only way to overcome this phobia is to confront it. And the only way to confront it is to throw up.”
We had many versions of this conversation over the course of several months. I trusted Dr. M., who was kind and smart. So one autumn day I surprised her by saying I was open to thinking about the idea. Gently, reassuringly, she talked me through how the process would work. She and the staff nurse would reserve a lab upstairs for my privacy and would be with me the whole time. I’d eat something, take the ipecac, and vomit in short order (and I would survive just fine, she said). Then we would work on “reframing my cognitions” about throwing up. I would learn that it wasn’t something to be terrified of, and I’d be liberated.
She took me upstairs to meet the nurse. Nurse R. showed me the lab and told me that taking ipecac was a standard form of exposure therapy; she said she’d helped preside over a number of exposures for now-erstwhile emetophobes. “Just the other week, we had a guy in here,” she said. “He was very nervous, but it worked out just fine.”
We went back downstairs to Dr. M.’s office.
“Okay,” I said. “I’ll do it. Maybe.”
Over the next few weeks, we’d keep scheduling the exposure—and then I’d show up on the appointed day and demur, saying I couldn’t go through with it. I did this enough times that I shocked Dr. M. when, on an unseasonably warm Thursday in early December, I presented myself at her office for my regular appointment and said, “Okay. I’m ready.”
The exercise was star-crossed from the beginning. Nurse R. was out of ipecac, so she had to run to the pharmacy to get some more while I waited for an hour in Dr. M.’s office. Then it turned out that the upstairs lab was booked, so the exposure would have to take place in a small public restroom in the basement. I was constantly on the verge of backing out.
What follows is an edited excerpt drawn from the dispassionate-as-possible account I wrote up afterward, on Dr. M.’s recommendation. (Writing an account of a traumatic event is a commonly prescribed way of trying to forestall post-traumatic stress disorder after a harrowing experience.) If you’re emetophobic yourself, or even just a little squeamish, you might want to skip over it.
We met up with Nurse R. in the basement restroom. After some discussion, I took the ipecac.
Having passed the point of no return, I felt my anxiety surge considerably. I began to shake a little. Still, I was hopeful that sickness would strike quickly and be over fast and that I would discover that the experience was not as bad as I’d feared.Dr. M. had attached a pulse-and-oxygen-level monitor to my finger. As we waited for the nausea to hit, she asked me to state my anxiety level on a scale of one to 10. “About a nine,” I said.
By now I was starting to feel a little nauseated. Suddenly I was struck by heaving and I turned to the toilet. I retched twice—but nothing was coming up. I knelt on the floor and waited, still hoping the event would come quickly and then be over. The monitor on my finger felt like an encumbrance, so I took it off.
After a time, I heaved again, my diaphragm convulsing. Nurse R. explained that dry heaving precedes the main event. I was now desperate for this to be over.
The nausea began coming in intense waves, crashing over me and then receding. I kept feeling like I was going to vomit, but then I would heave noisily and nothing would come up. Several times I could actually feel my stomach convulse. But I would heave and … nothing would happen.
My sense of time at this point gets blurry. During each bout of retching, I would begin perspiring profusely, and once the nausea passed, I would be dripping with sweat. I felt faint, and I worried that I would pass out and vomit and aspirate and die. When I mentioned feeling light-headed, Nurse R. said that my color looked good. But I thought she and Dr. M. seemed slightly alarmed. This increased my anxiety—because if they were worried, then I should really be scared, I thought. (On the other hand, at some level Iwanted to pass out, even if that meant dying.)
After about 40 minutes and several more bouts of retching, Dr. M. and Nurse R. suggested I take more ipecac. But I feared a second dose would subject me to worse nausea for a longer period of time. I worried that I might just keep dry heaving for hours or days. At some point, I switched from hoping that I would vomit quickly and be done with the ordeal to thinking that maybe I could fight the ipecac and simply wait for the nausea to wear off. I was exhausted, horribly nauseated, and utterly miserable. In between bouts of retching, I lay on the bathroom tiles, shaking.
A long period passed. Nurse R. and Dr. M. kept trying to convince me to take more ipecac, but by now I just wanted to avoid vomiting. I hadn’t retched for a while, so I was surprised to be stricken by another bout of violent heaving. I could feel my stomach turning over, and I thought for sure that this time something would happen. It didn’t. I choked down some secondary waves, and then the nausea eased significantly. This was the point when I began to feel hopeful that I would manage to escape the ordeal without throwing up.
Nurse R. seemed angry. “Man, you have more control than anyone I’ve ever seen,” she said. (At one point, she asked peevishly whether I was resisting because I wasn’t prepared to terminate therapy yet. Dr. M. interjected that this was clearly not the case—I’d taken the ipecac, for God’s sake.) Eventually—several hours had now elapsed since I’d ingested the ipecac—Nurse R. left, saying she had never seen someone take ipecac and not vomit. [I’ve since read that up to 15 percent of people—a disproportionate number of them surely emetophobes—don’t vomit from a single dose of ipecac.] After some more time, and some more encouragement from Dr. M. to try to “complete the exposure,” we decided to “end the attempt.” I still felt nauseated, but less so than before. We talked briefly in her office, and then I left.
Driving home, I became extremely anxious that I would vomit and crash. I waited at red lights in terror.
When I got home, I crawled into bed and slept for several hours. I felt better when I woke up; the nausea was gone. But that night I had recurring nightmares of retching in the bathroom in the basement of the center.
The next morning I managed to get to work for a meeting—but then panic surged and I had to go home. For the next several days, I was too anxious to leave the house.
Dr. M. called the day after the ordeal to make sure I was okay. She clearly felt bad about having subjected me to such a horrible experience. Though I was traumatized, her sense of guilt was so palpable that I felt sympathetic toward her. At the end of the account I composed at her request, which was accurate as far as it went, I masked the emotional reality of what I thought (which was that the exposure had been an abject disaster and that Nurse R. was a fatuous bitch) with an antiseptic clinical tone. “Given my history, I was brave to take the ipecac,” I wrote.
I wish that I had vomited quickly. But the whole experience was traumatic, and my general anxiety levels—and my phobia of vomiting—are more intense than they were before the exposure. I also, however, recognize that, based on this experience in resisting the effects of the ipecac, my power to prevent myself from vomiting is quite strong.
Stronger, it seems, than Dr. M.’s. She told me she’d had to cancel all her afternoon appointments on the day of the exposure—watching me gag and fight with the ipecac had evidently made her so nauseated that she spent the afternoon at home, throwing up. I confess I took some perverse pleasure from the irony here—the ipecac I took made someone else vomit—but mainly I felt traumatized. It seems I’m not very good at getting over my phobias but quite good at making my therapists sick.
I continued seeing Dr. M. for a few more months—we “processed” the botched exposure and then, both of us wanting to forget the whole thing, turned from emetophobia to various other phobias and neuroses—but the sessions now had an elegiac, desultory feel. We both knew it was over.
Is pathological anxiety a medical illness, as Hippocrates and Aristotle and many modern psychopharmacologists would have it? Or is it a philosophical problem, as Plato and Spinoza and the cognitive-behavioral therapists would have it? Is it a psychological problem, a product of childhood trauma and sexual inhibition, as Freud and his acolytes once had it? Or is it a spiritual condition, as Søren Kierkegaard and his existentialist descendants claimed? Or, finally, is it—as W. H. Auden and David Riesman and Erich Fromm and Albert Camus and scores of modern commentators have declared—a cultural condition, a function of the times we live in and the structure of our society?
The truth is that anxiety is at once a function of biology and philosophy, body and mind, instinct and reason, personality and culture. Even as anxiety is experienced at a spiritual and psychological level, it is scientifically measurable at the molecular level and the physiological level. It is produced by nature and it is produced by nurture. It’s a psychological phenomenon and a sociological phenomenon. In computer terms, it’s both a hardware problem (I’m wired badly) and a software problem (I run faulty logic programs that make me think anxious thoughts). The origins of a temperament are many-faceted; emotional dispositions that seem to have a simple, single source—a bad gene, say, or a childhood trauma—may not. After all, who’s to say that Spinoza’s vaunted equanimity, though ostensibly a result of his philosophy of applying logical reasoning to irrational fear, wasn’t in fact a product of his biology? Mightn’t a genetically programmed low level of autonomic arousal have produced his serene philosophy, rather than the other way around?
I don’t have to look far to find evidence of anxiety as a family trait. My great-grandfather Chester Hanford, for many years the dean of Harvard College, was in the late 1940s admitted to McLean Hospital, the famous mental institution in Belmont, Massachusetts, suffering from acute anxiety. The last 30 years of his life were often agonizing. Though medication and electroshock treatments would occasionally bring about remissions in his suffering, such respites were temporary, and in his darkest moments, in the 1960s, he was reduced to moaning in a fetal ball in his bedroom. Perhaps wearied by the responsibility of caring for him, his wife, my great-grandmother, a formidable and brilliant woman, died from an overdose of scotch and sleeping pills in 1969, a few months before I was born.
My mother, Chester’s granddaughter, is, like me, an inveterate worrier, and, though she enjoyed a productive career as an attorney, she suffers from some of the same phobias and neuroses that I do. She assiduously avoids heights (glass elevators, chairlifts), and tends to avoid public speaking (when she has to talk publicly, she takes beta-blockers in advance) and risk taking of most kinds. Like me, she is mortally terrified of vomiting (and has not done so since 1974). As a young woman, she suffered from panic attacks. At her most anxious (or so my father, her ex‑husband, says), her fears verged on paranoia: just after I was born, while suffering from postpartum depression, she became convinced that a serial killer in a yellow Volkswagen was watching our house. (Today, my mother and father, now divorced 15 years, disagree about the severity of the paranoia: my mother says it was negligible—and that, moreover, there really was a serial killer afoot at the time, a fact that research confirms.) My only sibling, a younger sister who is a successful cartoonist and editor, struggles with anxiety that is different from mine but nonetheless intense. She, too, has taken Celexa—and also Prozac and Wellbutrin and Klonopin and Nardil and Neurontin and BuSpar. None of them worked for her, and today she may be one of the few adult members of my mother’s side of the family not currently taking a psychiatric medication.
On the evidence of just my mother’s side of the family (and there is a separate complement of psychopathology coming down to me on the side of my father, a respected research physician who drank himself unconscious many nights throughout much of my later childhood), it is not outlandish to conclude that I possess what Sigmund Freud called “the hereditary taint,” a genetic predisposition to anxiety and depression.
But these facts, by themselves, are not dispositive. In the 1920s, my great-grandparents had a young child who died of an infection. This was devastating to them. Perhaps this trauma, combined with the later trauma of having many of his students die in World War II, cracked something in my great-grandfather’s psyche. Perhaps my mother, in turn, was made anxious by the fussy ministrations of her worrywart mother; the psychological term for this ismodeling. And perhaps I, observing my mother’s phobias, adopted them as my own.
Or maybe the generally unsettled nature of my childhood psychological environment—my mother’s constant anxious buzzing; my father’s alcoholic absence; their sometimes unhappy marriage, which would end in divorce—produced in me a comparably unsettled sensibility. Both my mother and father were well intentioned and loving, but between them, they combined overprotection and anger in a way that may have been particularly toxic for a child with an innately nervous temperament. On many occasions, my screaming bouts of nighttime panic would awaken the whole family, and my father would lie patiently with me, trying to calm me down enough to sleep. But sometimes, exhausted and frustrated, he would lash out at me physically. My mother dressed me until I was 9 or 10 years old; after that, she picked out my clothes for me every night until I was about 15. She ran my baths until I was in high school. Any time my sister and I were home while my parents were at work, we had the company of a babysitter. By the time I was a young teenager, this was getting a bit weird—as I realized the day I discovered, to our mutual discomfort, that the babysitter was my age (13). My mother did all of this out of genuine love and anxious concern. And I welcomed the excess of solicitude: it kept me swaddled in a comforting dependency. But our relationship helped deprive me of autonomy and a sense of self-efficacy.
Medication has more reliably soothed my anxiety than other forms of therapy have. Yet the case for medication is not at all clear-cut.
Still, in most respects my parents maintained a safe, loving, and stable suburban home; many people grow up in circumstances far more traumatic than mine and don’t develop clinical anxiety. Ultimately, it’s impossible to disentangle nature and nurture—my anxiety is surely the result of both, and of the interaction between the two. For instance, it’s possible that my mother’s anxiety while pregnant with me—having endured two miscarriages followed by difficulty getting pregnant again, she says her already high level of worry was inflamed by the fear that she wouldn’t carry me to term—produced such hormonal Sturm und Drang in the womb that I was doomed to be born nervous. Research suggests that mothers who suffer stress while pregnant are more likely to produce anxious children. Thomas Hobbes, the political philosopher, was born prematurely when his mother, terrified by a rumor that the Spanish armada was advancing toward English shores, went into labor in April 1588. “Myself and fear were born twins,” Hobbes wrote, and he attributed his own anxious temperament to the ambient turmoil of his gestation. Maybe Hobbes’s view that a powerful state needs to protect citizens from the violence and torment they naturally inflict on one another (life, he famously said, is nasty, brutish, and short) had its origins in utero, as his mother’s stress hormones washed through him.
Or do the roots of my anxiety lie even deeper and extend more broadly than the things I’ve experienced and the genes I’ve inherited—that is, in history and in culture? My father’s parents were Jews who emigrated from Weimar Germany. My father’s mother became a nastily anti-Semitic Jew—she renounced her Jewishness out of fear that she would someday be persecuted for it. My sister and I were raised in the Episcopal Church, our Jewish background hidden from us until I was in high school. My father, for his part, has had a lifelong fascination with World War II, and specifically with the Nazis; he watched the 1973–74 television series The World at War again and again. In my memory, that program, with its stentorian music accompanying the Nazi advance on Paris, is the running soundtrack to my early childhood. Jews, of course, have millennia of experience in having reason to be scared—which perhaps explains why some studies have suggested that Jewish men are more likely to suffer from neuroses than are men in other groups.
My mother’s cultural heritage, on the other hand, is heavily WASP; she is a proud Mayflower descendant who until recently subscribed to the notion that there is no emotion and no family issue that should not be suppressed.
Thus, me: a mixture of Jewish and WASP pathology—a neurotic and histrionic Jew suppressed inside a neurotic and repressed WASP. No wonder I’m anxious: I’m like Woody Allen trapped inside John Calvin.
Everyone knows that anxiety can cause gastrointestinal distress. (My friend Anne says that the most effective weight-loss program she ever tried was the Stressful-Divorce Diet.) But medical researchers have charted the connections in precise and systematic detail: as one’s mental state changes, for instance, so does blood flow to and from the stomach. The gastrointestinal system is a concrete and direct register of one’s psychology. In their 1943 landmark of psychosomatic research, Human Gastric Function, the physicians Stewart Wolf and Harold Wolff concluded that there was a strong inverse correlation between what they called “emotional security” and stomach discomfort.
That’s certainly true in my case. Being anxious makes my stomach hurt and my bowels loosen. My stomach hurting and my bowels loosening makes me moreanxious, which makes my stomach hurt more and my bowels even looser, and so nearly every trip of any significant distance from home ends up the same way: with me scurrying frantically from restroom to restroom on a kind of grand tour of the local latrines. For instance, I don’t have terribly vivid recollections of the Vatican or the Colosseum or the Italian rail system. I do, however, have detailed memories of the public restrooms in the Vatican and at the Colosseum and in various Italian train stations in the winter of 2002. One day, I visited the Trevi Fountain—or, rather, my wife and her family visited the Trevi Fountain. I visited the restroom of a nearby gelateria, where a series of impatient Italians banged on the door while I bivouacked there. The next day, when the family drove to Pompeii, I gave up and stayed in bed, a reassuringly short distance from the bathroom.
When your stomach governs your existence, it’s hard not to be preoccupied with it. A few searing experiences—soiling yourself on an airplane, say, or on a date (and yes, I have done both)—will focus you passionately on your gastrointestinal tract. You need to devote effort to planning around it—because it will not plan around you.
Case in point: In the summer of 1997, while researching my first book, a biography of Sargent Shriver—who founded the Peace Corps for his brother-in-law John F. Kennedy—I spent part of the summer living with the extended Kennedy family on Cape Cod. One weekend, then-President Bill Clinton, who was vacationing on Martha’s Vineyard, went sailing with Ted Kennedy, and I suspected that Hyannis Port, Massachusetts, where the Kennedys have their vacation homes, would be crawling with Secret Service agents. With some time to kill before dinner, I decided to walk around town to take in the scene.
Bad idea. As is so often the case for people with unruly, nervous bellies, it was at precisely the moment I passed beyond Easily-Accessible-Bathroom Range that my plumbing came unglued. While sprinting back to the house where I was staying, I was several times convinced I would not make it and—teeth gritted, sweating voluminously—was reduced to evaluating various bushes and storage sheds along the way for their potential as ersatz outhouses. Imagining what might ensue if a Secret Service agent were to happen upon me crouched in the shrubbery lent a kind of panicked, otherworldly strength to my efforts at self-possession.
As I approached the entrance, I was simultaneously reviewing the floor plan in my head (Which of the many bathrooms in the mansion is closest to the front door?) and praying that I wouldn’t be fatally waylaid by a stray Kennedy or celebrity (as I recall, Arnold Schwarzenegger, Liza Minnelli, and the secretary of the Navy, among others, were visiting that weekend).
Fortunately, I made it into the house unaccosted. Then a quick calculation: Can I make it all the way upstairs and down the hall to my suite in time? Or should I duck into the bathroom in the front hall? Hearing footsteps above and fearing a protracted encounter, I opted for the latter and slipped into the bathroom, which was separated from the front hall by an anteroom and two separate doors. I scampered through the anteroom and flung myself onto the toilet.
My relief was extravagant and almost metaphysical.
But then I flushed and … something happened. My feet were getting wet. I looked down and saw to my horror that water was flowing out from the base of the toilet. Something seemed to have exploded. The floor—along with my shoes and pants—was covered in sewage. The water level was rising.
Could the flooding be stopped? Turning around, I removed the porcelain top of the toilet tank, scattering the flowers and potpourri that sat atop it, and frantically began fiddling with its innards. I tried things blindly, raising this and lowering that, jiggling this and wiggling that, fishing around in the water for something that might stem the swelling tide.
Somehow, whether of its own accord or as a result of my haphazard fiddling, the flooding slowed and then stopped. I surveyed the scene. My clothes were drenched and soiled. So was the bathroom rug. Without thinking, I slipped off my pants and boxer shorts, wrapped them in the waterlogged rug, and jammed the whole mess into the wastebasket, which I stashed in the cupboard under the sink. Have to deal with this later, I thought to myself.
It was at this unpropitious moment that the dinner bell rang, signaling that it was time to muster for cocktails in the living room.
Which was right across the hall from the bathroom.
Where I was standing ankle-deep in sewage.
I pulled some towels off the wall and dropped them on the ground to start sopping up some of the toilet water. I got down on my hands and knees and, unraveling the whole roll of toilet paper, began dabbing frenziedly at the water around me. It was like trying to dry a lake with a kitchen sponge.
What I was feeling at that point was not, strictly speaking, anxiety; rather, it was a resigned sense that the jig was up, that my humiliation would be complete and total. I’d soiled myself, destroyed the estate’s septic system, and might soon be standing half naked before God knows how many members of the political and Hollywood elite.
In the distance, voices were moving closer. It occurred to me that I had two choices. I could hunker down in the bathroom, hiding and waiting out the cocktail party and dinner—at the risk of having to fend off anyone who might start knocking on the door—and use the time to try to clean up the wreckage before slipping up to my bedroom after everyone had gone to bed. Or I could try to make a break for it.
I took all the soiled towels and toilet paper and shoved them into the cupboard, then set about preparing my escape. I retrieved the least soiled towel (which was nonetheless dirty and sodden) and wrapped it gingerly around my waist. I crept to the door and listened for voices and footsteps, trying to gauge distance and speed of approach. Knowing I had scarcely any time before everyone converged on the center of the house, I slipped out of the bathroom and through the anteroom, sprint-walked across the hallway, and darted up the stairs. I hit the landing, made a hairpin turn, and headed up the next flight to the second floor—where I nearly ran headlong into John F. Kennedy Jr. and another man.
“Hi, Scott,” Kennedy said. (I’d just met him for the first time the day before. “I’m John Kennedy,” he had said when he extended his hand in introduction. I know, I had thought as I extended mine, thinking it funny that he had to pretend courteously that people might not know his name, despite the ubiquity of his face on the cover of checkout-counter magazines.)
“Uh, hi,” I said, racking my brain for a plausible explanation for why I might be running through the house at cocktail hour with no pants on, drenched in sweat, swaddled in a soiled and reeking towel. But he and his friend appeared utterly unfazed—as though half-naked houseguests covered in their own excrement were common here—and walked past me down the stairs.
I scrambled down the hallway to my room, where I showered vigorously, changed, and tried to compose myself as best I could—which was not easy because I was still sweating terribly, right through my blazer, the result of anxiety, exertion, and summer humidity.
“Hi, Scott,” Kennedy said. He appeared unfazed—as though half-naked houseguests covered in their own excrement were common here.
If someone had snapped a photo of the scene at cocktails that evening, here’s what it would show: various celebrities and politicians and priests all glowing with grace and easy bonhomie as they mingle effortlessly on the veranda overlooking the Atlantic—while, just off to the side, a sweaty young writer stands awkwardly gulping gin and tonics and thinking about how far he is from fitting in with this illustrious crowd and about how not only is he not rich or famous or accomplished or particularly good-looking, but he cannot even control his own bowels and therefore is better suited for the company of animals or infants than of adults, let alone adults as luminous and significant as these.
The sweaty young writer is also worrying about what will happen when someone tries to use the hallway bathroom.
Late that night, after everyone had gone off to bed, I sneaked back down to the bathroom with a trash bag and paper towels and cleaning detergent I’d pilfered from the pantry. I couldn’t tell whether anyone had been there since I left, but I tried not to worry about that and concentrated on stuffing the soiled rug and towels and clothes and toilet paper I’d stashed under the sink into the trash bag. Then I used the paper towels to scrub the floor, and I put those into the trash bag as well.
Outside the kitchen, between the main house and an outbuilding, was a Dumpster. My plan was to dispose of everything there. Naturally, I was terrified of getting caught. What, exactly, would a houseguest be doing disposing of a large trash bag outside in the middle of the night? (I worried that there might still be Secret Service afoot, who might shoot me before allowing me to plant what looked like a bomb or a body in the Dumpster.) But what choice did I have? I slunk through the house and out to the Dumpster, where I deposited the trash bag. Then I went back upstairs to bed.
No one ever said anything to me about the hallway bathroom or about the missing rug and towels. But for the rest of the weekend, and on my subsequent visits there, I was convinced that various household-staff members were glaring at me and whispering. “That’s him,” I imagined they were saying in disgust. “The one who broke the toilet and ruined our towels. The one who can’t control his own bodily functions.”
On April 13, 2004, at 2 o’clock in the afternoon, I, then 34 years old and working as a senior editor at The Atlantic and dreading the publication of my Sargent Shriver biography, presented myself at the nationally renowned Center for Anxiety and Related Disorders at Boston University. After meeting for several hours with a psychologist and two graduate students and filling out dozens of pages of questionnaires, I was given a principal diagnosis of “panic disorder with agoraphobia” and additional diagnoses of “specific phobia” and “social phobia.” The clinicians also noted in their report that my questionnaire answers indicated “mild levels of depression,” “strong levels of anxiety,” and “strong levels of worry.”
Why so many different diagnoses? And why were they different from the diagnoses of my youth (“phobic neurosis,” “overanxious reaction disorder of childhood”)? Had the nature of my anxiety changed so much? How can we make scientific or therapeutic progress if we can’t agree on what anxiety is?
Even Sigmund Freud, the inventor, more or less, of the modern idea of neurosis—a man for whom anxiety was a key, if not the key, foundational concept of his theory of psychopathology—contradicted himself over the course of his career. Early on, he said that anxiety arose from unexpressed sexual impulses (anxiety is to repressed libido, he wrote, “as vinegar is to wine”). Later in his career, he argued that anxiety primarily arose from unconscious psychic conflicts. Late in his life, in The Problem of Anxiety, Freud wrote: “It is almost disgraceful that after so much labor we should still find difficulty in conceiving of the most fundamental matters.”
Today, the American Psychiatric Association’s Diagnostic and Statistical Manual (now in its just-published fifth edition, DSM-5) defines hundreds of mental disorders, classifies them by type, and lists, in levels of detail that can seem both absurdly precise and completely random, the symptoms a patient must display (how many, how often, and with what severity) to receive any given psychiatric diagnosis. All of which lends the appearance of scientific validity to the diagnosing of an anxiety disorder. But the reality is that there is a large quotient of subjectivity here (both on the part of patients, in describing their symptoms, and of clinicians, in interpreting them). Studies in the 1950s found that when two psychiatrists evaluated the same patient, they gave the sameDSM diagnosis only about 40 percent of the time. Rates of consistency have improved since then, but the diagnosis of many mental disorders remains, despite pretensions to the contrary, more art than science.
In the spring of 2004, such was my terror over the looming book tour that I sought help from multiple sources. I first went to a prominent Harvard psychopharmacologist. “You have an anxiety disorder,” he told me after taking my case history. “Fortunately, this is highly treatable. We just need to get you properly medicated.” When I gave him my standard objections to reliance on medication (worry about side effects, concerns about drug dependency, discomfort with the idea of taking pills that might affect my mind and change who I am), he resorted to the clichéd—but nonetheless potent—diabetes argument, which goes like this: “Your anxiety has a biological, physiological, and genetic basis; it is a medical illness, just like diabetes is. If you were a diabetic, you wouldn’t have such qualms about taking insulin, would you? And you wouldn’t see your diabetes as a moral failing, would you?” I’d had versions of this discussion with various psychiatrists many times over the years. I would try to resist whatever the latest drug was, feeling that this resistance was somehow noble or moral, that reliance on medication evinced weakness of character, that my anxiety was an integral and worthwhile component of who I am, and that there was redemption in suffering—until, inevitably, my anxiety would become so acute that I would be willing to try anything, including the new medication. So, as usual, I capitulated, and as the book tour drew closer, I began a course of benzodiazepines (Xanax during the day, Klonopin at night) and increased my dosage of Celexa, an antidepressant I was already taking.
But even drugged to the gills, I remained filled with dread about the book tour, so I went also to the Boston University center, and was ultimately referred to a young but highly regarded Stanford-trained psychologist who specialized in cognitive-behavioral therapy. “First thing we’ve got to do,” she said in one of my early sessions with her, “is to get you off these drugs.” A few sessions later, she offered to take my Xanax from me and lock it in a drawer in her desk. She opened the drawer to show me the bottles deposited there by some of her other patients, holding one up and shaking it for effect. The drugs, she said, were a crutch that prevented me from truly experiencing and thereby confronting my anxiety; if I didn’t expose myself to the raw experience of anxiety, I would never learn that I could cope with it on my own.
She had a point, I knew. But with the book tour approaching, my fear was that I might not, in fact, be able to cope with it.
I went back to the Harvard psychopharmacologist (let’s call him Dr. Harvard) and described the course of action the Stanford psychologist (let’s call her Dr. Stanford) had proposed. “You could try giving up the medication,” he said. “But your anxiety is clearly so deeply rooted in your biology that even mild stress provokes it. Only medication can control your biological reaction. And it may well be that your anxiety is so acute that the only way you’ll be able to get to the point where any kind of behavioral therapy can begin to be effective is by taking the edge off your physical symptoms with drugs.”
At my next session with Dr. Stanford, I told her I was afraid to give up my Xanax and related what Dr. Harvard had said to me. She looked betrayed. After that, I stopped telling her about my visits to Dr. Harvard. My continued consultations with him felt illicit.
Dr. Stanford was more pleasant to talk to than Dr. Harvard; she tried to understand what caused my anxiety and seemed to care about me as an individual. Dr. Harvard seemed to see me as more of a general type—an anxiety patient—to be treated with drugs. One day I read in the newspaper that he was administering antidepressants to gorillas at the local zoo. Dr. Harvard’s treatment of choice for the gorillas in question? SSRI antidepressants, the same class of medication he had prescribed for me.
I can’t say for certain whether the drugs worked for the gorillas. Reportedly, they did not. But could there be a more potent demonstration that Dr. Harvard’s approach to treatment was resolutely biological? For him, the content of any psychic distress—and certainly the meaning of it—mattered less than the fact of it: such distress, whether in a human or some other primate, was a medical-biological malfunction that could be fixed with drugs.
Not all therapists have such black-and-white views; many find room both for medication and for other kinds of therapy. Some cognitive-behavioral therapists, for instance, use certain drugs to enhance exposure therapy. And neuroscientists increasingly recognize the power of things like meditation and traditional talk therapy to render concrete structural changes in brain physiology that are every bit as “real” as the changes wrought by pills or electroshock therapy.
My own experience, of course, involves ample exposure to both drugs and other therapies, often in concert. Starting when I was 11, I saw the same psychiatrist once or twice a week for 25 years. Dr. L. was the psychiatrist who, when I was taken to McLean Hospital, administered my first Rorschach test. When I started therapy with him, he was approaching 50, tall and lanky, balding a little, with a beard in the classic Freudian style. Over the years, the beard came and went, and he lost more of his hair, which turned from brown to salt-and-pepper to white. Trained at Harvard in the 1950s and early 1960s, Dr. L. came of professional age in the late stages of the psychoanalytic heyday, when Freudianism still dominated. When I first encountered him, he was a believer both in medication and in such Freudian concepts as neurosis and repression, the Oedipus complex and transference. Our first sessions, in the early 1980s, were filled with things like Rorschach tests and free association and discussions of early memories. Our last sessions, in the mid-2000s, were focused on role-playing and “energy work”; he also suggested during those latter years that I sign up for a special kind of yoga program, later alleged to be a brainwashing cult by some former members, though their claims were never proved.
Here’s some of what we did in our sessions together over a quarter century: looked at picture books (1981); played backgammon (1982–85); played darts (1985–88); experimented sporadically with various cutting-edge psychotherapeutic methods of an increasingly New Age complexion, such as hypnotism, eye-movement desensitization and reprocessing, energy-systems therapy, and internal-family-systems therapy (1988–2004). During this period I also moved, in tandem with prevailing pharmacological trends, from one class of drugs to another, in often overlapping succession: from antipsychotics to benzodiazepines to tricyclic antidepressants to MAOI antidepressants to SSRI antidepressants back to benzodiazepines again. I was the beneficiary, or possibly the victim, of seemingly every passing fad in psychotherapy and psychopharmacology.
Medication has more reliably soothed my anxiety than various other forms of therapy have. (Without Thorazine and imipramine and Valium, I don’t know that I could have gotten through seventh grade.) Yet the case for medication, I can also tell you, is complicated by drawbacks and side effects that range from sedation to weight gain to mania to headaches to digestive and urinary troubles to neuromuscular problems to dependency and addiction to, some say, brain damage—and that’s leaving aside withdrawal symptoms that, in the case of many drugs, can be far worse than the side effects. While lots of people will testify that drugs have helped them, lots of other people will testify (and often do, in court filings and before Congress) that medication has ruined their lives. Though plenty of studies, and many individual experiences, suggest that drugs can be highly effective in treating anxiety, the benefits are at the very least not clear-cut.
Sigmund Freud relied heavily on drugs to manage his anxiety. Six of his earliest scientific papers described the benefits of cocaine, which he used regularly for at least a decade, beginning in the 1880s. Only after he prescribed the stimulant to a close friend who became fatally addicted did Freud’s enthusiasm wane. Much of the history of modern psychopharmacology has the same ad hoc quality as Freud’s experimentation with cocaine. Every one of the most commercially significant classes of antianxiety and antidepressant drugs of the past 60 years was discovered by accident or was originally developed for something completely unrelated to anxiety or depression: to treat tuberculosis, surgical shock, allergies; to use as an insecticide, a penicillin preservative, an industrial dye, a disinfectant, rocket fuel.
Prozac and other, similar selective serotonin reuptake inhibitors are currently the medications of choice for many psychiatrists, and have been for more than two decades. Given how completely SSRIs have saturated our culture and our environment, you might be surprised to learn that Eli Lilly, which held the U.S. patent for fluoxetine (the generic name for Prozac), killed the drug in development seven times, in part because of unconvincing test results. After examining the tepid outcomes of fluoxetine trials, as well as complaints about the drug’s side effects, German regulators in 1984 concluded, “Considering the benefit and the risk, we think this preparation totally unsuitable for the treatment of depression.” Early clinical trials of another SSRI, Paxil, were also failures.
I’ve been on one or another SSRI pretty much continuously for going on 20 years. Nevertheless, I can’t say with complete conviction that these drugs have worked, at least for long—or that they’ve been worth the costs in terms of money, side effects, drug-switching traumas, and who knows what long-term effects on my brain.
After the initial flush of enthusiasm for SSRIs in the 1990s, some of the concerns about drug dependency and side effects that had attached to tranquilizers in the 1970s began clustering around antidepressants. “It is now clear,” David Healy, a historian of psychopharmacology, wrote in 2003, “that the rates at which withdrawal problems have been reported” on paroxetine, the generic name for Paxil, “exceed the rates at which withdrawal problems have been reported on any other psychotropic drug ever.”
Even leaving aside withdrawal effects, there is now a large pile of evidence suggesting—in line with those early studies of the ineffectiveness of Prozac and Paxil—that SSRIs may not work terribly well. In January 2010, almost exactly 20 years after hailing the arrival of SSRIs with its cover story “Prozac: A Breakthrough Drug for Depression,” Newsweek published a cover story about the growing number of studies that suggested these and other antidepressants are barely more effective than sugar pills. A large-scale study from 2006 showed that only about a third of patients improved dramatically after a first cycle of treatment with antidepressants. Even after three additional cycles, almost a third of patients who remained in the study had not reached remission. After reviewing a host of studies on antidepressant effectiveness, a paper in the British Medical Journal concluded that drugs in the SSRI class—including Prozac, Zoloft, and Paxil—“do not have a clinically meaningful advantage over placebo.”
How can this be? Tens of millions of Americans—including me and many people I know—collectively consume billions of dollars’ worth of SSRIs each year. Doesn’t this suggest that these drugs are effective? Not necessarily. At the very least, this massive rate of SSRI consumption has not caused rates of self-reported depression to go down—and in fact all of this pill popping seems to correlate with substantially higher rates of depression. Meanwhile, the relationship between low serotonin levels and anxiety or depression (once, and to some extent still, the theoretical reason SSRIs, which boost serotonin, should work) now seems less straightforward than previously thought. George Ashcroft, who, as a research psychiatrist in Scotland in the 1950s, was one of the scientists responsible for promulgating the chemical-imbalance theory of mental illness, abandoned the theory when further research failed to support it. “We have hunted for big, simple neurochemical explanations for psychiatric disorders,” Kenneth Kendler, a co-editor of Psychological Medicine and a psychiatry professor at Virginia Commonwealth University, conceded in 2005, “and have not found them.”
Some drugs work on some people, but the reasons are murky, and the results sometimes fleeting. Of course, studies have generally not found the response rates to nonpharmacological forms of treatment to be better than the response rates to antidepressants or any other drugs. Some recent studies have found that the effects of cognitive-behavioral therapy are more enduring than drug treatment. But as a general rule of thumb across many types of therapy, patients tend to split pretty evenly among those who see long-term improvement, those who see only transient benefits, and those who see no improvement at all. (That’s generally true of placebo treatments as well.) And so, just as I find it difficult to endorse most of these treatments, I am also reluctant to condemn them. Like medication, they clearly do help some patients. This is a fact I can vouch for personally.
On the Sunday in the autumn of 1995 when my mother announced to him that she might want a divorce, my father, desperate to save the marriage, and in a gesture that was completely out of character, acquiesced to emergency couple’s counseling. When that didn’t work, and my mother left him, he became unmoored, and soon began seeing Dr. L., my psychiatrist. For years before that, my father, despite footing the bill for my sister’s and my shrinks, had disdained psychotherapy. “How was your wacko lesson?” he’d ask jeeringly after I’d had an appointment. He did this so often that the term became a part of the family’s lingua franca, and eventually my sister and I were referring without irony to our wacko lessons. (“Mom, can you give me a ride to my wacko lesson on Wednesday?”)
And yet, there he was, suddenly sharing a therapist with me. My own sessions with Dr. L. came to be dominated by the therapist’s questions about his new star patient, my father. I couldn’t blame Dr. L. for finding my father the more interesting patient. After all, while he’d been seeing me for more than 15 years, he’d been seeing my dad for only a few months. My dad entered therapy emotionally wrecked by his separation, profoundly shaken, and newly sober. He completed therapy less than two years later, happy, productive, remarried, and deemed (by himself and by Dr. L.) to be much more “self-actualized” and “authentic” than he had been before. He was in and out of therapy in 18 months. Whereas I was entering my 18th year of therapy with Dr. L. and was still as anxious as ever.
At some level, it is adaptive to be reasonably anxious. According to Charles Darwin (who himself seems to have suffered from crippling agoraphobia that left him intermittently housebound for years after his voyage on the Beagle), species that experience an appropriate amount of fear increase their chances of survival. We anxious people are less likely to remove ourselves from the gene pool by, say, frolicking on the edges of cliffs or becoming fighter pilots.
An influential study conducted 100 years ago by two Harvard psychologists, Robert M. Yerkes and John Dillingham Dodson, laid the foundation for the idea that moderate levels of anxiety improve performance: too much anxiety, obviously, and performance is impaired, but too little anxiety also impairs performance. “Without anxiety, little would be accomplished,” David Barlow, the founder and director emeritus of the Center for Anxiety and Related Disorders at Boston University, has written.
The performance of athletes, entertainers, executives, artisans, and students would suffer; creativity would diminish; crops might not be planted. And we would all achieve that idyllic state long sought after in our fast-paced society of whiling away our lives under a shade tree. This would be as deadly for the species as nuclear war.
Even if I can’t fully recover from my anxiety, I’ve come to believe there may be some redeeming value in it.
Historical evidence suggests that anxiety can be allied to artistic and creative genius. The literary gifts of Emily Dickinson, for example, were inextricably bound up with her reclusiveness, which some say was a product of anxiety. (She was completely housebound after age 40.) Franz Kafka yoked his neurotic sensibility to his artistic sensibility; Woody Allen has done the same. Jerome Kagan, an eminent Harvard psychologist who has spent more than 50 years studying human temperament, argues that T. S. Eliot’s anxiety and “high reactive” physiology helped make him a great poet. Eliot was, Kagan observes, a “shy, cautious, sensitive child”—but because he also had a supportive family, good schooling, and “unusual verbal abilities,” Eliot was able to “exploit his temperamental preference for an introverted, solitary life.”
Perhaps most famously, Marcel Proust transmuted his neurotic sensibility into art. Proust’s father, Adrien, was a physician with a strong interest in nervous health and a co-author of an influential book called The Hygiene of the Neurasthenic. Marcel read his father’s book, as well as books by many of the other leading nerve doctors of his day, and incorporated their work into his; his fiction and nonfiction are “saturated with the vocabulary of nervous dysfunction,” as one historian has put it. For Proust, refinement of artistic sensibility was directly tied to a nervous disposition. Dean Simonton, a psychology professor at the University of California at Davis who has spent decades studying the psychology of genius, has written that “exceptional creativity” is often linked to psychopathology; it may be that the same cognitive or neurobiological mechanisms that predispose certain people to developing anxiety disorders also enhance creative thinking.
Many of history’s most eminent scientists also suffered from anxiety or depression, or both. When Sir Isaac Newton invented calculus, he didn’t publicize his work for 20 years—because, some conjecture, he was too anxious and depressed to tell anyone. (For more than five years after a nervous breakdown around 1678, when he was in his mid-30s, he rarely ventured far from his room at Cambridge.) Perhaps if Darwin had not been largely housebound by his anxiety for decades on end, he would never have been able to finish his work on evolution. Sigmund Freud’s career was nearly derailed early on by his terrible anxiety and self-doubt; he overcame it, and once his reputation as a great man of science had been established, Freud and his acolytes sought to portray him as the eternally self-assured wise man. But his early letters reveal otherwise.
No, anxiety is not, by itself, going to make you a Nobel Prize–winning poet or a groundbreaking scientist. But if you harness your anxious temperament correctly, it might make you a better worker. Jerome Kagan says he hires only people with high-reactive temperaments as research assistants. “They’re compulsive, they don’t make errors,” he told The New York Times. Other research supports Kagan’s observation. A 2013 study in the Academy of Management Journal, for instance, found that neurotics contribute more to group projects than co-workers predict, while extroverts contribute less. And in 2005, researchers in the United Kingdom published a paper, “Can Worriers Be Winners?,” reporting that financial managers high in anxiety tended to be the best, most effective money managers, as long as their worrying was accompanied by a high IQ.
My anxiety can be intolerable. But it is also, maybe, a gift—or at least the other side of a coin I ought to think twice about before trading in.
Unfortunately, the positive correlation between worrying and job performance disappeared when the worriers had a low IQ. But some evidence suggests that excessive worrying is itself allied to intelligence. Jeremy Coplan, the lead author of one study supporting that thesis, says anxiety is evolutionarily adaptive because “every so often there’s a wild-card danger.” When such a danger arises, anxious people are more likely to be prepared to survive. Coplan, a professor of psychiatry at the State University of New York Downstate Medical Center, has said that worrying can be a good trait in leaders—and that lack of worrying can be dangerous. If people in leadership positions are “incapable of seeing any danger, even when danger is imminent,” they are likely, among other poor decisions, to “indicate to the general populace that there’s no need to worry.” (Some commentators have suggested, based on findings like Coplan’s, that the main cause of the economic crash of 2008 was politicians and financiers who were either stupid or insufficiently anxious or both.) Studies on rhesus monkeys by Stephen Suomi, the chief of the Laboratory of Comparative Ethology at the National Institutes of Health, have found that when monkeys genetically predisposed to anxiety were taken early in life from their anxious mothers and given to unanxious mothers to be raised, a fascinating thing happened: these monkeys grew up to display less anxiety than peers with the same genetic markings—and many also, intriguingly, became the leader of their troop. This suggests that, under the right circumstances, some quotient of anxiety can equip you to be a leader.
As always, all of this comes with the proviso that anxiety is productive mainly when it is not so strong as to be debilitating. But if you are anxious, perhaps you can take heart from these findings.
I’ve come to understand that my own nervous disposition is perhaps an essential part of my being—and not just in ways that are bad. “I hate your anxiety,” my wife once said, “and I hate that it makes you unhappy. But what if there are things that I love about you that are connected to your anxiety?
“What if,” she asked, getting to the heart of the matter, “you’re cured of your anxiety and you become a total jerk?”
I suspect I might. Military pilots, by reputation, at least, are famously unanxious. And one small-scale study from the 1980s found that nine out of 10 separations and divorces among Air Force pilots were initiated by wives. Perhaps the two are linked. Low baseline levels of autonomic arousal (which can correspond to low levels of anxiety) have been tied not only to a need for adventure (flying a fighter plane, say), but also to a certain interpersonal obtuseness, a lack of sensitivity to social cues. It may be that my anxiety lends me an inhibition and a social sensitivity that make me more attuned to other people and a more tolerable spouse than I otherwise would be.
The notion of a connection between anxiety and morality long predates the findings of modern science or my wife’s intuition. Saint Augustine believed fear is adaptive because it helps people behave morally. The novelist Angela Carter has called anxiety “the beginning of conscience.” Some research into the determinants of criminal behavior suggest that criminals tend to be lower in anxiety than noncriminals. (On the other hand, different studies have found that high levels of anxiety, especially in youth, correlate with delinquent behavior.)
My anxiety can be intolerable. But it is also, maybe, a gift—or at least the other side of a coin I ought to think twice about before trading in. As often as anxiety has held me back—prevented me from traveling, or from seizing opportunities or taking certain risks—it has also unquestionably spurred me forward. “If a man were a beast or an angel, he would not be able to be in anxiety,” Søren Kierkegaard wrote in 1844. “Since he is a synthesis, he can be in anxiety, and the greater the anxiety, the greater the man.” I don’t know about that. But I do know that some of the things for which I am most thankful—the opportunity to help lead a respected magazine; a place, however peripheral, in shaping public debate; a peripatetic and curious sensibility; and whatever quotients of emotional intelligence and good judgment I possess—not only coexist with my condition but are in some meaningful way the product of it.
In his 1941 essay “The Wound and the Bow,” the literary critic Edmund Wilson writes of the Sophoclean hero Philoctetes, whose suppurating, never-healing snakebite wound on his foot is linked to a gift for unerring accuracy with his bow and arrow—his “malodorous disease” is inseparable from his “superhuman art” for marksmanship. I have always been drawn to this parable: in it lies, as the writer Jeanette Winterson has put it, “the nearness of the wound to the gift,” the insight that in weakness and shamefulness is also the potential for transcendence, heroism, or redemption. My anxiety remains an unhealed wound that, at times, holds me back and fills me with shame—but it may also be, at the same time, a source of strength and a bestower of certain blessings.
We create a resentment because something is different than the picture of how we have made ourselves believe it should be.
Most of us have issues with gratitude and compassion. When are so out of alignment and self-centered that actions and intentions become destructive to ourselves and others.
We make our unforgiveness seem normal. And it’s because we make it seem normal that we don’t work that hard to change it.
When we have a real gratitude for our very life right now–when we embody it–we can touch the sacred mystery of our being here.
Its amazing we are breathing. It is amazing that breathing triggers hundreds of thousands of apical reactions.
There is a fragile and elementally fierce beauty to our solitary life and (in relation to the whole of existence) short life. We are all limited in this way.
The fact that we are here and conscious and able to love is staggering. If we can just remind ourselves to deeply be aware of these limitations, we can better align ourselves and when that happens we have little or no desire to harm anybody. We can’t then imagine, unless it is absolutely necessary, harming someone in word or deed. Why would we want to do that? Forgiveness is normal where forgiveness is part of our relationship to the whole.
We are little dots and there are six and a half billion of us. One thing that my little dot can do is let go of my negativity when possible. That is part of what the whole asks of us so that the whole can stay healed whenever possible.
The piece that we just miss so deeply is just the simplest “thank you”:
We can see that there is so much suffering: ”why am I wrapped up in mine?”
….There is so much pain there is so much horror, so much loss….why am I spending all these years obsessing about mine?
These recognitions help us to detach from the drama and then we can actually be of help.
This is the central reality of our individual transforming potential: the fact that we can make a difference by just doing this one loving thing.
I’m very pleased to have been able to find some time to give to you (my wonderful readers) to write you this post today! I know I haven’t been giving you as much of my time as you’d like and I’m sorry for that, but I am very happy to be back again writing for you!
Looking at last time’s post results, it seems that the topic desired by you is Cognitive Distortions. Before we get into the types of cognitive distortions and how they affect us and our relationships, let’s define what this term actually means. According to Psych Central, “Cognitive distortions are simply ways that our mind convinces us of something that isn’t really true. These inaccurate thoughts are usually used to reinforce negative thinking or emotions — telling ourselves things that sound rational and accurate, but really only serve to keep us feeling bad about ourselves.”
In other words, a cognitive distortion is an exaggerated or irrational thought pattern based on how your mind has interpreted an action, a term, an opinion, etc.
The Georgia Psychological Association states that “Cognitive behavioural psychologists believe that our feelings are largely dependent on our thoughts. Cognitive distortions, also known as errors in thinking, can lead to unnecessary fear, anxiety, hostility, and depression. Understandably so, cognitive distortions can truly affect our lives because we can make decisions, create mindsets, have perceptions and create behaviours based on how we think. Therefore, if we are not perceiving things correctly based on inconclusive or “unreal” thoughts, then we can treat the people around us negatively and thus create a reality that we do not wish to inhabit.
In order for us to to take the power back in our own lives, we must take responsibility for our thought processes and change our cognitive distorted thinking. The Georgia Psychological Association gives a fantastic summary as to the process of self-forgiveness, understanding and reflection that must occur in order to improve our mindsets: “ An important cue or signal that one or more of these errors in thinking is operating is your degree of emotional distress or interpersonal conflict. You may begin to feel better and function more effectively with others if you can learn to observe your thinking for such errors, and then develop (through intentional behavioral change) thoughts that are more logical, verifiable, and adaptive. In other words, if you want to change how you feel, then change how you think. At the same time, it is important to remember that no human being, including yourself, exhibits 100% logical thinking all the time.”
Now that we have a very good idea as to what cognitive distortions are, how they affect our lives currently and why, let us take a look at the process we need to go through in order to improve our thought processes and consequently our lives!
Psych Central provides an excellent tool kit of possibilities that each of us can own in order to help ourselves think more clearly:
We need to create a list of our troublesome thoughts and examine them later for matches with a list of cognitive distortions. An examination of our cognitive distortions allows us to see which distortions we prefer. Additionally, this process will allow us to think about our problem or predicament in more natural and realistic ways.
2. Examine the Evidence.
A thorough examination of an experience allows us to identify the basis for our distorted thoughts. If we are quite self-critical, then, we should identify a number of experiences and situations where we had success.
“Idle Thoughts”, 1898 (Photo credit: Wikipedia)
3. Double Standard Method.
An alternative to “self-talk” that is harsh and demeaning is to talk to ourselves in the same compassionate and caring way that we would talk with a friend in a similar situation.
4. Thinking in Shades of Gray.
Instead of thinking about our problem or predicament in an either-or polarity, evaluate things on a scale of 0-100. When a plan or goal is not fully realized, think about and evaluate the experience as a partial success, again, on a scale of 0-100.
5. Survey Method.
We need to seek the opinions of others regarding whether our thoughts and attitudes are realistic. If we believe that our anxietyabout an upcoming event is unwarranted, check with a few trusted friends or relatives.
What does it mean to define ourselves as “inferior,” “a loser,” “a fool,” or “abnormal.” An examination of these and other global labels likely will reveal that they more closely represent specific behaviors, or an identifiable behavior pattern instead of the total person.
Often, we automatically blame ourselves for the problems and predicaments we experience. Identify external factors and other individuals that contributed to the problem. Regardless of the degree of responsibility we assume, our energy is best utilized in the pursuit of resolutions to problems or identifying ways to cope with predicaments.
8. Cost-Benefit Analysis.
It is helpful to list the advantages and disadvantages of feelings, thoughts, or behaviors. A cost-benefit analysis will help us to ascertain what we are gaining from feeling bad, distorted thinking, and inappropriate behavior.
And finally, in order to implement these techniques, we must all be aware of the types of cognitive distortions that we may have within ourselves. Yet again, Psych Central provides a lengthy but extremely useful and accurate list of the distortions:
We take the negative details and magnify them while filtering out all positive aspects of a situation. For instance, a person may pick out a single, unpleasant detail and dwell on it exclusively so that their vision of reality becomes darkened or distorted.
2. Polarized Thinking (or “Black and White” Thinking).
In polarized thinking, things are either “black-or-white.” We have to be perfect or we’re a failure — there is no middle ground. You place people or situations in “either/or” categories, with no shades of gray or allowing for the complexity of most people and situations. If your performance falls short of perfect, you see yourself as a total failure.
In this cognitive distortion, we come to a general conclusion based on a single incident or a single piece of evidence. If something bad happens only once, we expect it to happen over and over again. A person may see a single, unpleasant event as part of a never-ending pattern of defeat.
4. Jumping to Conclusions.
Without individuals saying so, we know what they are feeling and why they act the way they do. In particular, we are able to determine how people are feeling toward us.
For example, a person may conclude that someone is reacting negatively toward them but doesn’t actually bother to find out if they are correct. Another example is a person may anticipate that things will turn out badly, and will feel convinced that their prediction is already an established fact.
We expect disaster to strike, no matter what. This is also referred to as “magnifying or minimizing.” We hear about a problem and use what if questions (e.g., “What if tragedy strikes?” “What if it happens to me?”).
For example, a person might exaggerate the importance of insignificant events (such as their mistake, or someone else’s achievement). Or they may inappropriately shrink the magnitude of significant events until they appear tiny (for example, a person’s own desirable qualities or someone else’s imperfections).
With practice, you can learn to answer each of these cognitive distortions.
Personalization is a distortion where a person believes that everything others do or say is some kind of direct, personal reaction to the person. We also compare ourselves to others trying to determine who is smarter, better looking, etc.
A person engaging in personalization may also see themselves as the cause of some unhealthy external event that they were not responsible for. For example, “We were late to the dinner party and caused the hostess to overcook the meal. If I had only pushed my husband to leave on time, this wouldn’t have happened.”
7. Control Fallacies.
If we feel externally controlled, we see ourselves as helpless a victim of fate. For example, “I can’t help it if the quality of the work is poor, my boss demanded I work overtime on it.” The fallacy of internal control has us assuming responsibility for the pain and happiness of everyone around us. For example, “Why aren’t you happy? Is it because of something I did?”
8. Fallacy of Fairness.
English: A diagram illustrating graphically the generalization process, using trees. (Photo credit: Wikipedia)
We feel resentful because we think we know what is fair, but other people won’t agree with us. As our parents tell us when we’re growing up and something doesn’t go our way, “Life isn’t always fair.” People who go through life applying a measuring ruler against every situation judging its “fairness” will often feel badly and negative because of it. Because life isn’t “fair” — things will not always work out in your favor, even when you think they should.
We hold other people responsible for our pain, or take the other track and blame ourselves for every problem. For example, “Stop making me feel bad about myself!” Nobody can “make” us feel any particular way — only we have control over our own emotions and emotional reactions.
We have a list of ironclad rules about how others and we should behave. People who break the rules make us angry, and we feel guilty when we violate these rules. A person may often believe they are trying to motivate themselves with shoulds and shouldn’ts, as if they have to be punished before they can do anything.
For example, “I really should exercise. I shouldn’t be so lazy.” Mustsand oughts are also offenders. The emotional consequence is guilt. When a person directs should statements toward others, they often feel anger, frustration and resentment.
11. Emotional Reasoning.
We believe that what we feel must be true automatically. If we feel stupid and boring, then we must be stupid and boring. You assume that your unhealthy emotions reflect he way things really are — “I feel it, therefore it must be true.”
12. Fallacy of Change.
We expect that other people will change to suit us if we just pressure or cajole them enough. We need to change people because our hopes for happiness seem to depend entirely on them.
13. Global Labeling.
We generalize one or two qualities into a negative global judgment. These are extreme forms of generalizing, and are also referred to as “labeling” and “mislabeling.” Instead of describing an error in context of a specific situation, a person will attach an unhealthy label to themselves.
For example, they may say, “I’m a loser” in a situation where they failed at a specific task. When someone else’s behavior rubs a person the wrong way, they may attach an unhealthy label to him, such as “He’s a real jerk.” Mislabeling involves describing an event with language that is highly colored and emotionally loaded. For example, instead of saying someone drops her children off at daycare every day, a person who is mislabeling might say that “she abandons her children to strangers.”
14. Always Being Right.
We are continually on trial to prove that our opinions and actions are correct. Being wrong is unthinkable and we will go to any length to demonstrate our rightness. For example, “I don’t care how badly arguing with me makes you feel, I’m going to win this argument no matter what because I’m right.” Being right often is more important than the feelings of others around a person who engages in this cognitive distortion, even loved ones.
15. Heaven’s Reward Fallacy.
We expect our sacrifice and self-denial to pay off, as if someone is keeping score. We feel bitter when the reward doesn’t come.
I hope that these techniques and this list of cognitive distortions will truly improve your lives and thus your well-being. If we are all able to take this information into our own hands, we will all be able to have much happier and clear-headed minds to help us in our journey of wellness every single day!
It is my pleasure to bring this information to you and I hope it becomes useful to you in your lives! As usual, I will be leaving a poll below for you to choose the topic you would prefer for me to talk about in my next post. It always makes me so happy to write this and I am so happy to write this for all of you!
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health and substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical coverage.
MHPAEA applies to large group health plans. CMS has jurisdiction over non-Federal governmental plans, while the Department of Labor (866-444-3272) has jurisdiction over private group health plans. Employment-related group health plans are classified as either “insured” or “self-funded” and may be regulated by States, the Department of Labor, or both. The insurance that is purchased through a private employer-based group health plans is primarily regulated by the State’s insurance department (the group health plan is regulated by the Department of Labor). Private employer-based group health plans that pay for coverage directly, without purchasing health insurance from an issuer, are called self-funded group health plans. These plans are regulated solely by the Department of Labor. Contact your employer’s plan administrator to find out if your group coverage is insured or self-funded to determine what entity or entities regulate your benefits.
MHPAEA does NOT apply to small group health plans. For non-Federal governmental plans, a small group health plan is one that has 100 or fewer workers. Although there were changes to the definition of a small group health plan in the Public Health Service Act under the Patient Protection and Affordable Care Act, the Employee Retirement and Income Security Act and the Internal Revenue Code continue to define a small group health plan as one that has 50 or fewer workers. Until 2016, States may have different definitions of small groups for purposes of state insurance laws. (To view State specific information requiring mental health parity, visit www.ncsl.org, and on the right hand side of the page enter “mental health parity” then select “State Laws Mandating or Regulating Mental Health Benefits”.)
Summary of MHPAEA Protections
The Mental Health Parity Act of 1996 (MHPA) provided that large group health plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on medical/surgical benefits. MHPAEA preserves the MHPA protections, and adds significant new protections, such as extending the protections to substance use disorders. Although the law requires a general equivalence in the way MH/SUD and medical/surgical benefits are treated with respect to annual and lifetime dollar limits, financial requirements and treatment limitations, MHPAEA does NOT require large group health plans and their health insurance issuers to cover MH/SUD benefits. The law’s requirements apply only to large group health plans and their health insurance issuers that choose to include MH/SUD benefits in their benefit packages.
Key changes made by MHPAEA
Key changes made by MHPAEA, which is generally effective for plan years beginning after October 3, 2009, include the following:
If a group health plan includes medical/surgical benefits and MH/SUD benefits, the financial requirements (e.g., deductibles and co-payments) and treatment limitations (e.g., number of visits or days of coverage) that apply to MH/SUD benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits (this is referred to as the “substantially all/predominant test”).This test is discussed in greater detail in the MHPAEA regulation (linked below) and the summary of the MHPAEA regulation found below.
MH/SUD benefits may not be subject to any separate cost-sharing requirements or treatment limitations that only apply to such benefits;
If a group health plan includes medical/surgical benefits and MH/SUD benefits, and the plan provides for out-of-network medical/surgical benefits, it must provide for out-of-network MH/SUD benefits; and
Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD benefits must be disclosed upon request.
There are certain exceptions to the MHPAEA requirements.
MHPAEA requirements do not apply to:
Non-Federal governmental plans that have 100 or fewer employees;
Small private employers who have 50 or fewer employees;
Large group health plans that are exempt from MHPAEA based on their increased cost. Large group health plan sponsors that make changes to comply with MHPAEA and incur an increased cost of at least two percent in the first year that MHPAEA applies to the plan (the first plan year beginning after October 3, 2009) or at least one percent in any subsequent plan year (generally, plan years beginning after October 3, 2010) may apply for an exemption from MHPAEA based on their increased cost. If such a cost is incurred, the plan is exempt from MHPAEA requirements for the plan year following the year the cost was incurred. Subsequently, the plan sponsors must notify the plan beneficiaries that MHPAEA does not apply to their coverage. These exemptions last one year. After that, the plan is required to comply again; however, if the plan incurs an increased cost of at least one percent in that plan year, the plan could claim the exemption for the following plan year. The following set of FAQ’s provide additional information related to the application of MHPAEA. In particular, see Q. 11 for a discussion of the processes by which plans may claim a cost exemptionhttp://cms.gov/cciio/resources/factsheets/aca_implementation_faqs5.html); and
Self-funded non-Federal governmental employers that opt-out of the requirements of MHPAEA. Non-Federal governmental employers that provide self-funded group health plan coverage to their employees (coverage that is not provided through an insurer) may elect to exempt their plan (opt-out) from the requirements of MHPAEA by following the Procedures & Requirements for HIPAA Exemption Election posted on the Self-Funded Non-Federal Governmental Plans webpage (Seehttp://cms.gov/cciio/resources/files/hipaa_exemption_election_instructions_04072011.html), then issuing a notice of opt-out to enrollees at the time of enrollment and on an annual basis. Thereafter, the employer must also file the opt-out notification with CMS.
A regulation implementing MHPAEA was published in the Federal Register on February 2, 2010. The regulation, which is an interim final rule, is effective April 5, 2010 and applies to plan years beginning on or after July 1, 2010. See http://edocket.access.gpo.gov/2010/pdf/2010-2167.pdf for the full text of the regulation.
The regulation applies to non-Federal governmental plans with more than 100 employees, and to group health plans of private employers with more than 50 employees. It does not apply to group health plans of smaller employers. Like the statute, it does not require group health plans to provide MH or SUD benefits. If they do, however, the financial requirements and treatment limitations that apply to MH or SUD benefits cannot be more restrictive than the predominant restrictions and requirements that apply to substantially all of the medical/surgical benefits.
The provisions of the regulation include the following:
The substantially all/predominant test outlined in the statute must be applied separately to six classifications of benefits: inpatient in-network; outpatient in-network; inpatient out-of-network; outpatient out-of-network; emergency; and prescription drug. The regulation includes examples for each classification. Additionally, although the regulation does not require plans to cover MH or SUD benefits, if they do, they must provide MH or SUD benefits in all classifications in which medical/surgical benefits are provided.
The regulation requires that all cumulative financial requirements, including deductibles and out-of-pocket limits, must combine both medical/surgical and MH/SUD benefits. The regulation includes examples of permissible and impermissible cumulative financial requirements.
The regulation distinguishes between quantitative treatment limitations and nonquantitative treatment limitations. Quantitative treatment limitations are numerical, such as visit limits and day limits. Nonquantitative treatment limitations include medical management, step therapy and pre-authorization. There is an illustrative list of nonquantitative treatment limitations in the regulation. A group health plan cannot impose a nonquantitative treatment limitation with respect to MH/SUD benefits in any classification (outlined in #1) unless, under the terms of the plan as written or in operation, any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to MH/SUD benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical surgical/benefits in the classification, except to the extent that recognized clinically appropriate standards of care may permit a difference.
Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) are not group health plans or issuers of health insurance. They are public health plans through which individuals obtain health coverage. However, CHIP plans, Medicaid Benchmark Benefit plans, as well as managed care plans that contract with State Medicaid programs to provide services are subject to certain requirements of MHPAEA. Seehttp://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SHO110409.pdf for the State Health Official letter regarding State Medicaid programs and Children’s Health Insurance Program State plans. We anticipate issuing further responses to questions and other guidance in the future. We hope this guidance will be helpful by providing additional clarity and assistance.
If you have concerns about your plan’s compliance with MHPAEA, contact our help line at 1-877-267-2323 extension 6-1565 or at firstname.lastname@example.org.
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