Tuesday, June 26, 2018

Posts moving to Markham's Behavioral Health.

The psychotherapy book discussion group articles will no longer be posted here. From now on they will be posted on Markham's Behavioral Health. Thank you for checking it out.

Tuesday, May 15, 2018

What happened to you?

Paivio and Angus point out in their book, Narrative Processes in Emotion-Focused Therapy For Trauma, that overgeneral autobiographical memory contributes to emotional avoidance and  self-incoherence.

They point to research which indicates that a key cognitive marker for clinical depression is what they describe as "a preference for overgeneral autobiographical memory (ABM) representations and difficulty accessing and disclosing specific, or episodic, ABH narratives of personal life events." p.49

This statement reminds me of the work with ACEs and the difficulty people have identifying traumatic experiences which are left to contaminate physiological functioning contributing to symptoms and acting out.

Paivio and Angus write further, "This is important because the inability to access and integrate specific ABM has been associated with reduced self-coherence, increased rumination and worry, impairment in social problem solving, and a reduced capacity to imagine future events." p.49

Paivio and Angus note further, "Interestingly, cognitive researchers such as Teasdale (1999) have suggested that overgeneral memory representations may function as effective emotion avoidance strategy that results in impaired specific autobiographical memory recall that is essential for effective problem-solving and the articulation of new personal meanings." p. 49

Given these observations, Paivio and Angus note that "...therapists' ability to help clients move to more specific autobiographical memory disclosures in therapy sessions may be a key emotion processing step - and change event - in effective treatment of depression." p.49

The therapeutic activity is called deconstruction when the therapist asks the client for more detail about a more general reference. It is the breaking down of the general to the more specific that allows greater ability to manage emotions and thinking and meaning making about the traumatic event.

The trauma informed therapist does not ask, "What's wrong with you?" but rather "What happened to you?"

Monday, May 14, 2018

In Chapter three of The Deepest Well, Dr. Nadine Burke Harris points out that the original research that lead to the description of Adverse Childhood Experiences, ACEs, was done by Dr. Vincent Felitti and Dr. Robert Anda and collected data on 17,421 people.

The original study, published in the American Journal of Preventative Medicine, was entitled, "Relationship of Childhood Abuse and Household Dysfunction to any of the Leading Causes of Death In Adults: the Adverse Childhood Experiences (ACE) Study."

The Adverse Childhood Experiences were grouped in ten categories:

Recurrent emotional abuse
Recurrent physical abuse
Sexual abuse
Physical neglect
Emotional neglect
Substance abuse in the household
Mental illness in the household
Mother treated violently
Divorce or parental separation
Criminal behavior by member of the household

Felitti and Anda found that 67% of the population had at least one ACE and 12.6% had four or more ACEs.

The study described a strong dose-response relationship with a person of seven or more ACEs with triple the odds of getting lung cancer, three and one half times the odds of heart disease.

With such significant findings why hasn't Felitti and Anda's findings become better known? Harris writes that first, people falsely assume that this dose-response is just about behavior when it has to do with biochemical functioning in the body, and secondly, these findings are scary. The findings point to the responsibility we all have for creating our mental and emotional environments. These mental and emotional environments in turn contribute to our functioning and destructive behaviors. Guilt and shame may be the biggest reasons that people keep their ACEs in the dark which emerge sooner or later as symptoms of mental and physical disease.

Social workers, psychologists, have known this stuff for years but they get dismissed as their professions being based on "soft science" if any science at all. This mistaken perception is rapidly changing.

Sunday, May 13, 2018

Importance of meaning making in Narrative Therapy

In Chapter three of  Narrative Processes in Emotion-Focused Therapy For Trauma, Paivio and Angus discuss in the section subtitled, "Reflective Functioning and Narrative Processes" the ideas of "reflective functioning" and "mentalization" which they use interchangeably. The definition of "reflective functioning" is the "sociocognitive capacity to think about oneself and others as psychological beings and to consider underlying mental states and motivations when interpreting behaviors." p.46

This "sociocognitive capacity" might be what Michael White calls the "landscape of meaning" or simply "meaning making."

Paivio and Angus write that this capacity requires secure attachment. Without secure attachment, meaning making can be interrupted due to an arousal of negative emotion. I see this often when people are afraid of crying. They apologize for crying or even before they start say something like, "I promised myself, I wasn't going to cry today."

Paivio and Angus point out that what is significant in observing this reflective functioning is not the content of the disclosures but the process. Is the disclosure coherent or incoherent or even inchoate? Paivio and Angus point out that it is the therapist's role, in a secure attached therapeutic alliance, to "help break the cycle of the negative cycle of the stuck narrative, regulate emotional expression more effectively, and create and reflect on a personal story that is more balanced and coherent." p.48

Thursday, May 10, 2018

The Deepest Well, Chapter Two, Cortisol

Dr. Nadine Burke Harris's book is not only informative but also reads like a detective novel and a memoir. Dr. Harris seems to be not only a great pediatrician and public health scientist but also a great writer.

In Chapter 2 Dr Harris describes the function of corticosterone in animals including human beings. At the end of the chapter she writes, "Could this (health disparities between vulnerable and wealthy communities) be related to cortisol? Is it possible that the daily threat of violence and homelessness breathing down your neck is not only associated with poor health but potentially the cause of it?" pp. 25-26

It seems that Dr. Harris is on to something, something we Social Workers have observed for over 100 years in the United States. There certainly have been social, psychological, and political explanations for these health disparities, but never before have we had a physiological and biochemical explanation for it.

Wednesday, May 9, 2018

The Deepest Well by Dr. Nadine Burke Harris

Dr. Nadine Burke Harris has a wonderful book entitled, "The Deepest Well: Healing the Long Term Effects of Childhood Adversity" which is a very significant and important book that everybody should read which describes the  impact of Adverse Childhood Experiences (ACEs) on the human body and behavior.

Dr. Harris is a Pediatrician and has a Master's Degree in Public Health and straight out of her pediatric residency went to work for the California Pacific Medical Center in the Laurel Heights area of San Francisco and was the founder of the Bayview Child Health Center.

In the first chapter, "Something's just not right" Dr. Harris describes meeting and examining 7 year old Diego who is at the 50th percentile in his height. Why is his growth stunted? In an otherwise, healthy seeming 7 year old, Dr. Harris finds no immediate answers. Later she learns of the trauma that Diego and his family have been impacted by and this triggers an intriguing medical investigation which takes Dr. Harris on a circuitous route to discovering the impact of adverse childhood events on the human body.

I highly recommend, The Deepest Well and give it a 5 out of 5 on Psychotherapy Book Discussion Group scale.

Saturday, May 5, 2018

Narrative Processes in Emotionally-Focused Therapy for Trauma, Chapter 3 con't

Paivio and Angus make the point that overgeneral autobiographical memory, emotional avoidance and self-incoherence is associated with increased rumination and worry, impairment in social problem solving and a reduced capacity to imagine future events. They write, “Taken together, these findings suggest that therapists’ ability to help clients move to more specific autobiographical memory disclosures in therapy sessions may be a key emotion processing step-and change event-in effective treatments in depression. p.49

The basic idea in Narrative Therapy is that "deconstruction" helps client's thicken their stories so that become more meaningful and manageable. I say to my clients often, "If you can't name it, you can't manage it. Without naming it, you are doomed to being impacted by emotional and cognitive forces which are confusing and which you don't understand. So what did you mean when you said _____?"

Thursday, April 26, 2018

Narrative Processes in Emotion-Focused Therapy for Trauma by Paivio and Angus, Chapter 3

I an continuing my re-reading of Paivio and Angus's most excellent book. I enjoyed it very much the first time and now am re-reading it to digest the nuggets of wisdom that are contained therein.

In Chapter 3, Paivio and Angus make the case that storytelling matters. The idea seems to be that narrative coherence of a story about what has happened to the person aids in emotional regulation and emotional regulation contributes to the ability to purposefully choose behavioral options.

I have been studying Narrative Therapy for about 20 years and it has been a joy to see the model develop and become enhanced over time. Paivio and Angus' book is one of the most research based books on Narrative Therapy I have encountered.

It continues to pleasantly surprise me when clients tell me at the end of our meeting how much better they feel for having been able to talk as one client told me yesterday. I asked him at the end of our meeting what, if anything, had been useful to him. He said, "Yeah, all of it." I said, "Anything stand out?" He, "just being able to talk. I don't have anyone I can talk to about this stuff."

Earlier in my practice I would have attributed this client's description of his experience to "ventilation" or "catharsis." Now I have a much deeper understanding and appreciation of what is transpiring. Based on his experience there is verbal articulation of before unnameable emotional forces, emotional regulation accompanying this naming, reflection leading to more satisfying meaning making, leading to some transformation in awareness and functioning. We are told probably all of this is accompanied by a release in endorphins in the brain adding an element of pleasurable relaxation.

Paivio and Angus mention Baumeister & Newman’s use of the terms “self-narrative” and “macronarrative” which I take to mean the story one is about what one’s life is about on the one hand and then integrating that self narrative in broader social contexts such as family, school, work, church, community, etc.

Paivio and Angus tie together narrative self-coherence and emotion regulation with attachment. They write: “Secure attachment interviews are identified as balanced, emotionally differentiated, and open, and demonstrate narrative coherence. In contrast, dismissive interviews are overly brief, lack emotional expression, and are often marked by inherent contradictions between overgeneral, positive evaluations of childhood experiences and lack of convincing autobiographical evidence. Finally, preoccupied interviews contain long-winded and confusing accounts that are marked by continued emotional entanglement.” p.45

This description of attachment style with narrative performance fits exactly with my clinical experience. identifying the client's narrative performance with the possible explanation of the client's attachment style as great treatment and diagnostic benefit.

In the next article, I will continue a discussion of Chapter 3.