Talking about Diagnosis! Pt 1

I wanted to do a series of posts that are basically how excited I am about my new job.  Which I’m psyched to do.  But since my work is a little atypical now, I thought I would explain the typical first.

Getting a diagnosis

The traditional way of going about getting a mental health diagnosis is by seeing a clinician, this could be a psychiatrist (MD), Psychologist (PhD, PsyD, or EdD), counselor (MA or LMFT), or Social Worker (MSW or DSW).  They will do a clinical interview which will ask about your current symptoms, relevant history, family history, current stressors, trauma, and any major adjustments or other things can could be effecting your mental health.  They will also about your typical habits, like eating, sleeping, etc.

After this appointment, which is usually about an hour (often shorter for psychiatrists) they will be able to formulate a good idea of what diagnostic category you fit into.  They’ll talk to you about this diagnosis and give recommendations for how to treat it.  I’ve gone over this in a past post, but recommendations can include medication, individual therapy, hospitalization (if symptoms are very severe or risk of harm is high), or other types of therapy can be beneficial based on your symptoms.

The clinical interview approach can work well.  It’s quick, it’s non-invasive, and it allows us to begin treatment quickly.  For people with straight forward presentations, people that are able to easily verbalize and have insight into their symptoms, people that know their past and family history well, and those who have a great clinician, this is a great place to be.

But for many people, it’s not that easy.  Messy histories (because who of us doesn’t have a messy past and family), not by-the-book presentations, dual diagnosis, complicated patterns in how people experience symptoms can make the diagnostic process really hard.  This can lead people to have to try multiple treatments and medications before finding any symptom relief.  And with that comes continual suffering from symptoms as well as side effects, which can range from subtle and tolerable to disabling.

The clinical interview has other weaknesses.  Our diagnostic categories are pretty non-specific.  It’s guided by observable behavioral symptoms.  And, as most good diagnosticians will complain, the same feelings and symptoms, will present very differently in different people.  For example, what appears to be inattention, can also be dissociation, anxiety, or even seizures.  People’s panic attacks can look like hyperventilation or freezing.  And those can be caused by Panic Disorder or PTSD or other factors.   And Insomnia can be basically anything.  I really like this SA article, so rather than summarizing it, I’ll just link it.

What else is tough is how much your diagnosis depends on your clinician.  Mental Health diagnosis has notoriously bad Inter-Rater Reliability, meaning that compared to other health professionals, mental health clinicians are less likely to agree on diagnosis.  This is because of our vague criteria.  And because different clinicians have different training regarding diagnosis and different values/importance is placed on this aspect of things.  (There are good reasons for this and each branch has it’s own emphasis when it comes to mental health).  I’ll also link this post, which is lovely.

Like I said, diagnostic criteria for mental health diagnosis is pretty terrible.  The Diagnostic and Statistical Manual for Mental Health Disorders (DSM) has historically been criticized for not mirroring the reality of mental illness, developmental disorders, or symptom presentation.  It’s famously political and highly biased.

Explaining how this situation came to be is beyond my intention here.  But it is important to point out.  Whether or not a clinician believe a patient in their reporting of symptoms and events plays a role in their diagnosis and treatment, is a very obvious example.  Preconceived notions and gender, racial, ability, bias can run rampant when there is no biological markers for diagnosis.

Except that we are finally getting to a point where we are finding biological markers!  Psychology is a comparatively young science and our methods are getting better.  We no longer have to rely solely on the clinical interview to make diagnostic determination.  So the upcoming posts are going to look at these new (although more invasive and time-consuming methods).

Next time: (my personal specialty and favorite thing to do) Neuropsychological assessment!
Also upcoming: qEEG, SPECT, FMRI

Coming back Strong!

Hey all!
I haven’t been active writing lately.  Which sucks.  But it’s for a good reason!

I started a new job at the beginning of March in a neuropsych lab.  I get to be a part of some really cool clinical work and research, brain mapping and working to establish a more research-based way to approach psychiatric diagnosis and treatment planning.

In short: BRAINS!!!! and Brain work!  I’ll be doing neuropsych testing and data integration with they neuroscientist.

So, to help me get back into the brain flex from being in private practice for so long, I’m gonna do a series of posts about what we do at the lab: qEEG and brain mapping, neuropsych testing, neurofeedback, TMS, and other treatments.

I’m excited about this for many reasons.  (hint: I love brains) But also because it gives me the opportunity to work with people with, not only mental health disabilities, but physical disabilities and chronic illnesses as well.  There’s a lot of overlap in these communities and I’m interested in seeing how we can best identify and treat the problems so that people can live more full lives.  Here’s hoping for good things in the future!  And lots of learning!

Living with Social Anxiety

Alright!  I’ve eaten.  I’ve showered.  I’ve grounded myself.  I’m ready to go!

First off, I apologize greatly for not writing.  When I started this blog I told myself I would not go more than a month without writing.  And yet, here we are.  Sorry.  I was trying to cope with a lot of stress and change.  That lead me to spending a lot of time applying to jobs.  And that lead to an exciting new position for me.  So hopefully this means I can get back to writing more.  Cause I miss it so much!!!

But what I really wanted to take a minute to talk about was anxiety.  Something that I’ve had issues with for basically as long as I can remember.  When a lot of people think about anxiety, they wonder what the big deal is.  t’s something that everyone has.  And yes.  Everyone has it.  There really is no such thing as a life without anxiety.  Stress and anxiety often go hand in hand.  Anxiety can make us work harder and motivate us to an end.  The idea of “optimal anxiety” or “flow states” basically means when our anxiety and stress are at just the right level that we have the energy and drive to do our best to solve a problem.  There some research that this is how we get “in the zone.”

Unfortunately, anxiety can go well beyond the optimal point.  The higher up anxiety goes, the worse our functioning gets. The chart below is a super simplistic way of thinking about this.

Another factor that plays into this is where our anxiety is directed.  Is it directed toward something that we can do anything about?  Or is rational anxiety.  Are you anxious about getting a project done?  Well there’s probably something that you can do about that (do the project!).  Or are you anxious that no matter what you do it will never be enough and no one actually likes you?

Ok, so that’s where this writing comes in.   This is a pretty personal entry for me.  I can’t remember a time when I wasn’t constantly overcome with this sense that no one would ever like me.  That I would never be enough.  That everyone is judging or laughing at me or rejecting me in their mind.  I fidget constantly in public trying to look normal, to blend in, to be acceptable.  I’m my harshest critic, and never in a nice or productive way.  Whenever I speak I wonder how stupid I sound.  I’ll rack my brain for hours after I post this wondering what people think, assuming they see me childish, an attention seeker, incompetent, whatever else my mind can come up with at 2am.  I’ve worked myself up to the point I have panic attacks or throw up.  I piece apart my body, my face, my clothes wondering if it’s acceptable.  I piece apart my resume and CV wondering if they will ever pass as “good enough.”  It takes me about a year to feel comfortable with people and situations before this starts to let up.  Needless to say, I don’t like changes.

Like I said, I’ve lived with this just about my whole life.  There are times when it’s not so bad, when I find myself feeling a little freer and easier.

What brings this up now is where I am.  I am at what is probably my favorite conference in the world.  The Association for Women in Psychology.  I generally come alone.  In addition to being socially anxious, I’m also just genuinely an introvert.  So I take this weekend to learn, discuss, and recharge.  Order some room service, explore whatever town I’m in, and escape.  But there’s a lot of socializing here.  It’s a wonderful, friendly, incredibly welcoming atmosphere.  I feel like I should be more comfortable.  I’ve made friends.  But I do feel like I should do more, volunteer more, network and chat more.  So my anxiety stoked.  There’s no escaping this social anxiety thing.  I will judge myself if I partake in socialization for everything I say.  I will judge myself for not partaking because I “should do more.”  But that’s a cycle I’m familiar with.

My favorite part of this conference is the Coming Out Ceremony.  An exercise in radical acceptance.  A place for women to speak their truth and speak their distress, change, trauma, and their success.  Coming out with pride, coming out with fear, coming out with whatever salient feelings they have for whatever salient reason they have them.  This has been incredibly powerful for me in the past.  It’s a tool that I use every year and brings me to tears without fear.

This year I shared about my social anxiety.  And as I sat there in my feelings I realized how much it does effect me.  How much I stop myself from doing or saying.  How much I avoid socially.  How much I live in fear of getting anyone’s attention.  Maybe that’s why it’s easier for me to write online in such an anonymous way.  I shared that I’m afraid I will never be able to enjoy things.  That when I’ve tried, I end up nauseous and panicky.   And I shared that I feel stupid for having this problem.  I was given my space.  And before I left, a hug and a thanks from someone with similar worries.

And I went back to my room.  And for the first time since I’ve been doing this ceremony I cried again.  Normally I feel better after unburdening.   But not this time.  All I can still think about is what if what if what if what if.  I worry that I won’t be able to enjoy my wedding.  That I am burden to others.  That everyone here thinks I’m crazy or attention seeking or being childish.

How do I cope?  I don’t really know.  Acclimatize?  Again, it’s been like this for so long I’m just used to it. Sometimes if I let myself cry it out, I feel better.  Accept who I am? Yeah, I’m constantly working on it.  Deep breathing, a bit of self-indulgence, stretching, grounding, respecting the boundaries that I know I need, recognizing and challenging the “shoulds.”

I’m at a point in my life where I think this is just what I have to deal with.  I realize that I hide behind intellectualization.  It’s way easier to read a book alone than to push myself to talk to people.  I name it.  I do my best to respect and accept this flaw and remind myself that I have strengths.  I try to surround myself with people who I think will do this to.

In the past I have allowed myself to go down many a deep, dark hole.  It probably wouldn’t surprise people to know that there is a lot of overlap between Social Anxiety Disorder and Depression.  But I think I’ve gotten that part pretty well under control.  If I ever get the socializing part down I’ll let you know how I got there.

In case anyone’s wondering, when I work with people with social anxiety I let them know that this is a long journey.  And different things work for different people.  The rejection and judgement thoughts never let up for me.  I think the radical acceptance part was most important piece.

Another Moment Carol Gilligan Resonated A Little Too Much

This is going to be a bit of a different post.  I was hesitant to write it because it didn’t really fit with the theme of what I was trying to do here.  But fuck it.  This is my blog.  Stop reading here and return later for more research.

According to a recent study, 81% of women have experienced sexual harassment.   99% reported experiencing street harassment.

I recently posted this article on my facebook page.  It’s a wonderful and powerful article. At least it was to me.  Because it put into words what I have avoided saying for so many years.  “Of course I’ve been sexually assaulted. That’s just part of what it means to be a woman in America.”

And then I was quickly reminded of why I avoided saying that exact sentence.

Immediately family members began feuding.  One said that he didn’t feel that defines women.  Another defended the statement.  Defenses upon defenses went up.  The #notallmen came into play almost immediately.  The “my sexual harassment doesn’t define me” came up. (which no one ever said that it did but, hey, let’s just miss the point entirely.)  Insults were thrown.  My anxiety was through the roof.

I deleted it.

I’m mad at myself for deleting it.  Because it was something I was proud to find and share.  It was the voice I wish I had.  I shared something I found a lot of power in.  I don’t care that people disagree with it.  I care that no one actually listened to it.  The point of the article went over everyone’s head in their attempts to refute and defend themselves.  Then they attacked each other, then I gave up.

At this moment, Carol Gilligan’s words were never truer:

I wonder what would happen if we really said what we were thinking, and really heard what each other was saying.

What is we truly spoke about all of our sexual harassment and assault?  How would loved ones react when we told them about being sexuallized as early as age 7?  Being catcalled at age 9?  Being touched and grabbed as soon as we’re allowed to go to the mall or to concerts alone?  About every single time we were cornered in a bar and felt we couldn’t get away.  Every time we felt pressured to engage in sexual activity when we didn’t want to?

But to answer these questions we also have to explore why we don’t speak about all of this.  We don’t want to seem vulnerable.  We want to control how other’s view us.  And we fear how they will react to knowing this.  Will we be seen as weak?  Will we get the disingenuous “You’re so strong!”  Will they believe us?  Or think that we made it up?  Will they question?  Will they even care?  What will this change about our relationships with our loved ones?

Because what we often ignore, actively or unconsciously, about “why I didn’t tell” is how it will change our relationships.  How will it change how others perceive us.  What will we have to go through?

We don’t know.  So we keep silent.  Because we don’t be heard. And it’s less painful to keep it in.  It’s so much more painful to let it out and to not be heard.

Trauma and Memory

I’m going to take a quick break from the research posts.  Because I feel like there is something happening right now that I would like to contribute a bit more understanding to. (I’m really tired and haven’t edited this yet.  I’ll do that tomorrow, but wanted to get this up.)

See, I work with quite a lot of trauma.  I taught trauma theory.  I treat PTSD.  I have done explained the neuropsychological effects and symptoms to client time and time again.  So I’d like to take a moment to talk about why people don’t report trauma like sexual assault.  This was always one of my favorite lectures to give, because I think it helps a lot to understand the symptoms of PTSD, why people don’t report trauma, and the long-term effects on your brain and body.

Let’s start with understanding the parts of the brain effected by trauma.

This little upside down pyramid represents a brain.  It works from the bottom up.  Our most basic functions are at the bottom (breathing, eating) and the higher functions are at the bottom (thinking, attachment).  Those first two layers at the bottom there are what get activated when we experience high levels of fear, like we do in trauma.  What gets activated here is is a part of the brain called the reticular activating system or the reticular formation (there are differences here, but I want to break it down to be pretty simple).  As you can see in the image below, it’s pretty important.

The Reticular Activating System (RAD) centers around most of our regulatory functions, arousal, fear, stress response, etc.  It works in conjunction with another important part of the brain, called the Thalamus.  The Thalamus is like the intake center for all the sensory information, light, sound, pressure, all of that good stuff.  Before any of this information is organized, encoded into memory, or given meaning, the thalamus has to manage and direct it all.

You may have noticed, or not, that we’re moving up the brain.  There’s a good reason for that.  The simpler, more primitive functions (like fight/flight/freeze) are close to the inside and the base of the brain.  Evolution!  And then the further up and out that you go in the brain, the more complex it gets.

So once information is taken in by the RAS and processed through the thalamus it relayed up to the limbic system.  The limbic system is pretty complicated and is responsible for a lot of things, including the formulation of memory, emotional response, and behavioral response.  Here’s the other thing, these systems are not able to actually process ALL that much information.  Sensory information gets lost really easily.  This is an adaptive function.  It’s not adaptive for us to process every single detail.  That would be really obnoxious, right?  So our brains filter information.  We attend to and process only relevant stimuli.  For example, if you’re walking around Target and looking at the sale racks and looking for something in particular you are able to attend to the clothes, the textures, that Target smell.  But you can filter out the kid screaming two aisles away, all the Target worker chatter, the popcorn smell, the color of the carpet.  One important stop along the brain train here is the Amygdala, where a visceral response is created to the information.  This is an automatic, physical and emotional response, that “gut” reaction.”  Here again, the information still hasn’t really been organized or integrated, no memory or narrative of the information or event has been formed.

So the next stop is the hippocampus.  The hippocampus is responsible for memory formation.  It integrates sensory information to form what we think of as memories.  Contrary to the popular idea of memories, things are not encoded in the hippocampus as narrative events or stories.  It’s the sensations and input that goes in, which later gets re-formed when we “recollect” it (which is a great word because it’s actually what our brain is doing—re-collecting and ordering sensory information to formulate a memory).  So, for example, when Dr. Blasey Ford said her most significant memory of her trauma was the laughter of Kavanaugh and Judge, that makes perfect sense.  It’s auditory sensory input, that like created a heavy emotional reaction for her.  Strong sensations with strong emotional reactivity create the most significant memories.  When a vet with PTSD recalls the smell of gunfire or the sound of a blast, it’s the strong sensation plus a heavy emotional/visceral reaction.

The hippocampus isn’t just about memories.  It works together with the Autonomic Nervous System and the Endocrine System (which includes the Pituitary and Adrenal Glands) to react to stressors and regulate your body’s reaction to stress.  When these systems are activated, and work properly, the appropriate hormones are released in your body to protect it and regulate the stress response.  So cortisol, endorphines, and other hormones are released through your body to get you going and keep you safe.  This system is call the HPA Axis.  The HPA axis is…complicated.  And beyond the scope of this little intro.  So, you can check out more in the Wiki or here.

Alternatively:

Only after all of this happens can the information move up the brain into the cortex, where actual thoughts and problem solving and all of that good, interesting stuff happens.   In the cortex, these sensations get put into words, narratives, we can now use the information to problem solve.  Before it get here, we’re just working on gut reactions.

So given how all of this works, how many different systems are all involved, it’s easy to see how much can go wrong.  All of these systems that are in place in our brain, they are adaptive, and they are plastic.  When trauma happens, it activates these systems, the limbic system, the HPA Axis.  All of these systems are used to functioning at a relatively (relative to the experience of trauma) low level.  And they do a good job when they’re at that level.  Little threats happen that fight/flight/freeze goes into effect, we get out of the situation and our shit is able calm back down.  HPA goes back to a normal level of hormone secretion, the RAS is able to modulate our basic systems, and our neocortex goes along doing math or whatever.

However, when we experience a trauma things can go wrong. Remember how I said that we can’t process ALL the sensory information around us?  How normally that’s a good thing.  During instances of trauma, our brain does get really overwhelmed by all of the sensory stuff going around.  I’ll reframe from painting a picture, but I’m sure you have one in your brain.  When the lower parts of the brain, including the limbic system gets overwhelmed, it can interfere with all of the other processes.  This HPA axis can get out of what.  Too much of certain hormones and too few of other hormones are released.  The body goes into overdrive.  The Nervous System pumps quickly , you feel anxiety, panic, racing thoughts, fear.  What this also does is effect the hippocampus, which is responsible for making the memories of the event that is happening.  But it gets overwhelmed and can’t process and formulate memories for everything.  What the hippocampus tends to dump is those peripheral details.  Now, we don’t know how or really why this happens, but we see it as a general trend.  Information that had to do with emotional reactivity, visceral sensations and reactions.

Look at those cool little hippocampi!

(Fun fact: the hippocampus is named of a mythical Mer-Horse, Poseidon’s horse)

But anyway, you know that trauma effects the memory systems (as well as plenty others, I could write on this for days).  The longer a trauma goes on, the more severe we tend to see the effects of the trauma.  I’m pausing here to say that, basically everything exists on a normal curve.  This means that not everyone’s experience will be the same.  We only tend to judge and make decisions on trends and expectations for normal curves.

When people report not recalling their trauma or not recalling aspects of their trauma, this is actually what we expect.  We know that people will generally remember very sensory things the most, and peripheral things the least.  Most people who experience trauma won’t recall the day, some even black out for periods after the trauma.  All of this serves a function in the brain.  There are plenty of deep evolutionary theories about this, but we can’t really substantiate any of them.  We can only test what we see now.  We see changes in the brain structure and chemistry following a trauma.  And this important.

Resources:

Bessel Van Der Kolk

More BesselMore Bessel

Bruce Perry

Judith Herman

Human Brain Project

Reading Research 2: types of research design

Alright, let’s do this while I’m super motivated!  Why am I super motivated?  Same as usual, rage.  Saw someone insist that (essentially) reading a bunch of stuff online is the same as getting a degree.

So let me take a quick aside to clarify why that is not the case.  What you learn in school is not just a bunch of facts.  You’re not just regurgitating what you learn.  If that was all it was, it would have been way easier.  Schooling, at any level above elementary school, becomes more about critiquing and analyzing.  Can you not only read and memorize facts, but be critical of what you learn, challenge it, and integrate it into what you know, or weigh it against what you know to make a more informed decision.  It’s why medical and psychological diagnosis is often so difficult.  It’s not about just knowing the symptoms, but understanding all of the multitude of factors that could be contributing to them and being able to understand how those factors all fit together.

Consuming and knowing what those factors are, understanding those facts is just the first step.  So that’s where we’re going to begin.

To start: there is no such thing as a perfect research study.  All research has limitations.  The whole goal of a good research study is to be as specific as possible.  That generally means that a study will only investigate one or two small factors.  This is also why it’s important to be able to look at an entire body of research, not just a handful of studies.

One thing to understand is the different types of research design.  4 main types are:

1. Descriptive–something such as a case study or publication of survey findings.  All that is done in this type of study is describing what is observed.  This is the least controlled (really, very little if any control is applied to a Descriptive study).  And because it is the least controlled it is also the least powerful when we talk about convincing scientists or informing a new theory.  Descriptive studies are used when we discover something new, have an interesting case with unique features, or something like this.  It is best used to share a discovery or propose future research.  Most early psychological research is case studies, and they are easily disputed, flaws are easily identified, and we don’t really look back at them with great esteem.
2. Correlational–observational study, case controlled study.  In a correlation design, similarities are noted or things that occur together are noted.  How often things happen together is what we are looking for in a correlational design.  These are a step up from Descriptive studies, but anyone with the most rudimentary knowledge or science will remind you that Correlation does not equal Causation.  Just  because things happen together, or they increase and decrease at a similar rate, does not mean that one causes the other.  Even if we think one does cause the other, directionality, or which one causes the other to rise and fall, cannot be determined in this way.  Correlational design also does not control for confounding factors, third, fourth, fifth, etc. factors that could be leading to the relationship between the two being studied.  So, while Correlational designs are a step up, they are still imperfect.
3. Semi-Experimental–Working our way up, the next best design is Semi-Experimental.  This introduces a change, a treatment or intervention of some sort into a population.  It takes an idea that the research believes will create a positive change, and applies it directly, measuring relevant factors before and after application of the treatment to see if there is a change.  Often a convenience sample is used (a group of people that is easily accessible, eg. College Freshman in an intro psych class) or, when possible, an identified group (eg. a community sample in an urban neighborhood).  What’s important to know about these designs is that there is no control group, meaning the results have nothing to be directly compared to.  In clinical psychology, researchers may use a semi-experimental model to test, for example, a new treatment modality.  They will assess symptom levels before and after the intervention and compare them to individuals who were on a clinic waitlist for the duration of their experiment.  A confound in this example is that we know, from past research, that ANY intervention will lead to a short-term reduction in symptoms.  It does not necessarily mean that the treatment worked or that it works better than any other modality.  I’m sure that other fields have similar set ups (but you’d have to ask them cause I’m just a psychologist).
4. Experimental–This is the top tier of what we look for in research design.  It takes a control group (a group that stays the same, has no changes made to it) and an experimental group (a group that has the procedure/treatment/etc. directly applied.  It measures variables before and after (sometimes during, depending what you’re studying).  This allows us to make a direct comparison.  Is it specifically what we did that made this change?  Well designed experiments rule out as many other factors as possible.  The best studies are blind, meaning that the participants do not know what treatment they received.   Placebos or “treatment as usual” is often used for medications or behavioral interventions.

Beyond these research designs, literature reviews and meta-analyses are the best ways to gather grand amounts of research and compare them all.  A meta-analysis involves gathering all the relevant information on a subject (within specific, defined lines) and review it find the most consistent, robust findings.  When we look at 100 studies, for example, of treatment modalities for depression in adolescent females in the United States, what do we find?  What findings were the most consistent across studies?  What were confounds in many studies?  What are common pitfalls in the research?  What are some notable differences?  Did we really look at ALL adolescent females in the US, or just white, middle class females, with access to health insurance?  These things make a difference and guide our research.  We need to know the answers to all of these questions and more.

Results of all of these types of studies is what guides scientific decision making.  It is imperative that researchers follow the data, even if they don’t like it.  The body of research, the decades of scientists that have contributed to the field are who we follow.  And those researchers are flawed.  Ideally, science is a self-correcting field.  When our theories no longer work, we change them.  But we, like the rest of the population, can be guilty of hubris.  We had to admit that we are wrong, that our theories are wrong.  We get stubborn and dig our heals in.  In the end, good research should win out.  And in the mean time, the body of research continues to build around those stubborn folks.

I’m going to continue the next post in how to read scientific papers: a quick guide (I always say quick and then…well…yea).  But in the meantime, I figured I would give a recommendation of a book about a changing theory in science, and the internal battle.  Seven Daughters of Eve by Bryan Sykes is about the history of haplogroups, essentially tracing the evolution of man (though, really woman as the book describes).  The actual descriptions of the women/groups is less interesting than the authors story of the battle within the field upon discovery of evidence and development of the theory.  If you ever thought that scientists just sat around patting each other on the back and agreeing with you…you’ve clearly never been to an academic conference.  These arguments and debates can get intense and the drama is on par with any bad reality show.  Check it out!

Reading Research pt 1

This is the 5th draft of this post I’ve tried to write.  And I just now realized that I’m getting way ahead of myself every time I start to write.  I’m not sure where I start, but I know where I want to go.  So I keep revising and back tracking.  Now I’m going to start from the beginning.

A quick rant first: I am obsessing over writing this because I’ve seen how predatory certain communities can be.  Whether it is the Jordan Peterson acolytes or Clean Eaters, they take the same approach to reading research: ignore masses of research and cherry pick one to three studies that confirm only what they think.  People get sucked into these arguments and otherwise neutral observers get caught up in the “obvious” results of these studies.  Because reading a single case study or over simplified and exaggerated article is way easier than understanding the complexity of any issue.  It becomes easier to agree with that side, because it’s more convincing than swaths of research papers that require background knowledge before even going into.

Researchers, professionals….we generally suck at communicating our knowledge.  We have a lot of it.  And the more you understand something the more complex it is to you.  To the normal population, explaining Depression or Anxiety seems easy.  To me, I always feel the need to communicate all of the nuance, the neuroscience, the various ways it can develop.  If I’m feeling really geeky that day I might muse about the more recent research on autoimmune and inflammatory responses, even though none of that is conclusive.

Experts know how complex what they study can be.  We generally have a knowledge of the research base, how that research base developed over years, and what the different opinions in field are, both research supported opinions and non-research supported ones.

The thing is, most people aren’t really taught how to read research, how to critique research, or how to spot bad research.  Like I said, I wrote this article a few times before and realized I was in too deep.  So I’m breaking it up.  First I want to talk about reading research and then how to critique it.

I will do a little disclosure here.  Part of why this matters to me so much is very personal, beyond wanting everyone to better understand psychology.  I have Rheumatoid Arthritis.  I was diagnosed at 29 and it changed how I think about a lot of things.  It exposed me to the world of ableism and the predatory world of “Wellness.”  When you have a chronic illness, people will give you all kinds of shitty, uninvited advice.  They will insist that whatever their new “kick” is will cure all of your symptoms.  The amount of bullshit advice I’ve gotten from people, that turmeric will stop my inflammation, that mineral water will take away all my symptoms, that if I just go “all natural” I wouldn’t have any problems.  And, of course, that CBD oil solves everything.  I believe that most individual people who do this mean well.  However, the websites and retailers that peddle these products are, in my eyes, predatory.  They prey on people looking struggling and suffering.  They make promises with no evidence to back up their claims.  But people want promises.  They want hope and certainty.  And, generally, doctors are not going to give that.  When I meet with my rheumatologist, he reminds me that there is no cure for RA and, until there is, I will be living with this for the rest of my life.  We speak holistically, about my diet, my exercise, my lifestyle, my stress, and yes, my medication.  I know that even with medication I will still have this.  I will have it the rest of my life and it will change the way I make decisions about my life.  I wish I didn’t have to do that.  And so I get why people want cures and the seek out promises and guarantees.  I’ve been lucky enough to have a good doctor (and only because I had the privilege of good insurance that allowed me to seek a good doctor out.  My last one sucked and took none of the time that my current one does).  Many doctors don’t have the time to go in depth with patients, to geek out of neurological symptoms and assessments, to talk about managing neurological effects and which style of yoga is best for both my disease and my personality (over-achieving, self-competitive—Heated Vinyasa).  I’m not going to go too far into all of this, there’s a great article about it here.  I have a critical eye, in large part because I had great educators who nourished that in me and taught me these skills.  Not everyone has had that opportunity and that privilege.  So I will try to extend what I can to get people started.

I’ll end by saying that I find the wellness market and their “research” and marketing knowingly misleading, predatory, and ableist.  I want to arm people facing these discussions, chat groups, and communities with the tools they need to really comprehend, critique, and grok the information.

 

So that’s coming.  But I wanted to get this out now because it will motivate me to follow through.

Abortion and Mental Health

Abortion is a controversial issue…obviously.  It’s dumb to even write that sentence.  We all know that this is one of THOSE issues.  And because it’s one of THOSE issues, it rarely gets talked about with the nuance it deserves.  There is a lot that goes into talking about abortion, legalities, healthcare, and more.  I can’t and won’t speak about the medical methods of abortion and it’s safety.  You can get that here or a more detailed study here.  For more general information about abortion, Guttmacher is a good place to start.

What I can talk about, and what many of these other resources don’t really address adequately, in my humble psychologist opinion, is Mental Health and Abortion.

One of the reasons I think this is never adequately addressed and picked apart is the felt need to reassure people that there is not risk to mental health following abortion.  And that is true, which I’m going to talk more about.  However, in reducing argument to a “yes or no” matter, many voices are left out.

Pro-lifers will very often claim that women suffer from Post Abortion Syndrome (PAS) years after abortion.  In response, Pro-Choice people, I think in an overly reactive way, insist that there is no negative or mental health effect of abortion and everyone one is always fine.  I wanted to spend some time to really pick that apart.

If you’re a TL;DR person, here’s the quick: There is NO EVIDENCE that abortion itself leads to an increase risk of mental health symptoms.  But the conditions under which pregnancy and abortion happen (pre-existing conditions, trauma, reason for abortion) can effect one’s mental health.

Let’s start at the beginning-ish.  America’s obsession with proving that abortion led to mental health problems began with Ronald Reagan (everyone feign shock!).  In 1987 Reagan ordered the then Surgeon General, C. Everett Koop, to complete a report on the psychological effects of abortion.  After a lengthy review of the existing evidence, Koop sent an official letter declining to issue a report.  His 1989 letter stated “…obstetricians and gynecologists had long since concluded that the physical sequelae of abortion were no different than those found in women who carried to term or who had never been pregnant.”  (This quote is cited from the APA’s 2009 meta-analysis. I could not find the original for free, but the APA’s sourcing is pretty consistent with everything else I found.) The letter goes on to discuss how individual women’s experience will always be different but, on the whole, the risk to mental health is minuscule.

Obviously after this was released, there was a watershed of research into abortion and mental health (including one of my wonderful supervisor’s extensive dissertation).  Researchers seeking to prove a relationship between abortion and mental illness claimed to have evidence of PTSD symptoms in women who sought abortions.  The term/diagnosis “Post Abortion Syndrome” was coined.  This was reported to be experienced by women who underwent abortions and had severe negative reactions, which they then repressed, and experienced intrusive thoughts, guilt, and reduced responsiveness.  This was labeled “a public health crisis” and often used by pro-life groups, churches, and conservative politicians (and still is) to argue that abortion was dangerous to women.

The problem with this argument is simple: the research around PAS sucks.  One meta-analysis often cited from 2011 found that women were at a major risk for mental health consequences following an abortion.  Unfortunately, this study has been harshly critiqued by researchers since its publication.  One researcher stated that the 2011 study’s results were “invalid” due to not following the accepted research guidelines for meta-analysis.  Mainly it has been criticized for how it selected the studies to include in the meta-analysis.  For example, excluding studies that controlled for or excluded women with pre-existing mental health conditions, ones that excluded data on post-partum depression, etc.  Although many studies have linked abortion to mental health risk, those that have failed to address confounding factors, such as the conditions under which the individual sought abortion, pre-existing conditions, history of trauma, age, autonomy in the decision of abortion, and when in the pregnancy they sought abortion.   Also, many of these studies were retrospective, asking women who already reported high levels of stress and poor adjustment to their abortion, to describe their symptoms up to 40 years after having the abortion.

When more rigorous research has been done no significant differences in mental health effect has been found.  Again, this needs to be dug into a little bit deeper.  Because there are many factors that go into an individual’s circumstances and treatment before and after receiving an abortion that CAN effect mental health, such as Abortion Stigma, circumstances of the pregnancy, circumstances of the abortion, treatment by the community, how wanted the pregnancy was, when in the pregnancy the abortion occurred, and, again, pre-existing mental health and personality factors.

One long-term  study that I came across a lot and found incredibly useful in researching this post was The Turnaway Study (rather than linking, I’m just going to advise you to google this study.  Several publications came from the data, all are worth reading, but I’ll cite a few).  This was a 5 year-study that followed women who experienced unintended pregnancies and their choices, including obtaining an abortion, seeking but not being able to get an abortion, and carrying the child to term and keeping the child.  It also looked at the factors that women considered when seeking an abortion.  Unsurprisingly, most women cited multiple factors; but primary contenders were financial reasons (40%), timing (36%), partner-related reasons (31%), and need to focus on other children (29%).

Most researchers and doctors will tell you that women consider a lot before choosing to move forward with an abortion, and some of these factors are going to feed into whether or not women experience significant distress following the procedure.  First, whether or not the pregnancy was intended must be considered.  Women who undergo abortions following a wanted pregnancy (most often for health-related reasons, either the health of the mother or the fetus), do tend to experience more distress.  Ellie Lee conceptualized this as the experience of an intense grief for the loss of a child.  Women who sought pregnancy and planned for the arrival of a child, who struggled with unresolved grief, often in a culture where the processing of this grief is often unwelcome.  Lee also described this as more akin to women who experience miscarriages than the women who undergo elective abortions.

Before going into what happens after abortion, in order to understand mental health in a real, well-rounded way, we have to look at pre-pregnancy health and the conditions of the pregnancy.  A lot of what I’m citing here comes from two meta-analyses, here and here, as well as the Turnaway Study.  Factors that correlate with higher rates of unplanned pregnancy tend to be the same as those that correlate with higher life stress in general, including low income, minority status, lower level of education attainment, less access to healthcare.  Age is another major factor.  Pregnancy at a younger age is generally associated with higher levels of stress for SO MANY reasons.  The conditions under which pregnancy occurred also feed into levels of distress felt.  Clearly, if pregnancy occurs under coercion or sexual assault vs. consensual sex in a healthy relationship, things are going to be a bit different.

Looking at the context of relationships, existing mental health and lifestyle stability, and health are necessary to get a full picture of what someone’s experience with abortion is.  Adult women who sought medical abortions, under a doctor’s care, and of their own free choice, reported few to no mental health symptoms.  Some studies have also found a slight increase in self-esteem following abortion under these conditions.

What leads to higher levels of distress and mental health symptoms is pre-existing instability in lifestyle, poverty, lack of healthcare, rape and sexual assault, being coerced into getting an abortion, stigma, and loss of supports following an abortion. Women who were in abusive relationships or who felt coerced into getting an abortion reported higher rates of depression, distress, and anxiety.

Another factor that was found to increase distress following an abortion was getting an abortion later during the pregnancy.  About 90% of abortions occur in the first trimester.  Later term abortions often occur because a fetal abnormality or health problem has been identified.  Another reason why abortion often occurs later in the pregnancy term is restrictive abortion laws that force people to travel long distances and wait several days before being able to obtain an abortion.  Many people struggle to pay for abortions (which makes it more difficult when you recall that financial problems are a main reason that individuals cite for having and abortion).  Barriers to abortion and being denied an abortion has been found to be more damaging to women than being able to safely obtain an abortion in a healthy, supportive environment.

It’s also important to address what happens, socially, after an abortion.  Research on stigma has shown that women feel that they have to keep their abortion a secret from friends, family, and loved ones.  They fear judgment and losing the support of others; in fact, they report that this was a bigger source of distress than the abortion itself.  Women want and need support.  Lee and others have referenced Judith Herman’s (heart, everyone should read Judith Herman) conceptualization of “disenfranchised grief” when talking about women not feeling able to openly process and cope with any distress or questioning they might be experiencing.

When we look at the “consequences” of abortion, we also have to address what we are comparing.  There may very well be distress that goes with an abortion.  However, that must be compared to the distress that can also come with carrying the pregnancy to term, whether for adoption or to keep the child.  Carrying the child means facing a major life change, a different level of stigma, and potential for post-partum depression.  The best research I found were studies that compared outcomes for women who made different choices.  And those studies all found that choosing abortion did not leave women at a higher risk than any other choices.

What is often discussed in politics and media as a “yes/no” question, becomes a huge, entangled web of systemic and personal issues.  And in order to support reproductive health and choice, we have to address all of these issues and provide adequate resources.  That includes ACCESS TO ABORTION AND REPRODUCTIVE HEALTHCARE, accurate information, elective counseling, stigma reduction, and community support.  Individuals need to offer support to loved ones who are pregnant and those who have elected to have abortions.  Doctors need to be judgment free and affirming to all of their patients.  Therapists need to be well-versed in addressing issues of pregnancy, reproduction, and abortion.  Communities need to be open, free from judgment, and affirming of individuals.

I could go on about other political and medical questions about abortion.  But I’m going to stay in my lane and affirm this fact: There is no direct correlation between mental illness/PTSD and abortion.

 

 

Engaging in social change as a psychologist

I’ve been interested in the idea of social responsibility for psychologists (and medical & mental health practitioners in general) since early in undergrad.  I went to Catholic Jesuit college which had a significant focus on social justice and activism.  I found this energizing and brought a different light to what we were learning.

When I was applying to graduate school I chose clinical psychology because I thought I wanted to work directly with people and that was the biggest impact I could make.  I also have struggled with social anxiety for most of my life, so the idea of being any kind of leader seemed unfeasible at the time.  (This is a wrong idea.  I was wrong.  Anxiety doesn’t have to interfere with you being a leader.)

As I continued in school and into my early career, I continuously questioned this choice.  The majority of my professors reinforced the idea that psychologists belonged in the office.  That is where their role began and ended.  If we chose to engage in any activism, the message was that that should be outside of our work as clinicians.  The discussion of “advocating for your clients,” to them, meant consulting with schools or working with medical doctors.  Some students and professors would go so far as to say that even things like contacting housing or job programs was outside of our realm and “a social worker’s job.”  I always had to roll my eyes at the last part.  I found it condescending on multiple levels.  But I was so anxious about what my role as a psychologist was I was more apt to not do things than to stand out and speak up.

This always felt so limiting.  I felt uncomfortable engaging in activism in graduate school.  I was relieved to have a few excellent professors who felt we did have a responsibility to advocate for our clients and our field outside of the therapy office.  I was honored to train at a number of community mental health agencies with clinicians engaged in the community through public education and outreach.  I admired these clinicians.  I worked with a few professors who felt things like the school-to-prison-pipeline were things that psychologists should be speaking out against and using our expertise to end.  With their help I kind of got over (some of) my anxiety.  I got involved in a few local organizations and marches.  I was honored to be part of a teach-in on rape culture and lead discussions on abuse and women’s health.  I also discovered a few professional organizations that value political analysis and engagement.  I feel like I’m getting closer to finding my fit in this field, outside of the office. (Of late, my marching has been limited thanks to arthritis.  But I do what I can, be it donations, writing reps, etc.)

Of late, I have been thinking more and more about the role of psychologists in social activism and politics.  The detained immigrants, separation of immigrant families, and March for Our Lives events have filled up my brain space.  I spend a lot time wondering why I’m not hearing more psychologists speak out on these issues.  Sure we speak to each other.  We share among ourselves the attachment and neurological damage done by separating parents from children.  I had an amazing discussion about Trump’s “neurological exam” back several months ago.  I wish I had this blog running then.  I would have given a great run down.

The point I’m getting to is that I feel that psychologists have much more to offer than what we currently give to the world.  We make poor use of our pulpit.  We suck as communicating out expertise and why our work is important and why public officials should consult us.  We have a handle on research as well as sharing stories of our work.  It’s a unique combination of skills and stories that we bring to table.

I won’t act like my motivations for writing this blog aren’t partially political.  Work in anti-stigma is political.  Healthcare is political.  The personal is political.  In my private practice work I keep my politics mostly aside.  I work in service of my clients and this personal and systemic needs.  I love that work.  But I’ve always sought more political engagement.  And that’s what this blog is.  Education, destigmatization, empowerment, understanding, conversation.  The starting points for change.  My attempt to live up to my felt professional responsibility of sharing knowledge and empowerment.

Working

Sorry it has been quite a while since the last post.  I was on vacation and then work exploded a bit.  Posts coming soon include:

the history of psychiatric hospitals and understanding how they work today

Cognitive Dissonance & Group Think in our daily lives

Psychology and social responsibility

So I’m working.  Life has just been busy.<3