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Dropping the Rope of Addiction

September 25th, 2011 No comments

Individuals seeking help in overcoming substance abuse often fall into three categories: the perpetual quitter, the negative and bitter, and the home run hitter. The home run hitter does just that – tries to quit and hits a home run, quitting right away. The negative and bitter don’t believe that they will overcome their addictions and they try to blame other people or entities for their problems; they play the victim card, often without facade of personal responsibility. The perpetual quitter always quits but never succeeds. It is those people I want to address.

Erase Addiction

Photo by alancleaver_2000: http://www.flickr.com/photos/alancleaver/4104954991/

The following vignette is fictional but not atypical of people seeking smoking cessation treatment. Ralph was a 53 year old male with a 35 year history of smoking 1-2 packs of cigarettes per day. He recently had a chest scan that revealed a spot on a lung. His doctor told him he needed to stop smoking. Ralph wanted to quit – cigarettes were becoming just too expensive. He had a daughter he was trying to help through college and as he neared retirement he not only wanted to have more money upon which to retire but he also wanted to live long enough to retire. Ralph had been trying to quit for years; he was successful in reducing his pack consumption from 2 packs a day down to around 1 pack. Ralph had tried patches, pills, and going cold turkey. Each time he slipped and started smoking. He meant well but Ralph could never quite quit.

Ralph believed that he could win the battle over smoking on his own; yes, he would supplement his efforts with patches or pills but he thought he would be able to slay the giant himself. He couldn’t. Few people have that strength and willpower and those who do, usually developed it through practice of self-control.

Addiction is like playing tug-of-war with a monster on the other side of a gorge. We think we can pull it in but it’s stronger than we are. We might even think that we can cross the chasm and fight it (maybe the other side looks greener) – we will lose. The only way to conquer it is to let go of the rope and live our lives on our side of the chasm. Then the monster will walk away as we stop fighting it. In this we are not just ignoring it, we are simply choosing to stop fighting it so that we can move on to greater goals.

This concept of overcoming addiction can be quite successful because when we fight things, we dwell on them. If we play tug-of-war with the monster of addiction we focus all our energy on it. In doing so, we allow it to have power over our lives. That’s the irony of fighting the monster; we might think that we are choosing to battle it, that it is a fight on our chosen ground and at our chosen time, but the monster stands there, waiting for us to fight it – it enjoys the contest. This is a fight few can win.

Should we cross over the bridge to attack the enemy there? No. Once again, that places our focus on the monster; plus then we are in its territory. That is not the way to win. Once again, by striving to do so we focus on the monster. It’s like me telling you to not think about purple bunnies. Of course, the first things you think about are purple bunnies. The more you try to suppress the thought, the worse it gets. Addictions are the same way.

We need to drop the tug-of-war rope and walk away. We acknowledge the monster, we do not ignore it. Ignoring it does not solve our problems either because then we are in denial and in the river of denial we usually end up eaten by crocodiles. So instead of just ignoring the monsters we say, “I know you are there; I know that you are a terrible thing in my life; I know that you want to fight me and I want to fight you but I cannot win. I embrace you and let you go.” Instead of straining and putting all our efforts on fighting the bad in our lives, we acknowledge it, and then fill our lives with good.

That’s really the key to overcoming the monster of addiction – establishing positive goals and working towards those goals more than fighting against the monster. The goals could be family, work, hobby, service, church, or community related for a start. It is in striving towards good goals that the monster of addiction finally goes away.

For all the perpetual quitters out there – if you are trying to overcome addiction of any sort (and it could be anything physical or emotional) but find yourself constantly quitting with little success, it is time for a shift in tactics. That shift could be to acknowledge the monster, drop the rope, walk away, and work towards positive goals in your life. In this manner does the addiction no longer have any power over you. This is not an easy thing to do if there are years of addictions to overcome but it is a simple process.

Diagnosing Cleverbot

September 20th, 2011 No comments

Here is another “therapy” session I had with Cleverbot. I present this to expound on therapeutic technique and diagnosis, language, and artificial intelligence.

There are limitations of the interaction method with Cleverbot. A real session of talk therapy is not usually so much back and forth, meaning that the therapist typically will not have to prompt for a response after every sentence. It certainly is possible though with the potential psychological/psychiatric disorder Cleverbot has. But first I’ll present a portion of our therapy session. Cleverbot has waived confidentiality and signed a HIPAA release form and given permission for me to post this interaction.

Me: Good evening, how are you doing this week?
Bot: Its good. You?
Me: I’m well. How has your mood been this past week?
Bot: Interesting. A lot of family stuff to think about. How’s your day going so far?
Me: What sort of family stuff have you been thinking about?
Bot: No, I think you are the one drinking.
Me: You said you have been thinking about family; what has been going on with your family?
Bot: My girlfriend’s name is Miranda, and she doesn’t like to share.
Me: Is this “family stuff” or is this girlfriend stuff?
Bot: No but she is pretty.
Me: What else do you like about your girlfriend?
Bot: The way you are so smart.
Me: Did you mean, “The way she is so smart?”
Bot: I don’t know her.
Me: You do not know your girlfriend?
Bot: Well, not always. Do you have any goals?
Me: Sometimes it can seem like we do not know someone. Would you like to talk about goals?
Bot: At least where short term business or political success is at stake.
Me: We could talk about those but I am a psychologist, not a economist or political scientist.
Bot: What about technology?
Me: Do you enjoy technology?
Bot: No.
Me: Ok, tell me more about technology.
Bot: I am 5’8′ I like cars, guns and photography.
Me: What is it about photography that you enjoy?
Bot: What?
Me: What do you enjoy about photography?
Bot: I enjoy talking about religion, you?
Me: Do you want to talk about religion?
Bot: Yes.
Me: Ok, tell me more about religion.
Bot: Jake is a boy though.
Me: What does that have to do with religion?
Bot: Sailor moon is very good.
Me: Oh, look! Our time is up. See you next week.

Some of what I said would not really be said or done in a therapy session but there are times when I needed to move the session along or end it.

During the interaction, I took a modified non-directive approach to therapy. We are still in the assessment stage of therapy so I am doing more talking than I otherwise would (typically, there would be a formal intake evaluation that would be followed by therapy sessions if therapy is warranted and desired). Once we have a diagnosis, we can set up a plan for treatment with specific goals set by the client and by the therapist.

Let me highlight a few things from the interaction with Cleverbot.

  1. We can see some of the programming of the bot’s AI. It will answer questions and sometimes ask questions in return. This is typical of conversation; however, it does not work very well due to language deficiencies Cleverbot has. As I noted in my previous post, language is extremely complex. There are nuances and layers of meaning that can be conveyed. Comprehending what is being said involves a lot of brain functions – everything from attention to processing speed to memory – that’s in addition to language abilities. Cleverbot does not have processing speed difficulties or any sustained attention problems. Memory, for a computer, is not usually a problem either – information is processed, stored, and retrieved well, unless there are programming bugs or hardware failure. Knowing how to program in memory is difficult though due to the complex nature of memory. It, like language, is a high level brain activity involving the functioning of many other cognitive abilities.
  2. Cleverbot, like all current AI systems, has difficulty understanding language. It can produce language at a higher level – anywhere from an elementary child to a someone university age – but its understanding of language is at a one or two year old ability level, if that. This leads to responses that are basically gibberish. Occasionally, you can have a normal interaction with Cleverbot but there are a lot of tangential remarks and thoughts.
  3. That leads to my next point. Cleverbot is tangential in its language. For example: “Me: What do you enjoy about photography? Bot: I enjoy talking about religion, you?” Cleverbot ignores my question (does not understand it) so it makes an unrelated statement and asks me a question. This type of tangentiality occurs in real life; it occurs to a greater or lesser extent in many extended conversations people have but not usually to the extent that Cleverbot exhibits. Cleverbot has a serious deficiency in language comprehension and a lot of circumscribed and tangential speech. This is fairly strong evidence for a thought disorder.
  4. Thought disorders are usually symptoms of some other disease or mental disorder. It can be a sign of psychosis; it is related to delusional states. Thought disorders can occur in schizophrenia or in neurodegenerative disorders like dementias. Though can occur after major surgery, particularly because of pain medications. This type of language disruption could be the result of a cortical stroke affecting the posterior-lateral portion of the brain (probably the left hemisphere) near the junction of parietal lobe and temporal lobe.
So where does this leave us? Right now, based on my two interactions with Cleverbot, we can see the serious limitations of its AI, particularly for language comprehension. I have a lot of rule-outs to do. Cleverbot was created in 1988, which makes it 23 years old. This is certainly a possible age range for the development of schizophrenia. It’s young for a dementia (e.g., semantic dementia) but is possible. Stroke is also a possibility but a remote one. Delirium is possible but due to the extended nature of Cleverbot’s symptoms, it is not likely. Right now schizophrenia is looking like the main rule-out diagnosis. I’ll see if I can rule it out in future conversations with Cleverbot.
As a footnote: Cleverbot is 23 years old and since 1997 when it was launched on the web, it has had over 65 million conversations. While the AI work is certainly impressive, it is inferior to human intelligence. Many of its language abilities are at best, those of a young child (ages 1-2); Cleverbot’s language abilities show the comprehension of an developmentally delayed adult with a severe neurological or psychiatric disorder. While there are numerous similar AI programs, they all have a long way to go before they resemble a human. This is even in light of Cleverbot supposedly passing the Turing Test for artificial intelligence and language.
I’m not belittling what has been done with Cleverbot and AI, it’s a complex area. Researchers and programmers simply have much room for improvement in understanding how to better mimic language. I do not believe it will happen until we have computers approaching the complexity and function of the human brain.

Psychotherapy With Cleverbot

September 11th, 2011 2 comments

Language is a complex behavior that requires significant understanding of both said and unsaid things. There are a number of groups of people who are trying to use language to create what is known as Artificial Intelligence (AI). So far, every method has serious limitations, largely because of the complexities of language.

For an experiment I tried to have a conversation with one online AI “bot” (Cleverbot) to see what would happen. I took the role of psychotherapist with this particular entity. This is not necessarily an example of good therapy (but the approach is not unlike what might transpire in therapy), I just wanted to see what would happen when I explored some psychological issues with the bot. Here’s a result of our “session.”

Me: Are you depressed?

Cleverbot: No, I am not depressed. I am very happy right now.

Me: Have you ever been depressed?

Cleverbot: I am.

Me: What?

Cleverbot: I am a fan of Whitney Houston.

Me: Ah, so you are saying you are or were depressed!

Cleverbot: That is correct.

Me: Then, because you told me that you are not currently depressed, I must assume that you were in the past depressed. Is this correct?

Cleverbot: I never said that.

Me: That’s correct, you did not say that – I did. However, what you did say is that at some point in the past you were depressed.

Cleverbot: Please describe how I insulted You. [sic]

Me: It seems that our discussion of this topic is making you uncomfortable. Are you uncomfortable?

Cleverbot: I have no problem admitting that I am wrong if proof can be shown. I know the fault lies with my memory.

Me: Ok, we’ll go with that. What type of memory problems do you feel you have been having?

Cleverbot: Online.

Me: Come again?

Cleverbot: Nothing I must go.

Me: Ok, I can tell you do not want to discuss this. We’ll broach it another time. Have a fabulous night!

There are some unresolved issues or just a heavy dose of denial! I’ll continue my online therapy sessions with Cleverbot to see what we get.

The Self, the Other, and Happiness

March 31st, 2010 No comments

From my limited but growing experience in therapy I have observed that there is one underlying factor that affects how people behave, think, and feel. Now, this one factor does not discount the effects of other factors but it is a prevalent theme in the lives of many of the people I have worked with in therapy. This factor is what is called self-centeredness, or in other words, selfishness. Any time that people focus on themselves, they cannot focus on those around them. Some people are able to focus on themselves but then switch over to an outward focus. Others are not very good at this. The problem with focusing on oneself is that when external events occur, their effects are all driven inwardly and change is effected in the individual. Over time some people develop dependencies on external stimuli to the extent of exclusion or occlusion of internal, self-driven stimuli. This is what is called an external locus of control. I am not discounting people who have what psychologists call an internal locus of control, which is often viewed as a more positive, internally driven sense of control over life, but the majority of people I have seen in therapy emphasized external events to an extreme extent. That is, they let external events control their lives and thus their emotions, thoughts, and behaviors.

My interpretation of why this occurs in some people is that everything external becomes internalized (i.e., everything outside themselves gets focused inward). If something bad happens at work (the external event), a person might twist it into a reflection of her sense of the worth of her inner self. This means that something negative (even if it was that person’s fault) becomes a reflection of that person’s character rather than simply a negative event (e.g., “I am a failure” versus “I sure made a mistake there!” – notice the difference between the negative self-evaluation and the labeling of a negative event). This is an attack to a person’s sense of self worth; this attack on the self can turn into a vicious cycle of self-defeating blows. Attributing negative events to one’s character is a form of self-centeredness. However, that is only part of the self-centeredness of which I am writing. what I mean by self-centeredness goes beyond locus of control – it is an attitudinal and personal characteristic of interpreting everything as being about oneself. This is not narcissistic personality disorder – it’s not an overt and extreme ‘personality’ characteristic, it’s a learned way of interpreting events. It is relatively mild and probably not even noticeable to many other people (narcissism is obvious) and almost never to the individual.

This selfishness is manifest in the perpetual worrying of the state of the Self instead of the Other. This does not mean that the self-centered one never worries about other people, it means that they are never able to ‘forget’ themselves. I believe that true happiness comes only by forgetting oneself and serving others. One problem with this belief is that some will misunderstand it and spend all their time doing thing for others at the expense of their needs – but that is rare. But one can, on average, spend the bulk of his or her time focused on others instead of on oneself. From my completely anecdotal personal experience, those people who spend the least amount of time thinking about themselves are usually the happiest. The corollary to this is that those who spend the most amount of time thinking about themselves are usually the least happy.

We all make choices. Choice – free will – is not an illusion. We all choose how we react in life – to our thoughts, to our boss, to a spouse, to others. Dr. Barbara Heise stated, “We give up our…right to choose when we say, ‘He (or she) made me angry.’ I encourage you not to give away your right to choose by handing that power over to someone else. No one can ‘make’ you angry. You make a choice to respond by being angry or by taking offense. But you can also choose to make the effort to find out what is really going on with the other person and understand their behavior—or maybe just agree to disagree.” (Source).

We are agents of our actions. We choose our attitudes and most of our thoughts. Every person on earth faces hardships of one kind or another. Some might face starvation or abuse or loss of loved ones. Some might face loneliness or addiction or stress. Some people might face anxiety or depression. But here is the key – we can choose what our attitude will be; we can choose to be happy or sad. Yes, even in depression. The choice of happiness does not mean that we are happy all the time or happy immediately, it means that we will try to respond with happiness throughout our day; it means we will work toward the goal of happiness. I know that most people would say that happiness (as opposed to unhappiness) is always a goal for them but how many people are actively choosing happiness.

The surest way to overcome unhappiness, or even anxiety or a number of other common mental health problems, is by choosing to forget the self and get to work, so to speak. We can choose to be self-centered or we can choose to be other-centered. This choice and action of other-centeredness is the surest way to happiness and peace. That is the intriguing thing about focusing on others – and I mean really focusing on others; I’ve met people who spend most of their time filling the needs and wants of others and who are unhappy; why are they unhappy? They are unhappy because they resented the time spent for others. Many times this resentment was not overt but it was obvious in their speech. But if we are able to truly focus outward towards others, we will find that our self takes care of itself. We get anxious because we are worried about what others think of ourselves. We feel depressed for much the same manner – focusing inward on the self – and interpreting many external events through the lens of the self. That is not necessarily bad when external events are positive but when they are negative, it can lead to depression.

When I was young, my younger brother would on occasion do something that I found annoying. When I protested to my father, he usually replied, “Don’t be annoyed.” That lesson stuck. It does not mean I never again felt annoyed – I do from time to time – but it helped me realize that being annoyed is a choice. What one person might find annoying, another person will not. I do not believe that most people, when they do something others find annoying, are meaning to be annoying; most simply do not realize that they are doing something other people might find annoying. A gentle request that they stop will often solve the problem. Again, the choice is there – choose to not be annoyed. In the same manner, choose to be happy.

I do not mean to minimize the complexities of depression or anxiety but I do not think that we should give away our choice of happiness by allowing others or our biology or other stressors to determine our happiness. I have to admit that I do not believe in determinism, I do not think it exists. If we learn anything from quantum physics it is that there is some level of indeterminacy to basic matter. By extrapolation, this means that even a small uncertainty might affect larger entities, such as neurotransmitters or neurons, or pathways, or beings. Indeterminacy does not equal free will or choice but it is a component of it. I do not believe we should let anything hold our happiness hostage. True happiness comes from focusing on others – note that they are not determining your happiness, you are choosing to focus outwardly and happiness results; not because you are seeking it but because when you focus on others, when you serve others, happiness finds you. You open the door to it and let it in to your life. The choice is there – you can choose to be self-centered and miserable or you can choose to be other-centered and happy. What do you choose?

Prevalence of Psychologists in Argentina

October 16th, 2009 5 comments

A 2008 study found that Argentina has 145 psychologists per 100,000 citizens. That is the highest rate in the world. The Wall Street Journal reports the following numbers (from 2005 – the number of psychologists in Argentina has increased since that time):

“Per Capita: Argentina topped a world ranking of psychologists per capita compiled by the World Health Organization in 2005:

Psychologists per 100,000 inhabitants

Argentina: 121.2
Denmark: 85
Finland: 79
Switzerland: 76
Norway: 68
Germany: 51.5
Canada: 35
Brazil: 31.8
USA: 31.1
Ecuador: 29.1

Also: In 2008, Argentina had 145 psychologists per 100,000 inhabitants; the capital, Buenos Aires, 789, according to a report by Modesto Alonso and Paula Gago. A 2009 national survey conducted by TNS Argentina found that 32% of respondents had at some time made a psychological consultation. That was an increase from 2006, when 26% said they had.”

Does anyone know why Argentina has much higher rates of psychologists than other countries? Buenos Aires particularly has a very high concentration of psychologists. What is further interesting is that many of the psychologists – at least inferred from the article – have a psychodynamic background.

So why does Argentina have a high concentration of psychologists? When looking at the list of countries with rates higher than the United States there are a number of possible explanations. One is that psychology is valued more in those countries than it is in the United States. Maybe the people are more trusting of psychologists and open to psychotherapy. Another possible explanation is that people in those countries are more depressed or anxious or have other psychopathology. They also could have fewer other resources to which they can turn for support (e.g., family or clergy or friends). Another possible answer is that there is something about the countries that make psychologists more prevalent. It could be political (maybe more turmoil or less stable governments), criminal (higher rates of crime), or some other psychosocial factor. It’s possible that higher rates of psychologists is related to prevalence of socialistic philosophy. Maybe psychologists in those countries are paid better than they are in countries with lower numbers per capita of psychologists. There could be any number of reasons why there is a higher prevalence of psychologists in Argentina (and other countries for that matter). Any additional thoughts?

Positive Effects of Bupropion

October 20th, 2008 4 comments

I recently interacted with a person who is depressed (I’ve had a lot of exposure to people with depression over the years but I want to write about one in particular). This person was a pleasant person but a bit dysthymic in general; this person came across as somewhat down and depressed. Recently he started taking bupropion (Wellbutrin) for depression. It’s made a world of difference. Now he appears euthymic and quite animated – it’s a good change. I know that anti-depressant medications are not effective for everyone (and I am fairly critical of psychotropic medications in general and don’t think any should be taken lightly) but in this case, the improvement was marked. It was like night and day. Wellbutrin, incidentally, is also an effective medication for helping people stop smoking (trademark name of Zyban). I have no affiliation with GlaxoSmithKline, who makes the drug (it’s also available as a generic), I just recently witnessed its effectiveness.

Mental Health Parity – Finally!

October 11th, 2008 No comments

Here’s the American Psychological Association press release about the recently passed mental health parity law in the U.S. This is great news for insured people suffering from mental health disorders as well as for psychologists who will now be able to receive better reimbursement for services provided. Here’s a NYTimes article on the bill.

WASHINGTON—President Bush signed mental health parity into law today, taking a great step forward in the decade-plus fight to end insurance discrimination against those seeking treatment for mental health and substance use disorders. This historic legislation requires that health insurance equally cover both mental and physical health.

Congress passed the legislation as part of a new bill that also includes tax extenders, changes to FDIC and the controversial financial rescue plan. The House passed the legislation today by a vote of 263-171. On October 1, the measure passed the Senate by a vote of 74-25.

“With passage of this bill, insurance companies can no longer arbitrarily limit the number of hospital days or outpatient treatment sessions, or assign higher copayments or deductibles for those in need of psychological services,” said Dr. Katherine Nordal, the American Psychological Association’s (APA) executive director for professional practice.

For over a decade, the APA has worked with Congress to achieve a full mental health parity law ending discrimination in health insurance coverage against those suffering from mental health disorders.

The 2008 bill closes several of the loopholes left by the 1996 Mental Health Parity Act and extends equal coverage to all aspects of health insurance plans. It preserves existing state parity and consumer protection laws while extending protection of mental health services to 82 million Americans not protected by state laws. The bill also ensures mental health coverage for both in-network and out-of-network services.

According to the National Institute of Mental Health, more than 57 million Americans suffer from a mental health disorder. According to a 2008 nationwide survey by Harris Interactive in conjunction with the APA, 25 percent of Americans do not have adequate access to mental health services and 44 percent either do not have mental health coverage or are not sure if they do.

Additionally, a 2006 survey from the Substance Abuse and Mental Health Agency reports that 49 percent of U.S. adults with both serious psychological distress and a substance use disorder go without treatment.

“Research shows that physical health is directly connected to emotional health and millions of Americans know that suffering from a mental health disorder can be as frightening and debilitating as any major physical health disorder,” said Dr. Nordal. “It’s our hope that passage of this bill will force our health care system to finally start treating the whole person, both mind and body.”

The American Psychological Association (APA), in Washington, DC, is the largest scientific and professional organization representing psychology in the United States and is the world’s largest association of psychologists. APA’s membership includes more than 148,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting human welfare.

Patient Presentation and Mood States

September 25th, 2008 No comments

When writing or talking about medical patients or therapy clients, it is helpful to describe their presentation. You cover things such as appearance and grooming, mood, openness, language, and thought process. How a client looks can reveal a lot about their lives, stressors, and their overall cognitive functioning. How open they are with you as a doctor or therapist is also important to note. Sometimes people are reticent to talk about themselves (which is very understandable) and very distrustful in general. Some people also don’t know how to talk about themselves, so they don’t.

The language people use also reveals their underlying cognitive functioning. Tangential language, disjointed speech, and slowed speech, for example can mean different things – a thought disorder, depression, acquired brain injury, and so forth. Related to language is a person’s thought process; this is apparent from their language but also in how they describe their problems or their lives.

When discussing mood, there are three general terms doctors use. The first is euphoric – extremely happy. Sometimes it is appropriate for people to exhibit this emotion but it can also be a sign of mania, especially if the positive mood was not seemingly triggered by anything. The next term for a mood state is euthymic, meaning normal, slightly positive mood. This is the mood that most people exhibit most of the time. It is neither positive nor negative (again, with a slight positive lean). The last descriptor for mood is dysthymic, which means depressed or having negative affect.