Author:Paul Gilmartin

Importance of a Psychological Assessment: Guest Blog by Joel Schwartz PsyD

Imagine the following scenario:

You walk into your primary care doctor’s office. You are feeling sick, weak, and unlike yourself.  After describing your symptoms to the doctor, she smiles at you and says, “I think I have a general idea of what’s going on. I have about fifteen hypotheses about what is causing your distress. I am going to pick a hypothesis at random and treat it, hoping for the best. If I am wrong, we will try the next one.”

Wait, wait, wait, you may be thinking. Isn’t there a way to narrow this down before we embark on treatment that will be costly, time consuming, and may hurt me if it turns out to be the incorrect treatment. 

Of course this does not happen because medical doctors rely on tests to better understand what is going on. Unless they test for bacteria, they may be treating a virus, and your illness may be prolonged. Medical tests narrow down the hypotheses about symptoms in order to find the root cause, which can then be treated more efficiently.

However, the same cannot be said about the counseling profession. Even if a counselor is an astute diagnostician, diagnosis tells very little about the underlying processes that are causing psychological distress. In essence, the first months of therapy are, more often than not, an analogue of the above scenario; the counselor is working through hypotheses about what is really going on in order to figure out the best way to treat a client. Many medical professionals fall into similar patterns, providing potentially dangerous psychotropic medications based on symptoms alone, leading to ineffective treatment.  For example, symptoms of ADHD can manifest due to underlying anxiety, depression, trauma, autism, Bipolar Disorder or organic brain dysfunction. Without accurately assessing for all of these, treating for ADHD alone will likely be ineffective.

Just like the medical profession, the mental health profession has tests that can quickly and accurately identify what is going on with a client, thereby fast-forwarding the therapeutic process.  Testing includes questionnaires and interactive psychological tasks that determine information about psychological functioning. Most tests are based on decades of research. The process is long, but interactive, interesting, and often fun.

How accurate is psychological assessment? Meyer et. al. (2001) compared psychological testing with medical testing and commonly accepted medical advice and found psychological testing to be on par with, and some times more accurate than medical tests  and commonly accepted medical advice.

In their book, How to Fail as a Therapist: 50+ Ways to Lose or Damage Your Patients, Drs. Bernard Schwartz and John Flowers list reasons 8-13 as having to do with underutilizing psychological assessment. Lack of assessment carries with it the same dangers described above – incorrect medications, ineffective therapy, and high client drop out rate because of missing the mark when trying to figure out what is going on.

Here are some real-life case examples of how assessment can help:

1.     Trisha was a 19-year-old female residential client who had already been through weeks of intensive therapy with little improvement. One reason is she refused to connect with her therapist.  Testing revealed underlying personality dynamics characterized by anxious dependence. Trisha was extremely needy due to difficult early relationships. She would become too dependent on others who would always fail to meet her expectations, leading to retraumatization. When confronted with this, Trisha acknowledged she had refused to connect with her therapist in order to protect herself from this dynamic. This information was incorporated into the treatment, resulting in a positive outcome.

2.     Jerome was a 16-year-old traumatized male living with his parents and an older brother with schizophrenia.  He had become increasingly withdrawn as of late. Testing revealed extremely high suicidal ideation despite none being reported to his therapist. When this was brought to his attention, Jerome broke down and said he had recently purchased a gun. He had been experiencing strange things and was sure he was psychotic like his brother.  Further testing revealed no psychotic processes, but high levels of trauma-based dissociation.  This information drastically changed Jerome’s outlook and he re-engaged with therapy.

3.     Vanessa was a 45-year-old woman labeled as “Borderline” and Bipolar by many clinicians. She had been hospitalized multiple times in the past decade. Regular treatment for Borderline Personality Disorder led to little results and medications were ineffective. Testing revealed neurological and personality traits similar to those who have high functioning Autism and trauma-based dissociation. Within 6 months, Vanessa was tapered off of unnecessary medications and was provided with an environment that suited her needs. She improved more in those 6 months than in 10 years of previous treatment.

Other reasons for assessment may not be so dramatic. Assessment can help with all of the following:

1.     Clarifying diagnosis

2.     Differentiating difficult diagnoses where symptoms overlap such as ADHD and Hypomania

3.     Identifying intellectual strengths and giftedness

4.     Quickly identifying maladaptive interpersonal patterns or coping methods

5.     Recognizing underlying issues that perpetuate psychological symptoms

6.     Highlighting personality or cognitive strengths to help clients find their best path or career

7.     Understanding difficult therapy dynamics leading to “stuck” treatment

8.     Obtaining objective results to aid with medication management

9.     At the start of therapy, creating a list of goals based on difficulties revealed by testing

10.  Obtaining school or home based services

11.  Ruling out organic causes of dysfunction

12.  Determining the best type of treatment given a client’s personality

Mental health treatment does not necessarily require guesswork or long-term contact to discover deep personality dynamics. A good psychological assessment can vastly improve treatment outcomes, identify yet unknown strengths and weaknesses, and fast-forward the therapeutic process. For more information, please visit: http://psychcentral.com/lib/what-is-psychological-assessment/0005890

Dr. Joel Schwartz is a post doctoral psychological assistant with Poach Consulting and Associates (http://southbaytreatment.com/joel-schwartz-psy-d/).  He also provides assessments for Connolly Counseling and Assessment (http://www.connollycounseling.com/). He has particular interest in psychodynamic psychotherapy, trauma treatment, people on the Autism Spectrum, and LGBT issues and pychological evaluations for teens and adults. He may be contacted at dr.jschwartz1@gmail.com.

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What It’s Like to Have Tourette’s: A Guest Blog by Ellen

People are surprisingly bad at seeing minute details.

This has been what’s kept our species alive for so long.  If our ancestors heard a lion roar and saw a large shape prowling in the grass, they couldn’t afford to stand there and filter through all of the information pouring in from their five senses.  They had to take in enough to get a general picture so they could react in time.  Those who saw the lion and made a run for it were much more likely to be able to continue to live and have babies, while the person going over every little detail coming in to them before coming to a generalization was likely to be lion food.

It’s been in our best interest to scan something, generalize and then react off of that generalization.  We’ve become especially adept at doing with facial expressions, which is how we can tell if someone’s mad and might potentially hurt us, or if they’re happy and it’s safe to approach them.  Without this very necessary evolutionary gift, we wouldn’t be likely to have been able to have a society, much less survive.

When you’re walking down the street, your brain is telling you ‘okay, this person is happy, that person is angry and holding a knife, let’s avoid them’.  It probably isn’t telling you that someone is missing a button or has a slight limp or that they are shutting their eyes compulsively unless you’re looking for that detail.  It’s that reason that I could walk by you while ticcing and you wouldn’t be likely to give me a second thought, much less go ‘Oh, that person is ticcing.’.  Your brain has no reason to view my tic as a danger to you, so it dismisses it as unimportant filler to disregard.

Most people with Tourette’s are able to live normal lives with little notice given to them for this reason.  Our tics are so benign or minor that you have no real reason to notice them unless you’re looking for them.  This is generally a good thing, since it saves a lot of embarrassment once the person with Tourette’s realizes that there’s not a lot of reason to feel self conscious over something that hardly anyone even sees.  However, this can be bad because the only tics that the average person notices are the ones that our brains consider to be threatening.

If you see someone suddenly start yelling swear words, your brain will assume ‘this person is angry and potentially about to start a fight, you need to notice this person so you don’t get hurt by them’.  Usually, this is a very good assumption that has, and will likely continue to, keep you out of harm’s way.  The problem comes when you learn that the behavior that’s put your brain on edge is called Tourette’s and since that person is the only one you’ve noticed with Tourette’s, you assume that it’s all there is to the disorder.

What most people don’t know about Tourette’s is that there are different kinds of ticcing compulsions.  They aren’t really subtypes or different kinds of Tourette’s, but they’re used to describe what kinds of compulsions someone feels.  The three most common ones are named coprolalia, echolalia and echopraxia.

If you watch people have a conversation, you’ll notice that they often start unconsciously mimicking each other’s posture and moments.  What that does is to say through body language ‘I’m just like you.  I understand, because I’m like you’.  We don’t mean to do it, but it just happens.  Echopraxia is that phenomenon taken to an irrational extreme.  When someone has echopraxic tics, it means that they feel the compulsion to physically repeat an action that someone else is doing or has done.  Even the thought of that action can be enough to set off a tic.  For instance, if I start to think about my tics, I will start to feel the need to do my physical tics because I’m thinking about them.  Interestingly, someone can have echopraxic tics without having Tourette’s, as Tourette’s requires someone to have physical tics and at least one verbal tic.

Echolalic tics are the verbal equivalent to echopraxic tics.  An echolalic tic is one in which you feel the compulsive and involuntary need to repeat a sound from the outside world, or from inside your head.  For instance, someone with echolalia might feel hear the register beep at a store and feel the compulsion to recreate that sound or they may have an intrusive thought and blurt out that thought out.  Echolalic tics are pretty common, however it seems to be much more common for people with echolalic tics to be able to hold off ticcing until they’re alone.  They can’t make the tic go away, but they can often deal with the discomfort until in a private setting.

Coprolalic tics are the ones that the general public generally thinks of when they think of Tourette’s.  People who have coprolalic tics have the compulsive and involuntary need to say the most inappropriate things that are often sexist, racist, homophobic, misogynistic or just plain cruel.  The whole point of coprolalia is to say things that the sufferer knows are awful, but they just can’t help but say it.  If someone with coprolalic tics sees someone who’s fat and they know that the worst thing to say to that person is ‘piggy’, that’s the word they say.  They know that it’s terrible and bad but it is something entirely out of their control, and is generally deeply shameful to the person to say.

I don’t like to refer to myself as someone who suffers from Tourette’s as I have only have mild echolalia and echopraxia.  I can walk through my life and ‘pass’ as someone without the syndrome.  But I wouldn’t hesitate to refer to someone with coprolalia as someone truly suffering from the disorder.  I’ve had yet to meet someone or even hear of someone who likes their coprolalia or the things that it forces them to say.  Beyond that, the coprolalia means that their Tourette’s is made into something very obvious and public.  Imagine going into a store to pick up some bread knowing that you are likely going to hurt and offend someone solely because you do not want to hurt or offend them.  Try to picture the helplessness that you would feel having that big of a loss of control over your own body.

You might be wondering what you can do if you come across someone afflicted with coprolalia.  The best thing that I can suggest is to understand that the person saying those awful things is only saying them because they know that they are wrong.  Give them an understanding smile and try to ignore it, and that should help the tics to subside.  Tourette’s gets worse as someone gets stressed or anxious, so the best thing you can do is to facilitate stress reduction.  Whether that’s letting the person go to a quiet place with less simulation or by simply not making a big deal out of it, you will be helping that person to gain back some of their dignity.

With that being said, there’s not a lot that I hate more than feeling pitied about my Tourette’s.  It is what it is.  I can’t stop it, and I can’t make it go away, so I’ve come to accept it and move on with my life.  You have to find humor in the stupid, weird quirks that you do, because there are two options that you can do when faced with the inevitable.  You can either cry about it, or you can find the humor in it.  And frankly, crying about it is exhausting.  I’d much rather laugh about it.

I’ve never had anyone laugh at my Tourette’s, but if they did, I don’t think that I’d mind too much.  I make some seriously awesome sounds when I tic that should be appreciated for their glory.  So long as you’re laughing with me and have some understanding of why I’m doing this, people are welcome to find humor in my tics.  It’s for that reason that I really like ‘La Petite Tourette’, the episode of South Park when Cartman pretends to have Tourette’s so he can swear whenever he wanted.  Not only did the script point out how Cartman’s plan was awful, but it also showed the struggles that people with Tourette’s do go through.  The support group in particular was a great scene, even if some of the tics were played for laughs.  But they still discussed how it feels to not have control and feel like you’re an embarrassment.  They were showing understanding for the syndrome.  Yes, they did so in a crass and slightly offensive way, but it’s South Park.  They’re there to make a point while being funny, and they do it well.

What I do hate is the ‘Tourette’s Guy’ series of Youtube videos, if only for the fact that when I mention that I have Tourette’s, he always gets brought up.  For those who are lucky enough to not have watched his videos, they feature an alcoholic who wears a neck brace because people beat him up constantly for saying terrible things.  He says stupid and offensive things in his videos and that’s basically the jist of it.  If they had called him ‘Dumbass Guy’ I would have no problem with it.  But nope, he’s ‘Tourette’s Guy.’

If he has Tourette’s, he doesn’t have coprolalic tics, at least not ones that cause him to say the types of things he says.  But to the people who watch his videos who have never met someone who actually have Tourette’s, he becomes their mental image of what the disorder is.  In my head, it’s like looking at the Buffalo Bill character in Silence of the Lambs and going ‘Oh, so all crossdressers are like that.’  Besides that, I hate the fact that he’s specifically misrepresenting coprolalia and making it seem like people are saying those things because they want to and have no shame in doing so.  Not to mention the fact that the Tourette’s Guy getting beaten up for his ‘tics’ is played up as being funny, which ends up making it seem okay and like he deserved to get beaten up badly enough to get put into a neck brace.  That is the kind of misrepresentation that can get someone killed.

If you’ve watched those videos and laughed, that’s okay, I’m not going to hate you for it.  So long as people understand what the syndrome does and how it effects someone, you can watch a moronic parody all day so long as you do not begin to believe that the parody is in any way truthful.  Comedy is great and it’s sometimes offensive and Tourette’s can be funny. I would much rather have someone laugh at me than tell me that I can cure my Tourette’s by accepting Jesus as my savior. (Yes, that has actually happened.) All that I ask is that Tourette’s isn’t misrepresented.

The best way to keep the disorder from being misrepresented is, in my opinion, to be open about it.  People aren’t going to understand how it feels to have Tourette’s unless they have a personal connection to the disorder.  It reminds me of coming out of the closet in a way.  When people with mild Tourette’s remove themselves from their incognito life and thrust themselves out into the open, it opens up a dialogue that is sorely needed.  It’s kind of a scary concept because Tourette’s can be embarrassing and no one likes to be seen as weird, but staying quiet and unassuming has never been what creates change.

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I Had an Abortion 4 Weeks Ago: Guest Blog by Jan

I had an abortion four weeks ago.  It’s hard to describe how I feel about it.  I don’t think there are many emotions in the human vocabulary I haven’t felt between the time I began to fear that I was pregnant to the present moment.  I have had the wonderful fortune of a loving and open-minded boyfriend, immediate family, and close girlfriends who supported my decision to terminate the pregnancy, and yet I feel totally alone.  Statistically I know that three out of ten American women has an abortion in her lifetime, and yet no one speaks about it.  I have a history of anxiety and depression, and a heightened sensitivity to hormones, so the entire process has been extremely difficult, physically and emotionally.

I hardly know where to begin, but perhaps it will be most efficient to name some of the emotions and the thoughts attached to them:

Terror that if I had a baby my life would be ruined, that my boyfriend of only a few months abandon me to raise a child on my own, that I would be trapped in my dead end job indefinitely and doomed to live in poverty for the rest of my life.

Fear that I would suffer so badly from postpartum depression that I would be physically and mentally incapable of caring for a baby, if I gave birth.

Bewilderment that I became pregnant so easily.

Disappointment in myself that it didn’t occur to me to be more responsible in attempting to prevent the pregnancy.

Disgust with the way pregnancy hormones made me feel, and with the very smell of food.  I lost ten pounds in the four weeks I was pregnant.

Disconnection from my body, which began to go through changes I didn’t like and wasn’t prepared for.

Rage at anyone who might feel justified in judging me, or forcing me to give birth to a child I didn’t want.

Anxiety that a protestor might attack me physically on the way into the abortion clinic.

Paranoia of being “outed” as having had an abortion, and rejected by my extended family and the people I work with.

Nervousness over having a medical procedure that is stigmatized and shrouded in mystery.

Sadness over the fetus whose life I had terminated.

Obsessive hypochondria over the strange symptoms the resulting hormonal imbalance caused and continues to cause in my body (dizziness, migraines, nausea, shortness of breath, nerve pain, muscle spasms, and fatigue.)

Relief at finding the actual procedure was quick and simple.

Disbelief that it was really over, and that I no longer had anything to fear or dread.

Worry that I had gotten off too easily, and that some unforeseen punishment still awaited me.

Guilt that I had deprived my parents of a grandchild.

Happiness that I had gotten my future back.

Gratitude to the women who work at the abortion clinic for their kindness and bravery.

Pride as a feminist that I had taken advantage of my right to terminate an unwanted pregnancy.

I don’t feel normal yet, and I don’t know when I will. I still cry sometimes, I still feel a bit tired and depressed, and my hormones still feel out of balance. I have sought help, and I was very lucky to find a wonderful therapist who is sympathetic to my situation, and I urge any woman who has had an abortion to seek counseling, even if you’re afraid of being judged, and even if you think you’re fine. My therapist has helped me identify my biggest hurdle in healing after this experience: allowing myself to feel sadness. I thought that in choosing to have an abortion, I forfeited my right to feel sad about it. I don’t regret doing it, and if I had to do it over, I would make the same decision again. I cannot stress enough how important it was for me to be able to make that decision. But I do feel sad, for myself and for the baby I didn’t have, and instead of shifting into denial or sinking into despair, I choose to accept the reality of what has happened, with all its complexity, and forgive myself.

 

 

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Ian Gutoskie

The 37 year-old Canadian comic discusses his two psychiatric hospitalizations, his social anxiety, feelings of being overwhelmed by daily tasks and his Bipolar II (with rapid cycling); also how sports helped him channel his anger about his abusive dad and what he does to stay in balance today.

You can find Ian on Twitter @IGutoskie  His website is FunnyIan.com

This episode is sponsored by Love With Food.    Visit www.lovewithfood.com/happyhour to get your first monthly snack box free (plus $2 shipping) and Love With Food will also donate a meal to a hungry child.  Offer lasts until Jan 1st 2015.

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Oliver Sykes

Paul’s 41 year-old friend talks (and laughs) about his arrested emotional development and struggle to be an adult after a childhood where he often had to parent his parents because of their addictions, mental illnesses (including hospitalizations and suicide attempts) and lack of boundaries.

This episode is sponsored by Audible.  For a free 30 day trial and a free downloadable audio book go to www.audible.com/mentalpod and sign up.

 

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Gillian Callahan Chachere

The Marriage and Family Therapist Intern opens up about the rarely-discussed trauma of miscarriage, the lack of traditional grief support in our culture, and the surprising results she got from seeking an alternative healing therapy (a full spectrum doula) after her fifth miscarriage.

The blog piece that Gillian wrote is called The Closing of the Bones.

Her therapy website is http://gillianchacheretherapy.com/

The Youtube piece that Paul referenced about sexual trauma survivors’ is here.

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