Love

The ancient Greeks described three different forms of love:

1) Eros -- sensual desire; attraction and appreciation of beauty; passion
--In describing eros we need not assume that it only refers to sexual passion; I think there is a component of the "erotic"-- in a broad metaphorical sense--in all moments of life, all motivations, all experiences of beauty in all its forms--

2) Philia -- virtuous, loyal, attachment between friends or family members; dispassionate but balanced, stable, reciprocal, equal.

3) Agape -- this term was adopted by early Christian theologians, referring to unconditional, giving, selfless love for all. In this type of theological view, agape was felt to be the feeling of the divine towards humankind. Psychiatrically I might say that agape was a projection of a feeling onto the projected character of "God" that fit with an idealized philosophy of life which was prescribed by religious leaders to the rest of the community.

I have to wonder if the "agape" idea was a bit of a defensive construct, since people with conservative religious beliefs or values might not want to be using a "love" term associated with eroticism or sexuality in their description of the divine, or in a prescription for ideal behaviour to espouse.

--since I am neither a scholar in Greek, nor well-versed in theological debate, I recognize that my above introduction may contain inaccuracies--

I do think love is one of the great joys of life, a requirement for happiness, a requirement for life itself to continue. A life without love can be intolerable.

But many of the experiences of love can lead to exquisite suffering. Love can be unrequited. Love can lead to obsession and despair. Love can fade and disappear. Love sometimes can throw off our judgment.

I do think that love is an ingredient of the psychotherapy experience. The struggle with "love problems" is one of the most frequent themes bringing people to psychotherapy.

If love occurs between patient & therapist, this love exists within the boundary of the therapeutic frame. Actions associated with this love--according to the rules of psychotherapy--take place through dialog. Actions outside of dialog (such as gift-giving, etc.) may or may not be allowed within the therapeutic frame, but if they do occur certainly would require careful attention or discussion through dialog. In many cases I feel that to reject a gift would be akin to rejecting a handshake--at times it could be humiliating--and that it may sometimes be part of the development of a healthy relationship to permit gifts in psychotherapy. I realize that many of my colleagues would disagree with me (all kinds of talk about boundaries would arise, I'm sure). I do realize that accepting gifts could give rise to a variety of problems in some cases (e.g. anger at generosity not perceived to be reciprocated, or gift-giving "getting out of hand" with more and more financial expense involved, etc.); in some cases I will gently let people know that their presence is a gift, and that other types of gifts can't be something I can accept. Gift-giving can be a much subtler theme, as many times patients may "try harder" in their therapy as a gift to the therapist, etc. Such gifts should not be rejected, yet of course it is important therapeutically to understand this motive, and to find ways to expand the range of motivations for "trying harder".

I affirm strongly that I have--and aspire to maintain-- a feeling of agape towards my work as a psychiatrist, and towards all of my patients.

I feel it is important to convey this positive feeling directly at times, and that it is often a fear of impropriety, or of boundary-crossing, etc. that prevents many therapists from openly pronouncing positive regard for their patients. As a community of therapists, I think this fear stems in part from recognition of many disturbing examples of boundary-crossing behaviour(e.g. therapists having affairs with patients, often with components of exploitativeness, and often causing complex harmful consequences for the patients). Or some therapists may have been taught to believe that the therapist should not "meet a patient's dependency need" but should rather interpret such a need, or help problem-solve around it, to help the patient meet that need outside of the therapy. Well, in many cases I feel that depriving a patient -- in this case, let's use totally frank language: depriving a patient of love -- is merely a tactic that keeps the therapy less personal, more frustrating, and less helpful. Also it fosters greater detachment in therapists, which I think fuels a broader phenomenon of therapists not really enjoying their work, leading to increased cynicism, less appreciation for the beauty and potential of their patients.

I believe all three types of love exist in every human dynamic, in some mixture. This is normal and healthy, a fact of life. This includes patient-therapist interaction. Yet these other varieties of love dynamics may only colour the dialog or the narrative in a therapy setting, they cannot cause the therapeutic frame to change.

Having said this, I think that in many cases, the patient-therapist relationship is much more distant. It can be like the relationship between "homeowner & electrician" or "shopper and retail clerk". This kind of distance may work just fine, the therapy itself doesn't have to be a specific setting to work out "love problems". The therapy may simply be about obtaining advice to relieve a symptom.

There are some cases -- such as in patients who have a history of dangerous interpersonal behaviour, or in cases of psychosis which may involve the therapist in a delusional system -- where the therapeutic relationship has to be much more distant. It is still not without agape though. A truly loveless relationship cannot be of much help; in situations like this it is often necessary to refer the patient to a different therapist.

In some cases, the therapy itself becomes a setting to "work through" love problems, and the love dynamics present in non-therapeutic life may show up in the therapy itself. In the psychoanalytic community, this would tend to be called "transference". The idea of transference is extremely important, since feelings or dynamics in a person's personal or past life may very well appear in the therapy, towards the therapist, and this phenomenon may epitomize a recurrent relational problem in the patient's life. Yet the term "transference" may also be part of a defensive language on the part of the therapist, to negate "true" feelings which may exist between patient and therapist. So I feel that both "transferential" and "non-transferential" feelings can be present, may be something to acknowledge--and sometimes to affirm--in the therapy, provided the boundaries are clear and consistent.

The world needs to devote more of its energy and resources to solving its "love problems", and to celebrating its many examples of powerful, healing, healthy love.

The Tragedy of the Commons

In 1968 (just before I was born) Garrett Hardin published an article in the journal Science called "The Tragedy of the Commons" [Vol. 162, No. 3859 (December 13, 1968), pp. 1243-1248].

It is a metaphorical--and sometimes literal--illustration of how groups of humans behave, specifically when individuals are using a shared resource. It is a wonderful example of an academic area studied in the field of social psychology. But the ideas have been studied in other fields such as political science and economics.

In the metaphor, "the commons" could refer to a common pasture or field in a town of farmers. Each farmer would be entitled to use the pasture to feed his cows. With this system, each individual farmer will immediately profit most by allowing his cows to graze on the pasture for as long as possible. But, if each farmer does this, the pasture will quickly become overgrazed, and everyone loses. The question is, how long does it take between the time when individuals are "winning" and the time when everyone is "losing"?

Of course, the world has many examples of this situation. Pollution of all sorts is like this.

Proposed solutions to this problem have included the idea of privatizing everything (i.e. to eliminate any "commons"). The trouble is, part of the tragedy of the commons lies in an individual profiteer having a short-term motive. "Short-term" in an ecological sense could sometimes be considered to be 50-100 years. The profiteer may maximize his wealth by relentlessly exploiting a natural resource, whether he owns the resource privately or not. During his lifetime, there may not actually be overt negatives to this practice. But over several generations, this practice will destroy the environment.

So, privatization is not a rational solution (besides, carrying privatization to an extreme would yield such absurdities as individual private ownership of the atmosphere or the sky, etc.).

Shared resources must be managed. The management must be from a point of view of the community as a whole (hence it must be communal or governmental), and not only that -- the management must be from a point of view which encompasses the distant future as well as the present. So we must have a government, and a set of values, which makes substantial consideration for what happens even after every currently living person on the earth has died -- i.e. we must consider future generations of life.

I wonder if the common religious stories regarding the notion of an "afterlife" may touch metaphorically upon the importance of literally considering what comes after our own lives. In this practical case, though, we are considering our currently living role in caring for the lives of those who are yet to be born. We may exact such care by protecting "the commons." We may consider this a sacred act.

Such a perspective goes beyond what the mind has been evolutionarily programmed to do -- yet such a highly cultured perspective is what we are called to espouse, if we are to save ourselves, and to save "the commons." The most obvious example of such need is, once again, relating to pollution (of which the "global warming" issue is one of many facets).

The human mind has an innate difficulty with sharing, and it requires culture and a legal structure around the human individual's drives and yearnings, in order to prevent "the tragedy of the commons" from playing itself out.

In a modern society which allows a high degree of individual freedom, and highly advanced, unique forms of living out this freedom (e.g. the internet, telecommunications, rapid and convenient transportation almost anywhere in the world), we may be serving and developing those parts of our mind -- those parts we have evolved over millions of years -- which are most apt to "deplete the commons".

The parts we must strive to attend to are those which require us to use our intelligence, empathy, and imagination, in the process of learning how to share.

I think the modern conservation movements are just the tip of the iceberg, in terms of people making more deliberate, conscious, inspired efforts to protect the present and future environment. These efforts will not only literally protect the earth -- but they will protect our minds. The practice of empathy, and of sharing, of planning to protect something we will not even be around to see -- these are the crowning qualities of human culture, made possible by the human brain, but often thwarted by inherited aspects of the carniverous greed which our species required to survive for millions of years.

It is interesting that many dreams about fear, terror, and death feature wild creatures such as wolves. The wolf is an apt symptol for such frightening emotions--wolves and humans co-existed in a wild state prior to the development of a modern moral culture. In those prehistoric days, there might not have been much room for empathy and sharing in an average
human "household." Since that time, humans have befriended and domesticated wolves, (some of them at least) such that we have a type of wolf we keep in our homes, which we call a"dog." Perhaps to some degree me may remember in our dreams that dogs, or wolves, have been symbols of the terrors of the wild, of a simple but cruel kill-or-be-killed existence.

Our mind reverts to such "wild" states easily--after all, hundreds of thousands of generations of humans evolved under such wild conditions, and those traits in our minds have a strong genetic background. It is like a long war, which is finally over. We don't have to be wild anymore. It is no longer necessary--at least no longer in the peaceful parts of our world--to devour prey; to hunt; to kill our enemies before they kill us; to prepare for a panicked escape in the event of possible attack, etc.

In fact, as the tragedy of the commons metaphor illustrates, it is necessary to set aside aspects of our genetically programmed heritage, to over-ride this with a learned culture of love, sharing, and compassion, with the leadership offered in the culture (e.g. in the form of government or law) to ensure that moral excellence is favoured.

From a psychiatric point of view, I remind you that your mind is partially "wild", it strives for immediate safety, satiation, or relief. You may need to over-ride the wildness, using your intelligence, imagination, and culture (derived both from within yourself and from your community), in order to protect, or "conserve" your mind -- to protect your future mind from the wild emotional instability that may be seething in the present. Cognitive-behavioural therapy is a concrete example of this kind of idea. But more subtle -- and possibly more powerful -- examples include all imaginative, intelligent acts that are rooted in compassion, altruism, generosity, and protectiveness towards self & others.

Biases associated with Industry-funded research

There is evidence that research studies sponsored by pharmaceutical companies produce biased results. Here is a collection of papers supporting this claim:

http://ajp.psychiatryonline.org/cgi/content/full/162/10/1957
This paper from the American Journal of Psychiatry reports that industry-sponsored studies are 4.9 times more likely to show a benefit for their product.

http://www.ncbi.nlm.nih.gov/pubmed/15588746
In this paper, an association is shown between industry involvement in a study, and the study showing a larger benefit for the industry's product (in this case, with newer antipsychotics).

http://bjp.rcpsych.org/cgi/content/full/191/1/82
In this study, the findings suggest that the direct involvement of a drug company employee in the authorship of a study leads to a higher likelihood of the study reporting a favourable outcome for the drug company product.

http://jama.ama-assn.org/cgi/content/full/290/7/921
This is a very important JAMA article, showing that industry-funded studies are more likely to recommend the experimental treatment (i.e. favouring their product) than non-industry studies, even when the data are the same.

I do not publish this post to be "anti-drug company". I think the pharmaceutical industry is wonderful. The wealth of many of these companies may allow them to do very difficult, hi-tech research with the help of some of the world's best scientists. The industry has produced many drugs that have vastly improved people's lives, and that have saved many lives.

Even the profit-driven-ness of companies can be understandable and healthy...it may lead to economic pressure to produce treatments that are actually effective, and that are superior to the products of the competitors.

Sometimes the research trials necessary to show the benefit of newer treatments require such a large scale that they are very expensive...sometimes only a large drug company actually has enough money to sponsor trials of this type.

BUT...the profit-driven orientation of companies may cause them to take short-cuts to maximize profits...
-marketing efforts can distort the facts about effectiveness of a new treatment
-and involvement in comparative trials by eager, profit-driven industry, very likely biases results, and biases the clinical behaviour of doctors

A solution to some of these problems is a requirement for frank transparency always, when publishing research papers, in terms of industry involvement.

Another solution is to have more government funding for independent, unbiased large-scale clinical trials.

And another solution is for all of us to be better informed about this issue!

Assisted Suicide

I am intending this discussion to be focused specifically on the theme of suicidal thoughts which occur in chronic depression. While I think some of these ideas generalize to other areas of human suffering, I cannot claim to have a great deal of experience working with people outside the area of primary psychiatric illness, and so I don't want to sound preachy about an area outside my knowledge and experience.

When struggling with the question of whether to live, or whether to die, often there is longstanding ambivalence. The struggle with this question may have been going on for years. Reasons to live may lie in small or large connections with other people, other meaningful activities, other small pleasures, other small moments of relief, other hopes that things might get better in the future. Reasons to die may involve observations that things aren't getting better, that positive connections are disappearing or absent, that treatments aren't working, that hopes are fading or gone. Sometimes the ambivalence progresses to the point that one more bad, disappointing, enraging, or painful life event can "tip the balance".

While struggling with this kind of longstanding ambivalence, it can be an annoyance to hear many of the standard encouragements to live, such as:

1) "depression is a treatable illness!"
[well, yes it is, but often times the treatments don't work so well--and if they aren't, it can leave the person suffering from a refractory depression feeling even more alienated, hopeless, and irritated by someone sharing the cheerful news about treatability]

2) "it's wrong to kill yourself"
[while moral qualms can deter many people from killing themselves, moralisms can also sound irritating, preachy, and the product of a perspective which doesn't really understand the nature or intensity of depressive suffering]

3) "it will hurt or devastate your family or friends"
[this may be a deterrent for many, but often times with advancing chronic suicidal ambivalence, this thought may change to something like "my family will accept my decision in time", or "they're better off without me", etc. ]

...there are probably many other examples...

I understand that life can be intolerable. Maybe your life has been intolerable for a long time.

I encourage all of those who suffer to know that there is relief available in life. Always. There is connection available in life. Always! --either improvements of existing or past connections, or development and growth of new or future connections. Loneliness need not ever be permanent.

Some problems cannot be solved or fixed, but regardless of this, it is always possible for things to be better--in some way--than they are. It is always possible for pain to be relieved. It is always possible for a new connection to be made, or for meaning to be found and nurtured. No matter how bad things are, or have been, and no matter how long things have been bad (weeks, years, decades...), a new path can be forged today. If mistakes have ever been made, things can be mended, starting today.

I realize that the above advice may also be, for some, an annoyance to hear, perhaps the same old trite, easy-for-me-to-say attempt to console, or to instill hope. I deliberately say this, though, not as a person wanting to enter into an ethical debate about "right-to-die" issues, etc. but just so that a person researching suicide may encounter a consoling point of view. I do see that many with chronic illness can recover, or have a good quality of life, despite what can seem like a grim or intolerable prognosis.

Some people may be researching "assisted suicide" in their state of suffering and ambivalence. In today's world, such research may yield all kinds of advice about how to kill oneself. There was a front-page article in the newspaper the other day about this. I note that there was no article on the other side of that front page which was devoted to reasons NOT to consider assisted suicide. Therefore, despite the accuracy of the article, the newspaper did not give a truly balanced presentation of the subject. Therefore, if an ambivalent person were to read such an article, it could be an event leading to "tipping the balance."

While I support freedom of speech, I also recognize that research, especially on the internet, can cause an ambivalent person to become immersed in a highly biased information environment. What may be seen as research can become persuasion. A huge persuasive element in the world is social pressure (for a person researching assisted suicide, it may influence a person to choose suicide if they find an online community of others who are also choosing suicide). The presence of a positively-toned newspaper article on assisted suicide may encourage suicidal actions in people who are acutely struggling, but who may not be receiving good treatment yet for their underlying problem.

I encourage people to be wary of biased external persuasive factors. These may be altering your judgment, sometimes without you even knowing it. A guiding principle of many who espouse the idea of "assisted suicide" has to do with freedom, with human rights. However, biased persuasive factors are obstacles to free choice. The solution is for information to be fair, balanced, and thorough, with adequate presentation of multiple points of view. Most research on the internet does not offer such rigor. Most newspapers--unfortunately-- do not have a balance of articles having different points of view.

If you have searched for information on "assisted suicide" on the internet, and landed on this blog entry, I hope to remind you that connection and relief are possible, even if they seem unavailable to you. You deserve respect and support, given the very heavy burden you have been carrying, and I remind you that others are available to share the burden and to help you. It may be a difficult journey, though, to find the support and help that is best suited for you. I wish you the continued strength and courage to carry on.

Laughter

It is therapeutic to laugh. Humour is therapeutic.

Laughter can be practiced deliberately, and it is probably very healthy to do so.

Humour is important in psychotherapy as well. Psychotherapy need not always be serious, grave, or have an air of hard work or formality. But of course, it would be important for any humour initiated by a therapist to be gentle, sensitive, careful, and not excessive.

Here are a few links to references about laughter & humour in health & psychotherapy:

http://www.ncbi.nlm.nih.gov/pubmed/17464660

http://www.ncbi.nlm.nih.gov/pubmed/8307702
Here's a link to the website for the "Association for Applied and Therapeutic Humor"--it contains a lot of links to other interesting and funny sites (the fact that there is an association with this title is itself funny to me):
http://www.aath.org/ezine/index.html

Another relevant link:
http://www.helpguide.org/life/humor_laughter_health.htm

Pets are Therapeutic

It can be beneficial for mental and physical health to have a pet, for the following reasons:

1) pets offer companionship, and therefore may help people to cope with loneliness. At times I have seen relationships with pets be strong protective factors against suicide.
2) many pets, particularly dogs, may help their owners get outside regularly for exercise
3) dogs in particular may act as social catalysts, making it more likely to meet and converse with new people (this could happen while dog-walking).
4) the requirements of caring for a pet may add some structure and an external focus to daily activities, which can be healthy

For some people, having a pet can be more problematic, particularly if it is not possible, for health or economic reasons, to care for the pet adequately. And some people may have pets for unhealthy reasons (e.g. acquiring a large, vicious dog, encouraging its aggressiveness, or failing to train it adequately for safety).

The evidence on health benefits from pet ownership is actually a bit weak. I think part of this is due to inadequate studies on the subject. Also, in order for a pet to have a healthy emotional effect, there would have to be a good "match" between pet & owner, and adequate support for a healthy relationship to develop. Just as in human-human relationships, some people may choose a type of relationship that is not healthy or sustainable for them.

Here's a link to a review on pet ownership and human health:
http://www.ncbi.nlm.nih.gov/pubmed/16308387

Contact with animals can be therapeutic in other ways. There is a lot of anecdotal evidence about the merits of therapy animals. Dogs and cats are examples, but so are large animals such as horses.
Here are references to papers describing the benefits of "animal assisted therapy" with larger animals:
http://www.ncbi.nlm.nih.gov/pubmed/17444990

http://www.ncbi.nlm.nih.gov/pubmed/18405352

Here are some references about the benefits of therapy dogs:
http://www.ncbi.nlm.nih.gov/pubmed/17714002

http://www.ncbi.nlm.nih.gov/pubmed/15293482

I could not find very much in the research literature about "therapy cats"--but I think having a pet cat can be therapeutic.

How to make friends

There are many reasons why a person could have trouble making friends; here are a few:

1) shyness (social anxiety)
2) depression (with resulting lack of energy & motivation)
3) difficulty with social skills (in initiating contact or communication with new people, with continuing on after an introductory contact, or with maintaining healthy ongoing friendships)
4) difficulty finding a community of accepting peers, despite having addressed other factors, such as #1-3 above. So, for example, a person with a particular lifestyle or cultural interest may not be able to find many people with whom to share this in the local community.
5) sometimes there may be qualities about a person's behaviour that cause others not to want a friendship (e.g. recurring temper tantrums or other overt manifestations of hostility).
6) lack of time, energy, or money

Here are some ways to address the problem of making friends:

1) treat shyness. Pharmacologically and psychotherapeutically. Strong effort needs to be spent on practicing cognitive-behavioural techniques. I encourage all who believe they may be shy to start by reading some of the many books on the subject of shyness.
2) treat depression
3) Learn about social skills. This can start with reading. A therapy group of almost any sort can be a good resource. Psychotherapy can be a setting to practice social skills. Other activities can be great places to practice, such as taking a class, joining a group, Toastmaster's, etc. Skills have to be practiced. The skills need to be practiced in all three domains (initiating communication with new people, continuing on to the next step following an introduction, and maintaining ongoing positive communication and activity within existing friendships).
4) Identify individual lifestyle and cultural interests, and deliberately seek out groups that can share in this (for example, regarding music, the arts, orientation/identity issues, hobbies, sports). Be willing to at least slightly expand your horizons of cultural interest & involvement. If you have a healthy solitary interest, try to make it a healthy group interest.
5) Identify factors within oneself that may make it hard for someone to befriend you (e.g. temper problems, refusal to allow closeness, etc.) Be very honest with yourself about this. The gentle feedback or support from a therapist can help. It needs to be emphasized, though, that in a depressed state, many people believe they are unattractive for a variety of reasons, and this type of thinking about self can be a symptom of the depression. If you falsely believe that people don't like you -- for any reason -- then your social actions may lead you to become more isolated and alone.
6) Time, energy, and money may need to be set aside, to allow for the development of a social life. There are many community resources that are free, or that may specifically welcome and try to help those in economic need. Maybe your community does not have enough of these types of resources--if this is the case I hope there is the possibility that you can find a different community that does have enough.

In today's world, we of course have access to "virtual communities" and other types of relationship-building that can be done on the internet. I think the internet is a powerful resource, and can be very helpful for making friends, or practicing social skills. But the medium of the internet can itself be addictive, so this needs to be watched for. Some people may spend so much time on internet relationship sites that their non-internet relationship life may be shrinking rather than growing.

A brief google search on the internet with the name of your city or town plus "social networking" or "meetup" may yield a variety of possible real-life social groups to consider joining, some of them geared towards simple friendship, others may be oriented towards a particular activity, others especially for people who are shy, etc.

Here are some of the explanations people have given me about their difficulty making friends:

1) "I'm not attractive enough"
2) "This city is unfriendly"
3) "I can't be bothered"
4) "It's not worth the risk"
5) "I'm too busy"
6) "I'd rather be alone"
7) "I would be/am a burden on other people"

All of these explanations need to be addressed and challenged.
1) Beliefs about unattractiveness are a powerful social obstacle, because they cause the person who feels unattractive to withdraw, assume in advance that others don't like them, etc. Also a belief about innate unattractiveness can cause a person to be resigned to this false belief, such that actual esthetic enjoyments--including superficial but important things such as choice of attire, "spa treatments", etc.--may be unnecessarily avoided
2) While it may well be true that certain cultures or parts of the world have more or less social opportunities and a more or less socially engaging style, I find most complaints about the "unfriendly city" to be projections of one's own social frustrations onto the fairly neutral ground of the geographic city. I would encourage people to do what they can, with an open heart and mind, right where they are geographically, rather than contemplate a move right away to some supposedly more friendly place.
3 - 5) Friendship-building requires energy, and can be frustrating. There is a component of risk, at the very least of being disappointed. I stand by the advice that friendship-building is a necessary health activity for everyone, as is daily exercise of some sort. So it is necessary for your health to bother with it.
6) We all require solitude. Some of us are most comfortable alone. Many of us desire more closeness or intimacy, but have become resigned, such that we tolerate having very little. It can be a symptom of depression to become more and more isolated. Isolative resignation is a problem that needs to be worked on in the treatment of depression.
7) Belief in being a burden is another depressive assumption, just like feeling unattractive. It is time to let go of this kind of belief. Every relationship does require give and take, though, and it can be part of the process of practicing social/relationship skills to be observant of the general balance in your friendships, so that no one feels that the relationships are one-sided.