Critical Thinking: A Therapeutic Goal

 

 

 

Critical thinking — what the philosopher John Dewey called the ability “to maintain the state of doubt and to carry on systematic and protracted inquiry,” is the goal of reflection. To modify Dr. Dewey’s quote, psychotherapy/psychoanalysis aims to help the patient develop critical thinking about one’s own mind and about the minds of those that influenced them. “I am not interested in symptoms” I say, in a provocative manner, to my class, knowing that saying that contradicts all of their previous education in psychotherapy. “I am also not interested in symptom-relief,” I say, taking it one step further. “What I am interested in,” I say, “is how the patient is thinking about his life and why those symptoms are manifesting at the particular time, and in the particular way, in which they do. ”

Karen, sixty-two, comes to mind. She has what could be called Generalized Anxiety Disorder, and I prescribe her medication, so in that sense, I am interested in symptom-relief, but mostly I am curious why she has to worry. I am helping her be curious as to why her mind is preoccupied with worry. The key words are “has to”. As I understand anxiety, it is often a symptom of a deeper issue of insecurity and loneliness  and I would like to explore that with her. I want to explore that with her in a way that makes her curious about it in a way which generates a  “systematic and protracted inquiry” and which carries on both inside and outside my office. This is what I do, and this is what I teach. Sure, I tell patients with anxiety to try yoga, meditation, and dietary interventions, but that is merely the beginning, because as time progresses, the issue becomes, “so what is really go on here?” To that question, there are endless answers, requiring a “systematic and protracted inquiry.” Dr. Dewey, may he rest in peace, is my hero.

Health Care Apps

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In the “adapt or die” mode, part of moving into the next wave of health care changes is using applications to help patients understand and treat their ailments. Knowing which application to recommend to patients will be an important tool in the ever-expanding toolbox of treatment modalities. This application, pictured above, helps patients learn diaphragmatic breathing by showing a man lying on the ground with a book on his stomach, demonstrating that the book rises and falls with each deep breath, but not with shallow breathing. Deep breathing soothes anxiety, and is a relatively simple means of coping with stress in very powerful moments, such as learning about the Boston Marathon. Teaching people to breathe is that simple, elegant, intervention in which there are no negative effects. The smart phone allows people to teach themselves deep breathing in the privacy of their own space, along with the value of repetition, if need be. There is no doubt, that the smart phone will serve as both a health care passport, in which patients travel with vital medical information, along with serving as a  treatment tool, particularly for stress-related disorders such as anxiety or insomnia. This advanced technology thrills me beyond words. Only in my wildest dreams did I imagine such useful patient information to be so incredibly handy and useful. In this way, medicine is in an exciting era.

The Anxious Husband

Karen, fifty, married to Kip, fifty-five, for thirty years, says “I just realized that my husband is so anxious.” “After thirty years you realize this?” I ask, wondering how this happens that decades into a relationship new ideas are formed. “Well, yes, I know it sounds ridiculous, but last night as I was talking to him, I realized that the expression on his face was anxiety and not ‘spacing out’ like I used to believe.” “Tell me more,” I say, so curious about this pivotal moment. “We were talking about our financial situation and I was saying that I was worried about our retirement and he just went mute and in the past I thought he did not like to talk about this subject, but suddenly, I realized that it makes him anxious and that is why he does not like to talk about it. I never saw it as anxiety. I just saw it as avoidance. Now, I see that the avoidance is because of anxiety. Maybe I got this idea from reading your blog, but when I thought about it, his behavior made so much sense to me.” Karen says with the excitement of figuring out a puzzle.

“Did you tell Kip about your insight?” I ask, wondering if she had the courage to share her idea with Kip and wondering if he had the courage to consider this notion. “Yes, I did and he said he would think about it, so I was pleased with that.” “Is he anxious about other things?” I ask, wondering if there is a bigger theme in their relationship. “Yes, anything that has to do with losing control he gets anxious about. He seems anxious that I am going to gain a lot of weight and that really bothers me too.” Karen says with a feeling of irritability that his anxiety is infectious. “Maybe if he understands his anxiety then he can at least identify his feelings and communicate on that level and not on the level of the number on a scale.” I say, highlighting that this insight, if it fits Kip, could cause a major change in their communication style. “That would be interesting, after all these years.” Karen says, losing her irritable tone and regaining her enthusiasm.

“Anxiety is certainly a complicated feeling. You are right that so much of the time, the person does not even know they are experiencing it, but the people around them know.” I say, repeating a point I make in so many of my lectures. “Yea, but I did not know until now,” Karen repeats with the awe of reflecting over thirty years. “This is what is called the depth of a relationship. New things appear as time marches on.” I say, hoping not to speak in platitudes, but to emphasize that relationships deepen over time such that Karen should not be so mad at herself for not understanding this earlier. “I guess so,” Karen responds with some dismay. “I am glad you found my blog to be useful,” I say, reflecting on her comment and feeling cosy about it at the same time. Maybe the internet has helped Karen and Kip. Maybe I contributed to that through my work with Karen and through my blog. Maybe.

The Anxious Kid/The Disorganized Mom-Chicken or Egg?

   Leanne, fifty-one, is always confusing appointments, losing pieces of paper, and is in general a very disorganized person and a disorganized mom. Lesley, her twelve-year old daughter, feels she can’t count on her mom to follow-through in a timely fashion on scheduling doctor visits, or picking up things she needs so that she can be in the school play. Lesley compensates for Leanne’s unreliability by making a multitude of lists in which she tracks what needs to get done. At the same time, Lesley is constantly in a state of anxiety in which she is worried that she will not complete her task list. Lesley’s dad has suggested that she take medication for her anxiety. I question Lesley, “do you think you would be so anxious if your mom was more organized?” I wondered if Leanne’s unreliability made Lesley feel fearful that so much of the responsibility of moving forward in her life now fell on Lesley since her mom was not providing a safety net for her. In other words, the maternal role for an adolescent child is in large measure the job of making sure that the teenager can go to their various activities and that they have the right supplies. Without this infrastructure, teenagers are going to be impaired in their ability to engage in multiple life experiences.

 Lack of reliability can create anxiety in someone who is dependent on them. That is straightforward. Am I “blaming” Leanne for Lesley’s mental state, or am I understanding what Lesley is up against? Am I stepping on the therapist’s toes, by suggesting that the more Lesley understands that she is anxious because her mom is disorganized, the better Lesley will be able to cope with the demands of her life. The nature/nurture debate continues. Lesley is probably wired to tilt towards anxiety-an internalizer as we say. Her environment exacerbates her condition. She can learn coping skills and she can probably also benefit from medication. This is not a binary system. Yet, our brains wish for binary. We want answer, and sometimes that answer is medication. Multiple answers are usually harder to grasp, especially in crisis. Staying broad-minded is the goal. Lesley is going to do well. She needs help understanding her mom and her mom’s frailties, and she also needs help understanding the vulnerability in her brain to be anxious. She is up for both of those tasks. So, chicken/egg, does not matter.

Afraid of the World

   Rikki, twenty-two, female, has struggled over the fifteen years that I have worked with her. First, she had no friends; the Asperger’s label was thrown around. I did not think it fit. Rikki always appeared to me to be painfully afraid of taking chances: social or academic. She wanted friends, but she was too afraid to approach people. She wanted to do well in school, but sometimes she did not persevere with her studies. She was inhibited, terrified of moving forward, terrified of developing into an adult. High school years were miserable. She was teased mercilessly. College got a lot better. She made friends: weak ties, though. She did well in school, but she was still anxious and afraid. Graduating college was like falling off a cliff. Her weak-tie friends stopped calling and texting. She made a résumé, but she was too afraid to send it out. She now lives in her room, plays video games endlessly, and sees me consistently twice a week. “What do you think you are afraid of?” I ask her. “Well, my mom and dad need me around the house. If I move out, who is going to make sure that the dog gets fed, the garbage gets taken out, the computers work properly.” Rikki responds quickly, as if she has thought a lot about this question. “I know you are very important to your family, but I think you need to focus on moving forward with your goals. I think your parents will figure out how to keep their lives going after you leave.” I say, helping her to see that she needs to focus on growing up and out of the nest, rather than worrying how the nest will be when she is gone. “I know all that,” Rikki says to me impatiently, “but I can’t stop worrying about how things will be if I find a job.” “That is interesting. Maybe you can’t stop worrying because you are afraid to get a job, and so worrying about your parents, keeps things as they are.” I say, realizing that Rikki is using her worry about her parents as a protection from her worrying about her own development.

  Despite Rikki’s painful paralysis, Rikki has come a long way. Many professionals thought she would always be a loner, but her college years proved that friendships, although not strong friendships, were fulfilling and rewarding for her. She met people she really cared about. Predictably, it was hard for her to keep up the ties, when the structure of college went away, but she did prove that her social skills were good enough to create a network of people who cared about each other. At the same time, in the absence of college, Rikki has returned to a very lonely and isolated existence. If she could magically be placed in a good work environment, Rikki would be a diligent and loyal employee. The problem is that Rikki is too frightened to seek employment, even though she has a good skill set. My job is to help her, slowly and with patience, to take the baby steps towards financial and emotional independence from her parents. Fear is a powerful inhibitor. Hope is a powerful motivator. The tension is quite strong. Rikki and I are not giving up.

Chest Heaviness

   Harry, sixty-nine, a long-term patient, opens the session “I am not going to lie to you. I am having a hard time. I feel a heaviness in my chest all the time. Ever since my granddaughter was born five years ago, I have not felt right. She is not developing normally. The doctors say she has Autism, but I think it had something to do with the trauma that my daughter-in-law Regina did during her pregnancy. I think she drank too much and that is why little Evie is not normal. I know she is not normal and it just breaks my heart. She is about to start kindergarten and I am about to be seventy, so I think it is hitting me really hard that she is not going to be OK.” I look at Harry with sad eyes, a sense of compassion along with deep admiration for his love for Evie. I feel so touched that he cares so much, but I also feel bad for him that he is suffering. “It sounds like you feel very alone with your feelings,” I say, knowing that Evie’s parents, and Harry’s ex-wife are all saying that Evie is fine and that she will “grow out of it”. Harry starts to cry. “Yes, I do feel alone. I am so mad at my wife I can hardly stand it. Lonna (Harry’s wife) won’t engage with Evie. She just ignores her. I can’t believe it. I finally told Lonna that she had to step up and be a better grandma and that made things a little better.” “I am glad you spoke up. That took courage.” I say, thinking how hard that must have been for Harry to confront Lonna. “You have known something is wrong with Evie for a long time. I know that because you have been telling me that. I know that is a terrible thing to be right about, but you saw this coming.” I say, reminding him how many times we have discussed his concerns for Evie, but now his concerns are giving him somatic symptoms. “Things have come to a fever pitch,” I say, illustrating the build-up of his concerns. “Yea, I am glad you understand that. ” Harry says, with clear relief as the session progresses. “I hope you seek medical attention to be sure those chest pains are not coming from your heart. If it turns out to be anxiety, then I think we can work on that.” I say, not wanting to immediately attribute his symptoms to his worries, but recognizing that worrying about Evie is certainly a “heavy-hearted” experience.

Health Care Disparities

Rant alert-I am angry! In teaching my Family Medicine Residents about the delicate and complex role of benzodiazepines in the treatment of anxiety, one of my students informed me that at the low-income clinic where many of my students work, they have eliminated this class of drugs from their formulary. I could hardly contain my rage. In fact, I did not contain it and I began to try to turn my rage into an important teaching point. That is, regardless of income level, patients are entitled to have access to medication which can make their lives significantly better. Instead, this policy has made it so getting treated for anxiety is now a middle to upper middle class possibility, but lower-income folks have to find other means of dealing with anxiety. The unfairness of this discrepancy is hard to understand. The medications are cheap. There is no cost barrier.

  I do see how prescribing benzodiazepines are time intensive and therefore costly in that way. The medications need to be monitored. As with prescribing any medication, there is a risk of liability. Yet, it is a clinic, and the mission of the clinic is to help low-income people receive health care. Treating anxiety with available medications is part of that mission-I would think. Second, and terribly obvious, how are my residents supposed to learn how to prescribe these anti-anxiety agents if where they work does not allow them to use these agents? Yes, they do get experience with the likes of Xanax, Klonopin and Ativan on their other rotations, but they should also be able to learn to see how these medications impact people who are struggling with unemployment, foreclosures, and high intensity exposure to violence and substance abuse. Helping someone with anxiety, whether with medication and/or behavioral techniques, enables the patient to cope with what might otherwise feel like impossible situations. Further, anxiety causes medical problems to get worse, so if the doctors can’t treat their anxiety with psychotropics then they will be treating their medical problems, such as their increased blood pressure, their increased sugars, and their irritable bowel disorder. Treating the mind, helps the body, and treating the body helps the mind. Why is that not clear to policy makers?

Nail-Biting

    ‘Childhood Anxiety Disorders,’ that is what I went to talk to parents of children at the early childhood center at UCLA today at noon. Ten questions from parents; six about nail-biting. I go through my mantras. Children should be exuberant about their lives. Anxiety is normal in children, but it is a problem if it interferes with social or school functioning. Anxiety disorders in children is divided into six categories, according to our current diagnostic manual. Five of those disorders are the same as adult anxiety disorders. Medications are helpful, but they are a last resort. Mindfulness, for children and adults, along with deep breathing should be tried first.

    After that came the questions. “What should I do with my three year old who bites his nails?” “First” I say, “be an observer of your child. Determine what settings the nail-biting gets better or worse. Determine if your child seems to self-soothe by nail-biting. See how bad it is over time.” The parents nod in recognition that they have heard all that before. “The question,” I say, “is whether the nail-biting is a window into internal distress, and if so, how severe that distress might be.” “This is a field of subjectivity,” one mother says, expressing distress about the subject. “Absolutely,” I say. “Parenting is subjective. You have to use your intuition, your reflective functioning, to speculate about the internal state of your child.” I guess she was a scientist, since she looked at me with dismay. “It is hard to be a parent,” I say, trying to redeem myself in her eyes. She smiled and she seemed to relax. I think to myself that maybe next time I will stick with symptoms and checklists and avoid talking about internal states. Then, I think again, and say, no, maybe I will start with nail-biting as a symptom which might indicate distress, but it might also indicate the ability to self-soothe. Nail-biting, like all childhood anxieties, are curiosities demanding further exploration before intervention. I will stick with that.

No Gravity Anxiety

    Zachary, previously reported in this post, https://shirahvollmermd.wordpress.com/2010/04/14/prescription-drug-abuse/, age forty-one, says “you know anxiety has no edges.” “You mean it is like not having gravity,” I reply. “Yes, that’s it,” he says excitedly. The power of words to describe an internal state is so powerful. Zachary has a hard time understanding his anxiety, and hence he is vulnerable to prescription drug abuse of benzodiazepine medications such as Xanax. He wants to take this feeling state away. He does not know how to understand his discomfort, but he knows he wants to get rid of it. When I describe it by saying that anxiety  is as if he does not experience gravity, instantly his anxiety diminishes. His response to my comment made me painfully aware that not only was Zachary anxious, he was also  ashamed of his anxiety because he thought there was no way to convey the feeling, and as such, the feeling must be shameful. By using the word gravity, Zachary could now convey to his loved ones what he was experiencing, and hence he did not have to feel so alone with his feelings. Plus, Zachary appreciated that I was not criticizing him for his feelings, which is what he expected based on his childhood interactions, but rather I was explaining to him what he was experiencing.

    Anxiety is a concept that needs an art form-movies, paintings, words-to express the idea. Benzodiazepines can be very helpful to curb the anxiety instantly, as can understanding. The art of medicine lies in using ideas to show understanding, and/or medication to offer relief. When medicine tilts too far towards quick prescribing,  then the art of compassion is lost. Likewise, when medicine tilts too far towards understanding, then doctors miss the utility of prescribing medications. Every physician needs to search for that sweet spot of using both  the art and the science. Zachary benefits from anti-anxiety medication, but he does not need a big supply. Likewise, Zachary benefits from struggling to describe his internal feeling state with words. In so doing, Zachary found some “edges”.

Stop Yelling At Me

This blog is part of my series on anxiety disorders in children and adolescents.

A 17 year old boy comes in to my office with his mother crying hysterically that his entire body feels bad. I can hardly understand him through his tears. He has recently lost his paternal grandfather to end stage Alzheimer’s Disease. His paternal grandmother has recently been diagnosed with cancer. He is applying to college. He is a good student and he has lots of friends. His family situation is stable.  The precipitating stress is not clear, although it could relate to his stress with his grandparents.. He complains of strange feelings in his body.  His pediatrician stated that he is healthy. He states that he is worried he is losing his mind. I have known him since he was ten. He has always had anxiety. This episode appears to be an exacerbation. I suggest that he go back to taking medication for his anxiety, as he did when he was ten. He says “stop yelling at me”. He then starts to scream saying that the side effects make him anxious. I understand that he is anxious and he needs help, but the tool to help him makes him even more anxious. I explain to him that anxiety is a complicated state of being and that the symptoms make it hard for him to take advantage of the therapeutic intervention which might help, but he needs to take medication and he needs to cope with the risks involved. He repeats “stop yelling at me”. I wait a few moments. We start talking about sports. He is involved with gymnastics. He is talented. I show appreciation for his skills. At the end, I say “it was nice to see you” to which he responds “you too”. He leaves with a prescription. I will see him again in three days.

Disclaimer: Details have been changed in order to maintain privacy. This blog is for illustrative purposes only.