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Thursday, 24 September 2009 11:42

Clinician's Digest

Written by  Ari Rosenberg
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Clinician's digest

By Garry Cooper

Exercising for Mental Health

Therapist Jane Cibel really makes her clients sweat. After a brief check-in, during which they report how their lives and therapy homework have gone in the past week, they get on her treadmill for five to eight minutes, and then hit the weight machines in her office for a full workout. Throughout their workout, she'll ask them the kinds of questions about their thoughts, feelings, and memories that other therapists ask clients.

For years, Cibel, who's certified as both a social worker and personal trainer, had been thinking about integrating exercise and therapy. Then four years ago, as the research continued to accumulate showing that exercise is as effective as therapy or meds for certain conditions, Cibel finally made the break with tradition. She set up her Washington, D.C., office with exercise equipment and told her clients to wear workout clothes to sessions. As word of her unique practice spread, her caseload shifted toward clients who are unhappy with their bodies, although she doesn't specifically treat body-dysmorphic or eating disorders. Underlying her clients' dissatisfaction with their bodies, she says, is usually depression, anxiety, or other mood disorders, and those are the issues her distinctive approach primarily addresses.

Cibel believes that much of the benefit of exercise comes both from making an initial commitment to taking action and from an increasing sense of accomplishment. While her clients work on their bodies, she reinforces their courage to change, their strength, their endurance, and their balance. "I'm not just commenting on their physical effort but using metaphors for how resilient they are," she says.

Cibel also uses homework exercises to build psychological strength. She'll tell depressed or isolated clients to call a friend or check the newspaper for community activities. She'll instruct clients trembling at the brink of career transitions to bring in a draft of their re'sume' or schedule a few job interviews. She also advises them to do at least two workouts between weekly sessions. The sense of mastery they gain from their workouts and from her positive feedback, she says, stays with them during the week and encourages completion of the homework assignments.

Cibel carefully monitors her clients to make sure the exercise doesn't harm them. She warns that therapists who start their clients on exercise regimens without appropriate training might be exposing themselves to liability. But, she says, therapists who want to use exercise to bulk up clients' emotional confidence and strength can always suggest that they head for the nearest gym and sign on with a personal trainer.

Autism Epidemic?

It's been widely reported in the media that autistic disorders, once considered rare, are approaching epidemic proportions. As many as 1 in 150 children are now thought to have autistic, Asperger's, Rett's, childhood disintegrative, or pervasive developmental disorders. The Autism Society of America estimates that more than a million people, both children and adults, in the United States have an autistic disorder. In California, the number of individuals seeking services for autistic disorders jumped 273 percent between 1987 and 1998, and then doubled in the next three years; all told, that's a 634-percent increase from 1988 to 2002.

Many claim the epidemic is caused primarily by childhood vaccinations, with the major suspect a mercury-derived preservative called thimerosal. Animal studies clearly demonstrate its toxic neurological effects, and since 1991, when the Food and Drug Administration mandated three additional childhood vaccinations that were heavily laced with thimerosal, the incidence of childhood autism has increased fifteenfold. A few years ago, the FDA and other federal health agencies, responding to public concerns, called for eliminating and/or significantly reducing levels of thimerosal in childhood vaccines, while still maintaining that today's vaccines are safe.

This spring, an article in the April Current Directions in Psychological Science claimed that there never was an "epidemic," and that the increases in autism are actually caused by an expansion of diagnostic criteria. Morton Ann Gernsbacher from the University of Wisconsin, the article's lead author, points out that between 1980 and 1994, the DSM significantly broadened its diagnostic criteria for autistic disorders. The 1980 diagnostic markers of "pervasive lack of responsiveness" to others, "gross deficits in language development," and "peculiar speech patterns" evolved in 1994 into "impairments" in social interaction and communication and "restricted, repetitive and stereotyped patterns of behavior, interests and activities." While the 1980 DSM had only two autistic categories—Infantile Autism and Child Onset Pervasive—the 1994 edition has five.

While those convinced there's an autism epidemic point to the alarming increases in cases reported by school districts around the country, Gernsbacher says that the increase is due to new reporting requirements. In the years since the reporting requirement changed, she argues, larger and larger numbers of previously undiagnosed or misdiagnosed children have begun to show up. Such an increase isn't new. Gernsbacher points out that after "traumatic brain injury" became a mandated reporting category, its incidence increased 5,059 percent in a 10-year period, and no one would suggest a sudden epidemic of traumatic brain injuries.

The stakes are high in determining whether an autism epidemic exists. If increasing levels of mercury in the environment are causing more cases (in addition to thimerosal, mercury is present elsewhere in the environment), everyone needs to know. For legal and psychological reasons, parents need to know whether their child's autism has come from genetics, vaccines, the environment, or broader and more accurate diagnoses. Gernsbacher, whose 9-year-old son Drew is autistic, has her own personal stake. She believes that if people accept that autistic disorders are distributed randomly and in large numbers across the population, most of the stigma associated with autism will disappear.

Are Gay Parents Good for Children?

Last January, President Bush announced at a press conference, "Studies have shown that the ideal is where a child is raised in a married family with a man and a woman." But when you look more closely at the research, you begin to wonder about the validity of the studies the President had in mind.

The American Academy of Pediatrics (AAP), the established organization of pediatricians, has no doubts about the issue. Its guidelines, arising from a 2002 review of research by Tufts University Professor of Pediatrics Ellen Perrin, say there should be no barriers to gay-parent adoption and custody. "There's no good evidence that same-sex parents are any less fit than heterosexual parents, and some of them may provide subtle advantages," Perrin says. She admits, however, that there have been no definitive studies of the psychological effects of growing up in a gay household, primarily because of sample problems. Until recently, there just weren't that many openly gay parents. But that's been changing, she says.

The AAP stance is in marked contrast to that of the American College of Pediatricians (ACP), which says that children of gay parents are definitely at risk for emotional problems. But the ACP, a small organization that broke away from the AAP over its position paper, seems as concerned with promoting certain values as with promoting children's emotional and physical health. The college says its mission is "to develop sound policy based upon quality research," and that it "recognizes the inherent value of both a father and a mother, united in marriage." The ACP position paper opposing gay parenting cites no peer-reviewed studies that directly find a negative effect of gay parents on children. Instead, it draws its conclusion primarily from studies finding that gay adults have higher incidences of psychological and health problems.

In fact, the idea that children do worse when raised by gay parents appears to be based on the assumption that there's something inherently wrong with homosexuality. "Homosexual parents don't do well because they have more partner changes, more drug abuse, more history of missing work, and all these things conspire to make a homosexual parent less suitable," says psychologist Paul Cameron, perhaps the most prominent researcher who opposes gay parents. Cameron is Chairman of the Family Research Institute, an organization that believes "in preserving America's historic moral framework and the traditional family." Perrin, he says, used "biased studies from homosexual journals." (About 7 of her 23 journal citations come from peer-reviewed journals such as the Journal of Homosexuality). By contrast, 10 of Cameron's studies about homosexuals have been published in one journal, Psychological Reports, which, says Perrin, authors have to pay to be published in.

Responding to positions of researchers like Cameron, Perrin insists that it "isn't the sexual identity of the parents that matters: it's things like how well the parents get along, how integrated the kids are in school—the same social factors that matter to all kids."

On-line Case Consultation and Confidentiality

On a therapists' listserv, a therapist recently asked for advice about a client who'd been thinking about breaking up with his girlfriend, who's eight months pregnant and obsessed with a rock star. In using an online listserv to seek help, is this therapist leaving herself open for professional sanctions and lawsuits? Yes, says John Riolo, a social worker and consumer advocate for therapy clients.

Therapists don't realize, Riolo contends, that even their posts to invitation-only listservs are widely accessible—often for years—to a much wider audience. In actuality, the screening process for ensuring that only mental health professionals join a listserv is far from effective. It's easy for anyone, including clients, to join listservs under assumed identities. Meanwhile therapists, often lulled by the supposed anonymity of listservs, may think that by not naming their agency or the state in which they work, they're protecting their clients' confidentiality. But anyone can easily track down a therapist's location and affiliation from their name or e-mail address. From there, a husband can discover, for example, that his wife is having affairs, even from a seemingly innocuous statement like, "At our agency, a 30-year-old borderline married client confided to me that she's picking up men in a bar."

Not all professionals agree with Riolo. Social worker Joel Kanter, who moderates a listserv of clinical social workers, thinks that Riolo is being too alarmist. Therapists often share case material, prudently disguised, at conferences and in articles, he says, and if they take the same camouflaging precautions on listservs, they can adequately protect confidentiality. The advantages of online consults—getting quick feedback from a large community of professionals—far outweigh the small confidentiality risk, he says, pointing out that he's never heard of any complaints or sanctions arising from on-line consultations.

But Frederic Reamer, chair of the National Association of Social Workers (NASW) task force that wrote the association's code of ethics, points out that discussing a client on the Internet can run afoul of several of NASW's confidentiality provisions, including the proscription to "avoid discussing confidential information in any setting unless privacy can be ensured." The American Psychological Association's ethics code has similar provisions.

Some listserv moderators have modified their policies in response to Riolo's articles. One listserv asks members to send case consults directly to the moderators instead of to the entire list, so that the moderator can disguise identifying information about the clients and the therapist. That, Riolo contends, is insufficient, pointing out that several members of that listserv, forgetting the provision, have posted to the entire list, leaving themselves and their clients wide open to trouble.

Riolo's series of articles on confidentiality can be found at www.psychjourney .com/cseries.htm.

Examining Controlled Separations

Ever since the Wall Street Journal published an article last summer about therapists who use controlled separations with couples, Meg Haycraft, a therapist from Skokie, Illinois, who was mentioned in the piece, has been getting calls from couples who want to try it. The idea of a controlled separation, which its adherents paradoxically insist is a powerful tool for encouraging couples to stay together, is catching on, even, surprisingly, among the staunchest marriage proponents.

The intervention has been around since 1998, when Lee Raffel, a therapist from Port Washington, Wisconsin, published Should I Stay or Go: How Controlled Separation (CS) Can Save Your Marriage. The book lays out guidelines for helping couples craft a detailed agreement for temporarily living apart. But unlike standard separation agreements, the couple agrees not to file for divorce while they're separated. They also discuss how to continue seeing each other, and agree to work on their relationship through exercises, homework, and occasional conjoint therapy sessions.

It isn't for everyone. Raffel advises against it when there's violence or substance abuse involved, primarily because abusers and violent spouses probably won't honor the separation agreement. She also cautions therapists not to use it solely because they feel unable to manage conflictual sessions. She herself offers couples an eight-session contract in which to address their conflicts, only suggesting a controlled separation when they can't seem to make progress or avoid arguments. Other couples whom she considers candidates for controlled separation are already separated and may need the structure offered by this approach.

Raffel estimates that two-thirds of her controlled-separation couples have saved their marriages. Elsie Radtke, who counsels couples for the Archdiocese of Chicago, estimates that about half of her clients who separate end up divorcing. Whichever figures you use, it's still a lot of divorces avoided. "Controlled separations," says Haycraft, "may be the missing piece in today's culture that sees the only options as toughing it out or divorcing. It's a device to slow things down, to be the springboard of hope again."

When Grief Lasts

In recent years there's been a growing shift within the grief-counseling community: the old idea that grieving people must detach completely from the deceased has given way to a gentler notion that the bereaved should accept the reality of the death while maintaining thoughts of the deceased that are integrated into their ongoing lives. Now a new kind of grief therapy explicitly incorporating this perspective has been shown to work with the most stuck mourners of all, those people suffering from complicated grief.

While the usual acute grieving lasts anywhere from 6 to 18 months (with or without a therapist's help), the symptoms of complicated grief last much longer. Sufferers remain stuck in the initial, most debilitating stage of grief—longing for the deceased, avoiding places and situations that evoke memories of their loved one, experiencing recurrent pangs of grief, and unable to think about the future with any enthusiasm or hope. Now an article in the June Journal of the American Medical Association presents promising results for Complicated Grief Therapy (CGT), a therapy adapted from effective PTSD and depression treatments.

CGT, which takes about 16 sessions, begins with a history of the relationship with the deceased, including the story of the death, and psychoeducation about grief. The exercises and discussion that follow shuttle between helping grieving people engage with the loss and encouraging them to consider the future. This helps clients feel they can move forward at the same time that they cope with the loss of their loved one. Unlike previous models, it doesn't try to get people to achieve "closure" in their grief.

After the psychoeducation phase, "revisiting" begins. This is an exercise in which the bereaved person imagines that he or she is back at the time of the death and retells the story of how the person died, says the study's lead author, psychiatrist Katherine Shear, from Columbia University's School of Social Work. The therapist tape records the story, occasionally asking what the client is feeling. Clients take the tape recording home and listen to it between sessions.

After three to five sessions, the therapist introduces structured-memory exercises, instructing clients to recall favorite or positive memories of the deceased, then not-so-positive and even negative recollections. This helps clients feel that they're free to think about the deceased person in a range of ways. Interspersed with the memory work, therapists encourage clients to revisit situations and activities they've been avoiding. This strategy is similar to in vivo exposure in PTSD treatment. For instance, if the person has been avoiding movies, because going to movies was a favorite activity with the deceased, the therapist may encourage the client to merely look at the movie section of the newspaper and contemplate seeing a movie, with the eventual goal of actually sitting through a show.

A full manual of CGT will be ready in a few months. Shear encourages therapists to adapt the overall orientation and any of the techniques with their clients who are experiencing protracted grief.

Resources

Exercising: Cibel's website is at www.psychfitinc.com. For the latest review of research on exercise and mental health, see Harvard Mental Health Letter (December 2005); Autism: Current Directions in Psychological Science 14, no. 2 (April 2005): 55-58 ; Gay Parents: Perrin's report is at: http://pediatrics.aappublications.org/cgi/content/full/109/2/341 and the ACP's position is at http://www.acpeds .org; Grief Therapy: Journal of the American Medical Association 293, no. 21 (June 1, 2005): 2601-08.

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