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Energy Therapies Want Respect

By Garry Cooper

Helping Kids Take Charge

How to get young people to turn their problems into coping skills

By Ben Furman and Christine Beuer

Web Marketing on a Shoestring

The fundamentals of starting—or growing—a practice

By Elizabeth Doherty Thomas

How's God Doing?

Despite today's headlines, much better than you think

By Richard Handler


A603 Bringing the New Science of Love into Everyday Life

Learn a brief, powerful approach based on the science of bonding and attachment that helps emotionally estranged and bitter couples reconnect on a deep, intimate level. Click here for full course description.

Susan Johnson, Ed.D.
Clip Length: 63:50

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Getting Unstuck: Moving Beyond Depression, Anxiety, and Chronic Illness - A704

Learn creative mind-body techniques for helping clients extricate themselves from self-defeating patterns and increase their health and well-being. Click here for full course description.

James Gordon, M.D.
Clip Length: 54:34

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SCREENING ROOM
BY FRANK PITTMAN

Voices of Truth
What's the difference between honesty and spin?

When I was growing up, before TV came to our neck of the Alabama swamps, we had to imagine what the real world over the next hill might look like. We'd sit around the radio, envisioning the things we couldn't see—wars, baseball games, Burns and Allen, or Baby Snooks.

When TV finally came, in the early '50s, the world it brought into our living rooms was black and white, and dumbed way down. It hardly mattered—we'd watch anything, even test patterns, for hours. Anything was more interesting than Alabama in the '50s. Broadcasting only a few hours a day, TV gave us Hopalong Cassidy and Captain Video, relentless baseball games and wrestling matches, Lucy and Uncle Milty. And, of course, the news. TV news no longer came from disembodied voices, but from talking heads. Newsmen now had faces, and, as eyewitnesses, we could now determine who had an honest face and who didn't.

The most honest of the talking heads seemed to be the revered war correspondent Edward R. Murrow. He had a deeply trenched face and a nicotine-stained voice that seemed to arise from the depths of the world's wisdom. He sat calmly and spoke authoritarian truths through the haze.

The moment when TV ceased to be a silly toy and became the news itself was in 1954, when the audience watching at home became referees in a great debate over what was true, what was a lie, and whose view of the world we could trust. At that time, as the Cold War heated up, Joe McCarthy, a paranoid or merely unscrupulously ambitious senator, tried to stir the populace into a froth of fear over an imminent takeover led by hundreds of communist spies, whose names he claimed were inscribed on a piece of paper he'd wave at the TV cameras. Half of us were quaking in our boots over the imagined commies; the other half were terrified of the all-too-real McCarthy, who had the scary habit of declaring that anyone who disagreed with his hysterical demagoguery was, perforce, a communist sympathizer.

Murrow and his cohorts at CBS refused to bow to McCarthy. Murrow invited him to debate on TV and exposed him as a rabble-rousing showboat who, as the highly honorable Joseph Welch, special counsel for the Army, put it, had "no decency." With Murrow's inspiration, the Senate held hearings on McCarthy's antics. They censured the man and drove him into shamed retreat.

Now the actor George Clooney has put together a reenactment of the public clash between Murrow and the rabid senator. It's called Good Night and Good Luck. The hyperrealistic film is set in CBS television headquarters and studios, and shot in high-contrast black and white through air filled with cigarette smoke. It intercuts archival footage of McCarthy, sweating, raving, and ranting, with David Straithairn's Murrow, smoking calmly and cutting through the tirade with sepulchral voice and deep-set eyes.

Straithairn looks like a cross between Jason Robards and Abraham Lincoln, and sounds like the voice of God. Frank Langella plays William Paley, the founder and head of CBS, who'll have to bear the financial consequences if Murrow goes too far in offending McCarthy's loyal paranoids. He alternately tries to shield and rein in his iron-willed star. On the soundtrack, amidst the tension of the approaching duel between Murrow and McCarthy, the creamy-voiced Dianne Reeves sings jazz.

Clooney's film convincingly captures the look, sound, and feel of the early days of television, when this compelling and intrusive device brought the world into our livings rooms, dominating our picture of reality. It turned out that those who assaulted us, like McCarthy, didn't go over well on the intimate new medium. We preferred cool voices of reason, like Murrow, who dared to defend polite debate and proclaimed that "Dissension is not disloyalty."

Good Night isn't a biography of Murrow, but a reminder of the power of the people who come into our homes and tell us what's going on in the world out there. On See It Now, Murrow had gone to every corner of earth to report the news on location and firsthand. By the time he took on powerful politicians, we trusted him, maybe because he'd convinced us of his basic decency. Murrow wasn't neutral toward McCarthy. And he didn't attempt to silence him, but to prevent him from silencing everyone else. Murrow would fight with Paley as much as with McCarthy, to make sure no voice was silenced—-including, of course, his own. Ever since, our politics has been shaped by the powerful medium that Murrow mastered early on, as we continue to search for voices and faces who'll tell us the truth.

Those of us who learned to trust black and white may distrust color, or the tinge people put on the things they tell us and show us. The writer in the '50s who insisted most firmly he was telling the truth was Truman Capote, a self-styled genius and celebrity-seeking writer, who capitalized on the weirdness of his elfin body, the mousy squeakiness of his prepubertal voice, and the infantile beauty of his face. He wrote touching, ersatz memories of his fantasized childhood in Monroeville, Alabama, oiled his way into high society in New York, and became a famously catty purveyor of gossip among the Beautiful People. One of his most revealing creation was Holly Golightly in Breakfast at Tiffany's.

In 1959, Capote got wind of a murder in Kansas and set out to investigate it as the basis of a "nonfiction novel." He enlisted his childhood buddy from Monroeville, author Harper Lee, whose To Kill a Mockingbird won both the Pulitzer Prize and the hearts of the world around that time. The Alabamians set out for Kansas even before the murderers had been found. There Capote befriended the pair of ex-cons who'd killed a family while burglarizing their house. From them, he got detailed descriptions of the crime, but couldn't finish his book until he could write about the story's dramatic ending—the killers' execution by hanging, which was delayed by multiple appeals.

In 1965, Capote finally came out with the semi-journalistic, semi-novelistic In Cold Blood, which doesn't just focus on the murder of the farm family in Kansas, but examines the soul of one of the psychopathic murderers, Perry Smith, a stunted, part-Cherokee ex-con who'd been brutalized by his father, jerked out of school in the third grade, and turned loose on the world as a semiliterate, intellectually ambitious drifter.

In Cold Blood was an astounding success, and quickly, in the hands of Richard Brooks, became a great psychonoirish crime film. It tells the story of the murders, the town, and the murderers, but it leaves Capote out. Robert Blake played the perennial outsider Perry, who didn't understand that his partner, the charming chiseler Dick Hickock, talked tough about leaving no witnesses to a burglary, but that it was just talk.

The new film, Capote, written by Dan Futterman and directed by Bennett Miller, tells the story of the Kansas murderers from Capote's (tinted) perspective. The film is fittingly hyperrealistic. The photography, in Manitoba, which outflats Kansas, is grim and stark. The townspeople seem far more interested in the visiting celebrities than in murderers.

Capote is brilliantly played by Philip Seymour Hoffman, an actor who can transcend his physical ordinariness to do anything, from the suspicious rich kid in The Talented Mr. Ripley to the transsexual speech therapist in Flawless. Here he doesn't just capture Capote's fey gestures, he makes his body tiny, his face cherubic, his voice a chirpily drawling falsetto. He's indeed a mockingbird.

Catherine Keener, most notable as the depressive sexpot in Being John Malkovich, is the sparrowish Harper Lee, selfless, loyal, and calmly critical of Truman's intrusive narcissism. She's the earthling that keeps this space alien from being too weird for the plain folk of Kansas.

While Truman falls in love with his alterego Perry Smith, Lee notes his impatience with the appeal process, which keeps the murderers from hanging and means he can't finish his book and win the world's acclaim. She sees that Truman's enfant terrible posture disguises a murderous soul. When Lee isn't there, like Jiminy Cricket on Truman's shoulder, his coterie of cheerleaders and the glitterati of New York provoke and release his sadistic bitchiness.

Capote is the flip side of In Cold Blood. In it, we see the degree to which Capote lied and seduced the killers he "befriended." By the end, Truman's boyish innocence has faded, and we see him as a treacherously ambitious man, while we see Perry as an innocent, honest (albeit murderous) child. The film captures his tragic violence with an unforgettable line: "I thought Mr. Clutter was a very nice man. I thought that right up until I cut his throat." The boyish Perry's main concern, as he goes to the gallows isn't his life or the lives of the Clutters, but embarrassment over losing bowel control at the point of death.

Capote became famous for telling the "nonfictional" truth, about his childhood traumas, about the murders in Kansas, and about the secrets of his "friends." He always gave us facts, if not the facts, at least some facts, while managing to leave out his own influence on the reality he was shaping. The film Capote puts him back in and creates a far more compelling story.

The munchkinesque twitter of Capote's voice got him attention and made him unforgettable, but cost him friends every time he opened his mouth and barfed gossip. Maybe Capote's self-destruction is rooted in his furious need to say or be anything that would enable him always to stand apart, while still being the center of attention. His life may have all been fiction (some say even his voice was put on). But this great new movie is about more than this one insecure man. It probes deeply into the nature of truth, revealing how truth is always tinted, always subjective. At the end, we're left with only one certainty: the pretense of total honesty and nonfictional objectivity is always a lie.

Frank Pittman, M.D., is a contributing editor to the Psychotherapy Networker and is in private practice. Contact: fsp3md@aol.com. Letters to the Editor about this department can be e-mailed to letters@psychnetworker.org.

FROM RESEARCH TO PRACTICE
BY JAY LEBOW

The Verdict Is Clear
ESTs have an incontestable track record with anxiety

Every self-respecting therapist knows that the value of empirically supported therapies is a hotly debated subject these days. Critics repeatedly point out that, outside of therapy outcome studies, clients rarely present themselves with the sort of uncomplicated, pure, DSM-delineated diagnosis around which empirically validated treatments are structured and show such high success rates. To many therapists, manualized treatments feel rigid, agenda driven, and unequal to the messy reality they see in their offices every day. Even therapists who work on manual-driven projects have been known to report, off the record, that after the first few sessions, their work becomes increasingly variable and idiosyncratic—just like the real people they're treating.

Nonetheless, it can't be denied that, with certain problems, some empirically supported treatments (ESTs) have been proven highly effective. Probably the best example is anxiety treatment. The ESTs developed to treat anxiety have consistently demonstrated better results than medications, without the side effects and treatment dropout that often accompany meds. They've proven to be highly effective for the following problems:

Panic Disorder. Panic disorder strikes between three and six million Americans, and is twice as common in women as men. People diagnosed with it have recurrent attacks that include a variety of unpleasant symptoms—palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, choking feelings, chest pain or discomfort, lightheaded or fainting sensations, and fears of losing control. They also typically have pervasive fears of future attacks. Often, the fear of the fear is worse than the attacks themselves, so that people with panic disorder are endlessly worried about and preoccupied with the possibility of having an attack.

Although traditional talk therapies don't appear to have much impact on panic, there are several variants of cognitive-behavioral therapy that have been demonstrated to ameliorate this disorder. Most of these treatments share several interventions, including increasing clients' exposure to situations that lead to panic, helping them more effectively manage thoughts and feelings associated with panic, and teaching them how to engage in problem-solving self-talk.

Perhaps the most widely disseminated of the treatments for panic disorder is Panic Control Treatment (PCT), developed by David Barlow of Boston University and Michele Craske of UCLA. In PCT, clients are encouraged to experience the sensations of panic, so that they can master them. For example, Shannon, whose disabling panic in the workplace has left her reluctant to seek work, is encouraged in session to imagine being in an anxiety-laden work situation and to breathe in the same way that she does when she has a panic attack. By visiting her worst-case scenario, she's invited to master her fear.

PCT includes cognitive examination of the distortions typical in panic, as well as the automatic thoughts that go along with it—like overestimating the level of real threat during a panic attack. Thus, Shannon's dominant thought that her panic will lead to humiliation and rejection by others is elicited and examined in the light of her experience. This balanced examination of the evidence points to the fact that her panic is much more of a problem for her than for others. She's then encouraged to remind herself of this clear conclusion, and to engage in a rational examination of similar beliefs as they come into consciousness and influence her behavior. This therapy works with breathing to help people acquire the feeling that they can cope with the signs of impending panic and, eventually, acquire the ability to calm themselves down.

PCT has been frequently studied with impressive results. For example, in a large, rigorous, multisite study of this treatment conducted by David Barlow, Jack Gorman, and colleagues, clients were randomly assigned to groups receiving PCT, placebo, PCT plus medication, or PCT plus placebo treatments. The treatment period was three months. Although all the treatments produced more change than the placebo alone, several findings suggested the superiority of PCT. Adding medications to PCT didn't yield better outcomes than using PCT alone. And six months after treatment, there was greater relapse for those receiving medication alone or PCT plus medication than for those receiving PCT alone

Cognitive-behavioral therapy (CBT) for anxiety, following the protocol developed by Aaron Beck and colleagues and based on correcting cognitive distortions in self-talk, has amassed a similarly impressive record of outcomes when compared to medication in studies of treatments for panic. In fact, the evidence for the effectiveness of PCT and other cognitive-behavioral therapies for panic disorder vastly outweighs evidence for other approaches. As an example, a recent study by Michael Addis of Clark University and his colleagues found that 43 percent of those getting cognitive therapy in a managed care setting achieved clinically significant improvement, compared to only 19 percent of those getting other treatments in the same setting.

Just as CBT treatments are coming to be regarded as the treatments of choice for panic disorder, related treatments are emerging as especially potent in treating other anxiety disorders. Because conditioning plays such an important role in causing these difficulties, CBT seems to work by teaching clients new skills that override the earlier conditioned patterns.

Obssessive-Compulsive Disorder (OCD). This disorder includes recurrent obsessions and compulsions that interfere considerably with daily functioning. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and cause marked distress. Compulsions are repetitive behaviors designed to reduce anxiety that become problems in themselves. Examples include people who feel compelled to check and recheck their clothing, or the stove to make sure it's turned off, before leaving the house, making them chronically late. CBT treatments for these disorders, including those developed by Edna Foa of the University of Pennsylvania, typically feature exposure to the source of anxiety, coupled with disruption of the obsessive or compulsive behavior and the introduction of some other alternative behavior.

For example, Maurice, who engages in endless rituals of washing and straightening his clothes, is prevented from doing these behaviors. Instead, when thinking about going to school, a subject about which he has a good deal of anxiety, he's taught to fold his hands. Self-talk is also a frequent part of these treatments. So Maurice is helped to examine his belief about what'll happen if he doesn't engage in his compulsive washing. He and his therapist conduct a balanced examination of the chances that germs will harm him if he doesn't do his ritual washing is correct. As with panic disorder, he's taught a process of rationally examining his beliefs to be used when he encounters variants of these beliefs.

Here again, the CBT treatments are impressively effective. For example, a multisite study conducted by Foa found that both the exposure program and medication significantly reduced the symptoms of OCD, but that the exposure treatment was more effective than medication alone. The addition of the medication to the exposure treatment didn't seem to improve outcomes.

Simple phobia. Exposure-based treatments clearly are the treatment of choice for simple phobias. In these treatments, clients are gradually exposed to the feared situation, and given an opportunity to master their fear step by step. Generally, lots of exposure in short duration produces the best results.

New technologies that seem to improve upon the impressive results from these treatments are evolving. One technology is the virtual-reality simulator, which provides vivid exposure to feared situations without having to go out of the therapist's office. For example, Mike, who's afraid of crossing bridges, experiences in virtual reality the sights and sounds of this feared activity. Recent research demonstrates that virtual-reality procedures are especially effective as exposure-based treatments.

Other research has begun to look at the use of cognition-enhancing medications in these treatments. Cognitive enhancers aren't like traditional psychopharmacological medications. These medications, such as D-Cycloserine, increase the ability to learn without affecting feelings directly. Experiments in animals and humans have shown that these drugs lead to better, classically conditioned learning (like that experienced by Pavlov's dogs), which are at the root of behavioral treatments for phobia. A recent study by Kerry Ressler of Emery University utilizing D-Cycloserine showed that using this drug in treatment was more effective in conditioning people to be less afraid of heights than was traditional behavior therapy conducted without the drug.

It's essential here to grasp the role of these medications. These are medications that help clients learn, not medications that reduce anxiety directly. It continues to be a well-established finding that simple phobias typically don't respond well to medications that reduce anxiety, because clients develop less confidence in their ability to master a situation when that mastery is achieved while taking meds. With anxiety-reducing medications, clients usually attribute the lessening of symptoms to the medication and, therefore, fail to learn new coping behaviors. In contrast, these new cognition-enhancing medications seem to improve clients' ability to recondition themselves.

Generalized Anxiety Disorder (GAD). Individuals with GAD worry pervasively much of the time. The tendency to worry is the meat and potatoes of many psychotherapy practices, encountered far more often by more therapists than the relatively rare OCD and Panic Disorder. What probably isn't well-known by many therapists, however, is that CBT treatments have been shown to be highly effective with GAD. In one study, conducted by Thomas Borkovec at Pennsylvania State University, 60 percent of the clients engaging in a treatment were able to attain a level of functioning of anxiety and worry comparable to that of the general population. The treatment used in the study included an array of CBT techniques aimed at the rigid behavior and thoughts typical of those with GAD, including active self-monitoring to understand the anxiety triggers, specific training and practice in such relaxation techniques as progressive muscle relaxation and diaphragmatic breathing, "self-control desensitization" in which clients imagine their worries while practicing relaxation, and having designated worry periods to establish a sense of control over this experience.

A recent metanalytic review by Kristin Mitte of the University of Jena in Germany found that across 65 studies, CBT for GAD worked as well as medication, but without either the side effects or treatment dropout. The dropout rate for medications, Mitte pointed out, was 25 percent, compared to 9 percent for CBT. She found that studies that directly compared the two treatments should CBT to be superior.

So what are the implications from this research for us as clinicians? For anxiety disorders, it appears clear that the variants of CBT described above are the treatments of choice at this time. Nevertheless, these methods don't work for everyone, nor do they produce change in every aspect of a person's life—they aren't all-purpose therapy. But when clients specifically want relief from the symptoms of anxiety, these are the treatments they should get.

This means that, as responsible therapists, we need to know how to practice these techniques or be prepared to refer these clients to therapists who do. However, this doesn't mean that clients with anxiety problems should see only CBT therapists. At the Family Institute at Northwestern, where I practice, clients who are receiving more traditional therapies focused on broader life issues are often referred to an Anxiety Clinic for CBT, when they need help with their anxiety symptoms. In short, CBT isn't necessarily the only therapy people suffering from anxiety disorders need, but it's hard to argue that their anxiety treatment can appropriately exclude evidence-based CBT interventions.

Resources:

Barlow, David H. Anxiety and Its Disorders. New York: Guilford Press, 2002.

Mitte, Kristin. "Meta-Analysis of Cognitive-Behavioral Treatments for Generalized Anxiety Disorder: A Comparison With Pharmacotherapy. Psychological Bulletin 131, no. 5 (September 2005): 785-95.

Nathan, Peter, and Jack Forman. A Guide to Treatments that Work. New York: Oxford University Press, 2005.

Jay Lebow, Ph.D., is a contributing editor to the Psychotherapy Networker, senior therapist and research consultant at the Family Institute at Northwestern, and Clinical Professor at Northwestern University. Contact: j-lebow@northwestern.edu.Letters to Editor about this department may be e-mailed to letters@psychnetworker.org.

Networker News
BY ROB WATERS

Children in Crisis?
Concerns about the growing popularity of the bipolar diagnosis

Ten years ago, bipolar disorder was considered a disabling adult mental illness that was almost never described in children. Today child psychiatrists are diagnosing it in a growing number of children and adolescents, fueling a surge in the use of antipsychotic medications among the young. This has sparked a backlash from critics who see the rise of "juvenile bipolar disorder" as the latest fad sweeping the psychiatry field.

While the exact number of children diagnosed with the disorder is unknown, there's little doubt that it's risen dramatically. The Child and Adolescent Bipolar Foundation, a parent-led advocacy group, estimates that at least 750,000 American children and adolescents suffer from the disorder, most of them undiagnosed and untreated.

Data provided to the Networker by NDC Health Corp, an Atlanta-based firm that tracks trends in the use of prescribed medications, shows that the number of antipsychotic drugs prescribed to children and teenagers grew by 50 percent—from 250,000 to 375,000 prescriptions—between January 2002 and June 2005. While antipsychotics are prescribed to children for a variety of reasons, the most common, experts say, is to treat bipolar disorder.

Bipolar disorder was first flagged as a pediatric illness in the mid-1990s, when researchers led by Joseph Biederman of Harvard and Barbara Geller of Washington University in St. Louis published papers describing "mania-like symptoms" in young patients, many of whom were also diagnosed with attention deficit/hyperactivity disorder (AD/HD). Biederman and Geller contended that clinicians were failing to diagnose bipolar disorder in children, partly because the symptoms resemble AD/HD and partly because the disorder looks so different in children than in adults.

In the classic, adult version of the disease, people stay mired for weeks or months in a deep depression and then, almost overnight, fly into a manic phase, in which they're intensely creative, need little sleep, and exercise little control over their appetites for sex, alcohol, drugs, or gambling. With children, Biederman and Geller say, the shifts between depression and mania happen much more quickly—in days or even hours. The researchers term this "ultra-rapid cycling."

Critics scoff at this loosening of the criteria and argue that kids are being pathologized for normal behavior. "They're making a diagnosis of bipolar because a child has mood switches," say Dominic Riccio, a New York City psychologist and family therapist. "If a child goes from happy to sad and has impulsive outbursts, it's characterized as bipolar. But children have mood swings. To characterize this as mental illness is a serious flaw in scientific thinking."

Biederman and his colleagues at Harvard have redefined the disorder in another way, too. Bipolar kids, they say, are perpetually pissed off, slipping easily into explosive rages. These aren't just tantrums. Janet Wozniak, a Biederman associate and director of the pediatric bipolar clinic at Massachusetts General Hospital, describes such an episode as "an outburst with kicking, hitting, biting, and spitting that goes on for 30 or 60 minutes." Geller and her allies disagree with Biederman, however, contending that the use of irritability as the key sign of bipolar disorder in children stretches the criteria.

The debate over bipolar disorder's validity as a childhood diagnosis might have remained an obscure academic issue were it not for psychiatrist Demitri Papolos and his wife Janice, a journalist. Their 1999 book, The Bipolar Child, described the disorder as a "neglected public health problem," and put juvenile bipolar disorder on the map.

Spurred by the discussion of the Papoloses' book on morning talk shows, parents of children diagnosed with bipolar disorder created the Child and Adolescent Bipolar Foundation, with a large, active website and funding from pharmaceutical companies. Soon parents across the country began wondering whether their own children might have the disorder, and asking their doctors and therapists.

One such clinician was psychiatrist Jennifer Harris, who, in 2002, was completing a fellowship at the adolescent unit of Cambridge Hospital in Massachusetts. "We saw a huge number of kids coming in with that diagnosis," says Harris. "A lot of them turned out not to have it when you did a thorough assessment."

Harris's explanation for the increase of the bipolar diagnosis among children is that many clinicians find it easier to tell parents their child has a brain-based disorder than to suggest changes in their parenting. "The enormity of the problems many children face makes the simplicity of a biological explanation tremendously appealing," she says. "It allows us to feel we're doing something so that we can avoid feeling helpless with our most difficult patients."

Harris recently began working with a 10-year-old boy who was diagnosed with bipolar by another clinician and put on Neurontin, a mood stabilizer, and Zoloft, an antidepressant. When she probed deeper, she learned that his mother had metastatic cancer. She also found out that that child had a learning disability that made it hard for him to read social cues and, she believes, led him to erupt angrily when he felt someone was slighting him. In treating this boy, Harris did the kind of work few psychiatrists do these days: she met with his family and his teachers, worked with his counselor, and got him in a social-skills group. He's now off medications, and his behavior and moods have greatly improved.

Elizabeth Root, a social worker at a community mental health clinic in Cortland, a small town in upstate New York, has also seen a huge increase in children diagnosed with bipolar and taking medication cocktails. All of them, she says, have something in common: significant stress in their homes. "There are so many psychosocial pressures on parents and children today," she says, including divorce, family violence, and parents who work long hours with little time for shared meals or conversation. Food sensitivities and air pollution can also affect behavior, she feels. Also many children said to have bipolar disorder have previously been diagnosed with AD/HD, depression, or anxiety and put on stimulants, which are known to cause anxiety, or antidepressants, which can trigger edgy restlessness and manic behavior.

Instead of prescribing medications for seemingly out-of-control youngsters, Root says she works hard to learn about the stresses and strengths in the lives of children and their families, and to get family members to come in for therapy sessions. Mostly, she tries to get parents to use the Nurtured Heart approach designed by Howard Glasser, a Tucson-based child and family therapist.

Glasser developed his program for children with AD/HD, but says it works equally well for those said to have bipolar disorder. In fact, however, he rejects both labels; in his view, kids called AD/HD and those called bipolar are children with "more life force, more intensity, and more intense needs than they can handle. Some kids are born that way, and some kids acquire intensity living in homes that are stressful."

Glasser's approach takes typical behavior-management strategies and turns them on their head. Instead of setting out a program of escalating consequences for negative behavior, he advocates elaborately rewarding good behavior and accomplishments, while applying consequences for negative behavior in a low-key, nonemotional way.

Nurtured Heart therapy is one of several programs that offer parents techniques for supporting their children while managing their challenging behavior. Harvard's Ross Greene, author of The Explosive Child, has developed a system he calls Collaborative Problem Solving, which teaches children empathy and the ability to think through solutions before problems emerge.

Even the staunchest advocates of medication think such approaches are useful adjuncts to drug therapy. The trouble is that, in today's health care environment, medications are often the first resort, and psychotherapeutic approaches, if tried at all, are the first to fall away.

The message to all these children now being called bipolar is as distorted as is it reductionist. Instead of children's angry or disturbing behaviors being seen as essentially normal, if unproductive, responses to an increasingly fragmented and disconnected home and cultural life, the problem is located within the child. The explanation for their behavior becomes that their brains are biochemically imbalanced and need to be fixed. That's a message some parents and clinicians may find appealing, but it'll do little in the long run to address the serious family and social problems rampant today, which medications are powerless to treat.

Contributing editor Rob Waters can be contacted at robwaters@pacbell.net. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

Higher Ground
What clinicians should know about the "vertical dimension"

by Jonathan Haidt

Our life is the creation of our minds, and we do much of that creating with metaphor. We see new things in terms of things we already understand: life is a journey, an argument is a war, personal growth is flowering. With the wrong metaphor we are deluded; with no metaphor we are blind.

The metaphor that has most helped me to understand morality, religion, and the human quest for meaning is Flatland, a charming book written in 1884 by the English novelist and mathematician Edwin Abbot. Flatland is a two-dimensional world whose inhabitants are all geometric figures. The protagonist is a square. One day the square is visited by a sphere from a three-dimensional world called Spaceland. When a sphere visits Flatland, however, all that is visible to Flatlanders is the part of the sphere that lies in their plane—in other words, a circle. The square is astonished that the circle is able to grow or shrink at will (by rising or sinking into the plane of Flatland) and even to disappear and reappear in a different place (by leaving the plane, and then re-entering it). The sphere tries to explain the concept of the third dimension to the two-dimensional square, but the square doesn't get it. He cannot understand what it means to have thickness, in addition to height and breadth, nor can he understand that the circle came from up above him, where "up" does not mean from the North. The sphere presents analogies and geometrical demonstrations of how to move from one dimension to two, and then from two to three, but the square still finds the idea of moving "up" out of the plane of Flatland ridiculous.

In desperation, the sphere yanks the square up out of Flatland and into the third dimension, so that the square can look down on his world and see it all at once. He can see the inside of all the houses and the guts (insides) of all the inhabitants. The square recalls the experience:

An unspeakable horror seized me. There was darkness; then a dizzy, sickening sensation of sight that was not like seeing; I saw space that was not space: I was myself, and not myself. When I could find voice, I shrieked aloud in agony, "Either this is madness or it is Hell." "It is neither," calmly replied the voice of the sphere, "it is Knowledge; it is Three Dimensions: open your eye once again and try to look steadily." I looked, and, behold, a new world!

The square is awestruck. He prostrates himself before the sphere and becomes the sphere's disciple. Upon his return to Flatland, he struggles to preach the "Gospel of Three Dimensions" to his fellow two-dimensional creatures—but in vain.

We are all, in some way, the square before his enlightenment. We have all encountered something that we failed to understand, yet that we smugly believed we understood because we couldn't even conceive of the dimension to which we were blind. Then one day something happens that makes no sense in our two-dimensional world, and we catch our first glimpse of another dimension. My claim is that the human mind perceives a third dimension, a specifically moral dimension that I will call "divinity." I am not assuming that God exists and is there to be perceived. Rather, my research on the moral emotions has led me to conclude that the human mind simply does perceive divinity and sacredness, whether or not God exists. This is an ancient truth that devoutly religious people grasp, and that secular thinkers often do not: that by our actions and our thoughts, we move up and down on a vertical dimension. An implication of this truth is that we are impoverished as human beings when we lose sight of this dimension and let our world collapse down to two dimensions. A further implication is that psychotherapists, who work hard to help people grow, may benefit from understanding this third dimension, on which many people are struggling to grow, whether they know it or not.

Disgust and the Ethic of Divinity

I am a social psychologist. I study the moral emotions, and the first emotion I worked on in graduate school was the emotion of disgust. Disgust is fascinating: it clearly evolved to be a guardian of the mouth, to protect us from eating foods that may be contaminated by dangerous bacteria and parasites. But then why does disgust play an important role in so many religions? Why is there so much legislation in Judaism, Islam, Hinduism, and most traditional societies about issues of "purity and pollution"—issues such as menstruation, food, bathing, disease, and the handling of corpses? My collaborators Paul Rozin and Rick McCauley developed a theory that took seriously the culturally widespread use of disgust as a social regulator, and we posited that disgust has become in part a guardian of the "soul," of the human sense of being special, and different from other animals. It is as though there is a vertical dimension of social cognition, in which the animals are below us and the gods are above. Disgust happens whenever we see someone blur the lower boundary of the category of humanity. We turn away in disgust, and refer to people who disgust us as beasts, animals, or monsters. This vertical dimension was perfectly captured by the seventeenth-century New England Puritan Cotton Mather, who observed a dog urinating at the same time he himself was urinating. Overwhelmed with disgust at the vileness of his own urination, Mather wrote this resolution in his diary: "Yet I will be a more noble creature; and at the very time when my natural necessities debase me into the condition of the beast, my spirit shall (I say at that very time!) rise and soar."

After graduate school, I spent two years working with Richard Shweder, a cultural psychologist at the University of Chicago. Shweder does his research in the Indian city of Bhubaneswar, on the Bay of Bengal. Shweder's research shows that when people think about morality, their moral concepts cluster into three groups, which he calls the ethic of autonomy, the ethic of community, and the ethic of divinity. When people think in terms of the ethic of autonomy, their goal is to protect individuals from harm and grant them the maximum degree of autonomy, which they can use to pursue their own goals. When people think using the ethic of community, their goal is to protect the integrity of groups, families, companies, or nations, and they value virtues such as obedience, loyalty, and wise leadership. When people think in terms of the ethic of divinity, their goal is to protect from degradation the divinity that exists in each person, and they value living in a pure and holy way, free from moral pollutants such as lust, greed, and hatred.

To learn more about the ethic of divinity, I went to India for three months in 1993, to interview priests, monks, and other "experts" on Hindu worship and practice. When I arrived in Bhubaneswar, I quickly found that the ethic of divinity is not just ancient history. Even though Bhubaneswar is physically flat, it has a highly variable spiritual topography with peaks at each of its hundreds of temples. As a non-Hindu, I was allowed into the courtyards of temple compounds; and if I took off my shoes and any leather items (leather is polluting), I could usually enter the antechamber of the temple building. I could look into the inner sanctum where the god was housed, but had I crossed the threshold to join the Brahmin priest within, I would have polluted it and offended everyone. Hindu homes had the same concentric structure as the temples: leave your shoes at the door, socialize in the outer rooms, but never go into the kitchen or the room or area where offerings are made to deities. These two areas are maintained as zones of the highest purity. Even the human body has peaks and valleys: the head and the right hand are pure, while the left hand and the feet are polluted. As I moved around Bhubaneswar, I felt like a square in Spaceland, trying to navigate a three-dimensional world with only the dimmest perception of its third dimension.

The interviews I conducted helped me to see a little better. My main goal was to find out whether purity and pollution were really just about keeping biological "necessities" separate from divinity, or whether these practices had a deeper relationship to virtue and morality. For many of the people I interviewed, purity and pollution practices were really just means to the end of spiritual and moral advancement. For example, when I asked why it was important to guard one's purity, the headmaster of a Sanskrit school (a school that trains religious scholars) responded in this way: "We ourselves can be gods or demons. It depends on karma. If a person behaves like a demon, for example he kills someone, then that person is truly a demon. A person who behaves in a divine manner, because a person has divinity in him, he is like a god. We should know that we are gods. If we think like gods we become like gods, if we think like demons we become like demons."

The headmaster, who of course had not read Shweder, gave a perfect statement of the ethic of divinity. Purity is not just about the body, it is about the soul. If you know that you have divinity in you, you will act accordingly: you will treat people well, and you will treat your body as a temple. In so doing, you will accumulate good karma, and you will come back in your next life at a higher level—literally higher on the vertical dimension of divinity. If you lose sight of your divinity, you will give in to your baser motives. In so doing, you will accumulate bad karma, and in your next incarnation you will return at a lower level—as an animal or a demon. This linkage of virtue, purity, and divinity is not uniquely Indian; Ralph Waldo Emerson said exactly the same thing: "He who does a good deed is instantly ennobled. He who does a mean deed is by the action itself contracted. He who puts off impurity thereby puts on purity. If a man is at heart just, then in so far is he God."

Sacred Intrusions

When I returned to Flatland (the United States), I didn't have to think about purity and pollution anymore. Yet once I had learned to see in three dimensions, I saw glimmers of divinity scattered all about. I began to feel disgust at the American practice of marching around one's own house—even one's bedroom—wearing the same shoes that, minutes earlier, had walked through city streets. I adopted the Indian practice of removing my shoes at my door, and asking visitors to do likewise, which made my apartment feel more like a sanctuary, a clean and peaceful space separated more fully than before from the outside world. I began to notice the language of "higher" and "lower" that people used to talk about morality. I became aware of my own subtle feelings upon witnessing people behaving in sleazy or "degraded" ways, feelings that were more than just disapproval; they were feelings of having been brought "down" in some way myself.

In my academic work, I discovered that the ethic of divinity had been central to public discourse in the United States up until the time of the First World War, after which it began to fade. For example, advice aimed at young people in the Victorian era routinely spoke of purity and pollution. In a widely reprinted book from 1897 entitled What a Young Man Ought to Know, Sylvanus Stall devoted an entire chapter to "personal purity" in which he noted that: "God has made no mistake in giving man a strong sexual nature, but any young man makes a fatal mistake if he allows the sexual to dominate, to degrade, and to destroy that which is highest and noblest in his nature." To guard their purity, Stall advised young men to avoid eating pork, masturbating, and reading novels. By the 1936 edition, this entire chapter was removed.

But as science, technology, and the industrial age progressed, the Western world became "desacralized." At least that's the argument made by the great historian of religion Mircea Eliade. In The Sacred and the Profane, Eliade shows that the perception of sacredness is a human universal. Regardless of their differences, all religions have places (temples, shrines, holy trees), times (holy days, sunrise, solstices), and activities (prayer, special dancing) that allow for contact or communication with something otherworldly and pure. In order to mark off sacredness, all other times, places, and activities are defined as profane (ordinary, not sacred). The borders between the sacred and the profane must be carefully guarded, and that's what rules of purity and pollution are all about. Eliade says that the modern West is the first culture in human history that has managed to strip time and space of all sacredness and to produce a fully practical, efficient, and profane world. It is this world that religious fundamentalists find unbearable, and are sometimes willing to use force to fight against.

Eliade's most compelling point, for me, is that sacredness is so irrepressible that it intrudes repeatedly into the modern profane world in the form of "crypto-religious" behavior. Eliade noted that even a person committed to a profane existence has "privileged places, qualitatively different from all others—a man's birthplace, or the scenes of his first love, or certain places in the first foreign city he visited in his youth. Even for the most frankly nonreligious man, all these places still retain an exceptional, a unique quality; they are the "holy places" of his private universe, as if it were in such spots that he had received the revelation of a reality other than that in which he participates through his ordinary daily life."

When I read this, I gasped. Eliade had perfectly pegged my feeble spirituality, limited as it is to places, books, people, and events that have given me moments of uplift and enlightenment. Even atheists like me have intimations of sacredness, particularly when in love or in nature. We just don't infer that God caused those feelings.

Elevation and Love

My time in India did not make me religious, but it did lead to an awakening. Shortly after moving to the University of Virginia in 1995, I was writing yet another article on how social disgust is triggered when we see people moving "down" on the vertical dimension of divinity. Suddenly it occurred to me that I had never really thought about the emotional reaction to seeing people move "up." I had referred in passing to the feeling of being "uplifted," but had never even wondered whether "uplift" is a real, honest-to-goodness emotion. I began to interrogate friends, family, and students. I found that most people had the same feelings I did, and the same difficulty articulating exactly what they were. People talked about an open, warm, or glowing feeling. Some specifically mentioned the heart. Some people mentioned feelings of chills, or of getting choked up. Most people said that this feeling made them want to do good deeds themselves or become a better person in some way. Whatever this feeling was, it was beginning to look like an emotion worthy of study. Yet there was no research of any kind on this emotion in the psychological literature.

If I believed in God, I would believe that he sent me to the University of Virginia for a reason. At UVA a great deal of crypto-religious activity centers around Thomas Jefferson, our founder, whose home sits like a temple on a small mountaintop (Monticello) a few miles away. Jefferson wrote the holiest text of American history—the Declaration of Independence. He also wrote thousands of letters, many of which reveal his views on psychology, education, and religion. After arriving at UVA, having an Eliade-style crypto-religious experience at Monticello, and committing myself to the cult of Jefferson, I read a collection of his letters. There I found a full and perfect description of the emotion I had just begun thinking about.

In 1771, Jefferson's relative Robert Skipwith asked him for advice on what books to buy for the personal library he hoped to build. Jefferson, who loved giving advice almost as much as he loved books, happily obliged. Jefferson sent along a catalogue of serious works of history and philosophy, but he also recommended the purchase of fiction. In his day, plays and novels were not regarded as worthy of a dignified man's time, but Jefferson justified his unorthodox advice by pointing out that great writing can trigger beneficial emotions:

When any . . . act of charity or of gratitude, for instance, is presented either to our sight or imagination, we are deeply impressed with its beauty and feel a strong desire in ourselves of doing charitable and grateful acts also. On the contrary, when we see or read of any atrocious deed, we are disgusted with its deformity, and conceive an abhorrence of vice. Now every emotion of this kind is an exercise of our virtuous dispositions, and dispositions of the mind, like limbs of the body, acquire strength by exercise.

Jefferson went on to say that the physical feelings and motivational effects caused by great literature are as powerful as those caused by real events. He considered the case of a contemporary French play, asking whether the fidelity and generosity of its hero does not "dilate [the reader's] breast and elevate his sentiments as much as any similar incident which real history can furnish? Does [the reader] not in fact feel himself a better man while reading them, and privately covenant to copy the fair example?"

This extraordinary statement is more than just a poetic description of the joys of reading. It is also a precise scientific definition of an emotion. In emotion research, we generally study emotions by specifying their components, and Jefferson gives us most of the major components: an eliciting or triggering condition (displays of charity, gratitude, or other virtues); physical changes in the body ("dilation" in the chest); a motivation (a desire of "doing charitable and grateful acts also"); and a characteristic feeling beyond bodily sensations (elevated sentiments). Jefferson had described exactly the emotion I had just "discovered." I began to call this emotion "elevation," a word Jefferson himself had used to capture the sense of rising on a vertical dimension, away from disgust.

For the past seven years I have been studying elevation in the lab. My students and I have used a variety of means to induce elevation and have found that video clips from documentaries about heroes and altruists, and selections from the Oprah Winfrey show, work well. In most of our studies, we show people in one group an elevating video, while people in the control condition see a video designed to amuse them. So far we have found that elevation makes people feel warm, calm, and loving feelings. It makes people want to become better themselves—it motivates them to rise on the dimension of divinity. It seems to open people up, releasing the milk of human kindness.

In our most exciting discovery, my student Jen Silvers found that elevation seems quite literally to release milk: she brought lactating women into the lab with their babies. One half of the women watched an elevating video; the other half watched a comedy video. The women who were elevated were much more likely to nurse their babies in the minutes afterwards, or to leak milk into a nursing pad. Why? Because elevation may trigger the production of the hormone oxytocin, and oxytocin is the direct trigger for milk release. So those warm fuzzy feelings you get in your chest when you see someone do something kind, loving, or beautiful may reflect real physiological changes in your heart and lungs brought on by oxytocin.

Awe, Transcendence, and the Satanic Self

Virtue is not the only cause of movement on the third dimension. The vastness and beauty of nature similarly stirs the soul. Immanuel Kant explicitly linked morality and nature when he declared that the two causes of genuine awe are "the starry sky above and the moral law within." The New England transcendentalist movement was based directly on the idea that God is to be found in each person and in nature, so spending time alone in the woods is a way of knowing and worshiping God. Ralph Waldo Emerson, a founder of the movement, wrote: "Standing on the bare ground, — my head bathed by the blithe air and uplifted into infinite space, — all mean egotism vanishes. I become a transparent eyeball; I am nothing; I see all; the currents of the Universal Being circulate through me; I am part or parcel of God."

There is something about the vastness and beauty of nature that makes the self feel small and insignificant, and anything that shrinks the self creates an opportunity for spiritual experience. Sages (and psychologists) have long written about the many ways in which people feel as though they have multiple selves or intelligences which sometimes conflict. This division is often explained by positing a soul—a higher, noble, spiritual self—which is tied down to a body—a lower, base, carnal self. It's as though the soul were a helium balloon tied to a brick. The soul escapes the body only at death, but before then, spiritual practices, great sermons, and awe at nature can give the soul a taste of the freedom to come.

Awe is the emotion of self-transcendence. My friend Dacher Keltner, an expert on emotion at the University of California at Berkeley, proposed to me a few years ago that we review the literature on awe and try to make sense of it ourselves. We found that scientific psychology had almost nothing to say about awe. It can't be studied in other animals or created easily in the lab, so it doesn't lend itself to experimental research. But philosophers, sociologists, and theologians had a great deal to say about it. As we traced the word "awe" back in history, we discovered that it has always had a link to fear and submission in the presence of something much greater than the self.

Keltner and I concluded that the emotion of awe happens when two conditions are met: a person perceives something vast (usually physically vast, but sometimes conceptually vast, such as a grand theory, or socially vast, such as great fame or power); and the vast thing cannot be accommodated by the person's existing mental structures. Something enormous can't be processed, and when people are stumped, stopped in their cognitive tracks while in the presence of something vast, they feel small, powerless, passive, and receptive. They often (though not always) feel fear, admiration, elevation, or a sense of beauty as well. By stopping people and making them receptive, awe creates an opening for change, and this is why awe plays a role in most stories of religious conversion.

In what is still the greatest work on the psychology of religion, William James analyzed the "varieties of religious experience," including both rapid and gradual religious conversions, as well as experiences with drugs and nature. James found such extraordinary similarity in the reports of these experiences that he thought they revealed deep psychological truths. One of the deepest truths, James said, was that we experience life as a divided self, torn by conflicting desires. Religious experiences are real and common, whether or not God exists, and these experiences often make people feel whole and at peace. In the rapid type of conversion experience the old self, full of petty concerns, doubts, and grasping attachments, is washed away in an instant, usually an instant of profound awe. People feel reborn and often remember the exact time and place of this rebirth, the moment when they surrendered their will to a higher power and were granted direct experience of deeper truth. After such rebirth and revelation, fear and worry are greatly diminished and the world seems clean, new, and bright. The self is changed in ways that any priest, rabbi, or psychotherapist would call miraculous.

Yet the self is one of the great paradoxes of human evolution. Like the fire stolen by Prometheus, it made us powerful but exacted a cost. In The Curse of the Self, the social psychologist Mark Leary points out that many other animals can think, but that none, so far as we know, spend much time thinking about themselves. Only a creature with language has the mental apparatus to focus attention on the self, to think about the self's invisible attributes and long-term goals, to create a narrative about that self, and then to react emotionally to thoughts about that narrative. Leary suggests that this ability to create a self gave our ancestors many useful skills, such as long-term planning, conscious decision-making, self-control, and the ability to take other people's perspectives. These skills are all important for enabling human beings to work closely together on large projects, and so the development of the self may have been crucial to the development of humanity's extreme sociality. But by giving us each a world inside our own heads, a world full of simulations, social comparisons, and reputational concerns, the self also gave us each our own personal tormenter. We all now live amid a whirlpool of inner chatter, much of which is negative, most of which is useless.

Leary's analysis shows why the self is a problem for all major religions: the self is the main obstacle to spiritual advancement, in three ways. First, the constant stream of trivial concerns and egocentric thoughts keeps people locked in the material and profane world, unable to perceive sacredness and divinity. This is why Eastern religions rely heavily on meditation, an effective means of quieting the chatter of the self. Second, spiritual transformation is essentially the transformation of the self, weakening it, pruning it back—in some sense, killing it—and often the self objects. Give up my possessions and the prestige they bring? No way! Love my enemies, after what they did to me? Forget about it. And third, following a spiritual path is invariably hard work, requiring years of meditation, prayer, self-control, and sometimes self-denial. The self does not like to be denied, and is adept at finding reasons to bend the rules or cheat. Many religions teach that egoistic attachments to pleasure and reputation are constant temptations to leave the path of virtue. In a sense, the self is Satan, or, at least, Satan's portal. For all these reasons, the self is a problem for the ethic of divinity. It stands in the way of spiritual and moral progress.

Divinity in Therapy

What does all of this have to do with psychotherapy? Here are three thoughts, three possible ramifications of these ancient ideas for the modern therapeutic community.

First, nearly all Americans are religious to some degree, yet psychologists are much less religious than the average American. This means that there may often be a mismatch between the "dimensionality" of the client and the therapist. Secularly trained therapists might not recognize the striving to "rise" on the dimension of divinity. (Even secular clients may have such feelings without understanding them.)

Second, the modern psychological emphasis on self-esteem, self-knowledge, and self-development more generally might be counterproductive. Particularly for religious clients who would like to weaken their grasping, petty selves, encouragement to strengthen the self and satisfy the self's needs might be in conflict with other ways of growing and improving.

And third, this perspective on divinity may help therapists to find new tools, such as the emotions of elevation and awe, that may be powerful adjuncts to the therapeutic process. Might talking about role models and moral exemplars create windows of opportunity? Might self-transcendent emotions create brief "melting moods" in which the client finds him or herself "washed and soft of heart and open to every nobler leading"—that is, to leading upwards on the dimension of divinity?

From the book The Happiness Hypothesis by Jonathan Haidt. Copyright © 2005. Reprinted by arrangement with BasicBooks, a member of the Perseus Books Group (www.perseusbooks.com). All rights reserved.

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