With the return of our soldiers from Iraq and Afghanistan and an increasing concern about how mental health professionals may help these courageous men and women overcome the traumatic effects of war has come a resurgence of public interest in an intervention called mindfulness. Mindfulness is a form of meditation that actually has been taught for centuries in many of the world’s greatest religions. In the 1980’s, Jon Kabat-Zinn introduced mindfulness skills as a way of helping medical patients manage chronic pain and symptoms of anxiety. More recently, researchers and clinicians have found mindfulness techniques effective in reducing symptoms of depression, eating disorders, borderline personality disorder, and PTSD.
But what exactly is mindfulness? In their book The Dialectical Behavior Therapy Skills Workbook, McKay, Wood, & Brantley (2007) define mindfulness as “the ability to be aware of your thoughts, emotions, physical sensations, and actions—in the present moment—without judging or criticizing yourself or your experience” (p. 64). There are two important aspects of this definition. First, you need to learn to discern your experience as you live it on a number of different levels: what you are thinking, what you are feeling, how your body is responding, and what you are doing. Second, you need to learn to recognize that multi-faceted experience without judging yourself, anyone else, or the situation. You need to shut off the internal negative conversations that you often automatically have with yourself. The basic tenet of mindfulness is that the more skilled you become, the more control you feel over your moment-to-moment experience and, thus, your life.
Mindfulness skills training may be a component of individual or group therapy. For example, Marsha Linehan (1993) has included mindfulness as a core skill in her dialectical behavior therapy-an effective treatment intervention originally developed for borderline personality disorder. Many VA hospitals have developed intervention programs for their veterans that include mindfulness skills training. Some intensive inpatient or residential psychiatric treatment facilities include mindfulness skills interventions in their treatment of severe mental disorders and substance abuse. And, some excellent self-help books, such as the one cited above by McKay and associates, have recently been published.
In his 1997 book, Taming the Tiger, Dr. Peter Levine introduced Somatic Experiencing as a short term and naturalistic form of therapy aimed at healing the psychological and physical sequelae of both single-episode trauma (e.g., a natural disaster, a car accident, a rape) and ongoing developmental trauma (e.g., ongoing childhood neglect ). Normally, when an individual is confronted with such traumatic stress, the autonomic nervous system (ANS) is activated to provide the bodily mechanisms for survival-orientation to the danger, and the fight, flight, or freeze behavioral response to the danger. Dr. Levine proposed that symptoms of post-traumatic stress disorder (PTSD) and other psychological and physical problems associated with such stress arise in humans because the ANS becomes dysregulated and the physical tension normally associated with the adaptive ANS response is not fully discharged following the trauma.
Somatic experiencin (SE) therapy is typically conducted in a face-to-face session similar to traditional psychotherapy. The SE client is encouraged by the therapist to slowly explore the nature of the trauma and to focus on sensations (arousal or freezing) that are stored in the body. Through a “titration” process (use of small, incremental steps), the therapist helps the client move between an experience of physical tension (dysregulation) and discharge of the tension (a return to a state of regulation). The client then renegotiates the trauma, rather than repeatedly reliving or physically re-enacting it.
To family members, friends, and other observers, it may seem to be a “no-brainer” that a woman who is abused by her partner should leave the relationship. But, in fact, research indicates that leaving a relationship that involves intimate-partner violence is a complex and, often, dangerous process. First, empirical studies suggest that a woman (and, at times, her children) may be in greatest physical danger when she is attempting to negotiate separation from an abusive partner. In fact, it has been reported that the most deadly time for a woman is when the batterer believes that she intends to end the relationship.
Second, separation is a process rather than a one-time event. It is not unusual for a woman to consider physically leaving her relationship and then reconsider; it is not unusual for a woman to actually arrange to move out and then cancel all plans. And, according to a new University of Illinois journal article describing the research of Lyndal Khaw, there are several stages of the leaving process, each one complicated by unclear boundaries. For example, even if a woman physically leaves and establishes a separate living environment, practical and/or legal issues often necessitate her continued contact with her partner. If the couple has children, court-ordered child visitation with the partner contributes to the confusion over the partner’s physical presence in the woman’s life. Further, in addition to the issues of physical separation, the woman must negotiate emotional separation from her partner, including memories of more positive times with her partner, her dreams of a happy family, and other emotional ties to her partner and to the relationship.
Mental health professionals who are experienced in the assessment and treatment of domestic violence can offer crucial, and, at times life-saving, assistance to the woman caught in intimate-partner violence, as well as to her family and friends.
Over the last several years, researchers have reported that depression is associated with life-threatening conditions. According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR, 2000), up to 15% of individuals with severe Major Depressive Disorder die by suicide. In addition, depression frequently co-occurs with other mental disorders that carry significant health risks (e.g., substance-related disorders and eating disorders). And, depression has been linked to diabetes and to heart disease, two diseases known to pose serious threats to the lives of patients. The question that has motivated further research is whether depression directly increases the risk for such life-threatening conditions or is simply a correlate of the condition (e.g., individuals have a genetic predisposition to both depression and the condition).
A recent 12-year longitudinal study of more than 1,200 men by Jeffrey Scherrer (Washington University and the Veterans Affairs Medical Center in St. Louis, Missouri) and his colleagues found that depression directly contributes to (and almost doubles) the risk of heart disease. Their study controlled for genetic factors (recently thought to explain the depression-heart disease association) by including both identical and fraternal twins in the sample of men. Remarkably, their findings indicated that depression contributed to the risk of heart disease as much as other well-documented factors such as high cholesterol, obesity, or diabetes.
Researchers and clinicians responding to Scherrer et al.’s findings caution that further research is required to address some critical implications of this study. First, the study participants were all men. The question remains whether women would evidence similar results. Second, further research is required to understand the mechanism of the apparent effects of depression on the risk for heart problems. For example, does depression contribute to a patient’s more sedentary lifestyle or greater subjective experience of stress which over years contributes to heart disease? And third, we need research to provide evidence as to whether treating depression in individuals will result in a decreased risk of heart problems.
Bipolar disorder is a complex mood disorder. Patients suffering from the disorder experience episodes of mania, hypomania, major depression and/or mixed moods. Once considered an adult disorder, more recent research and anecdotal reports suggest that the onset of the disease for many may begin in childhood, adolescence, or early adulthood. Unfortunately, evidence is also emerging that the diagnosis of bipolar disorder may be missed or confused for other disorders in many younger patients. In such cases, the young patients may be given medications for ADHD or depression which can trigger symptoms of mania. In addition to inappropriate (or even dangerous) treatment, failure to accurately diagnose bipolar disorder in younger patients can lead to years of misery, feeling misunderstood, school and social difficulties, legal problems, substance abuse, and loss of trust in the mental health profession. Actress Patty Duke poignantly reported her personal experience at this year’s annual meeting for the American Psychiatric Association in Washington, D.C. She suffered for more than 15 years before being diagnosed with bipolar disorder at the age of 35. Recent studies of adult bipolar patients suggest that about 60% of them experienced their first symptoms before 18 years of age.
Mental health professionals who specialize in the assessment and treatment of bipolar disorders disagree over the specific symptom clusters that should be diagnosed as bipolar in younger patients. Some suggest that many younger patients previously identified as hyperactive or evidencing behavior of conduct disorder are actually suffering from bipolar disorder. Others are more cautious, warning that longitudinal studies of children diagnosed with ADHD and aggressive behavior suggests that only about 1/3 develop adult bipolar disorder (according to DSM-IV TR criteria). Part of the confusion appears to stem from the fact that bipolar disorder itself varies greatly in its symptom presentation and it also often co-exists with other disorders (like anxiety and ADHD).
There is not an easy solution to this conundrum. Individuals suffering from symptoms of volatile and unstable moods, provocative, impulsive, and/or aggressive behavior, substance and/or computer addiction, and changes in sleeping patterns should seek a formal assessment from a mental health professional familiar with the diagnostic issues described above. One factor that is especially important in such an assessment is an understanding of the individual’s family history. Twin and adoption research provide strong evidence of a genetic predisposition for Bipolar I disorder. Estimates of the risk of developing Bipolar I disorder if the individual has a first-degree relative with the disorder ranges from 4% to 24%, according to the DSM-IV TR.
