Psychotherapy Brown Bag

Dialectical Behavior Therapy Skills Part 2: Interpersonal Effectiveness

by Michael D. Anestis, M.S.

Yesterday, I began a discussion of DBT by providing an introduction to mindfulness, the core skills and first module of the treatment.  Today, I will shift my focus to the second module, interpersonal effectiveness.  Before doing so, however, a brief description of what goes on in a skills training group seems worthwhile.  Group sessions last two hours and typically include two co-leaders.  During the first hour, the group members take turns briefly explaining a time when they successfully implemented a DBT skill in the prior week as well as a time when they were less successful in utilizing a DBT skill.  Importantly, this is not treated as brief individual therapy sessions for each group member - that type of interaction is meant for the individual therapy component of DBT.  Instead, this is a teaching tool, an opportunity for clients to practice speaking about emotional events in an objective, fact-based manner and for group members to problem solve better ways for implementing certain skills into their lives.  Group members organize their information during the week on "diary cards," which list all of the DBT skills and provide space for the group member to indicate how often the skill was used and to list important notes.  The second hour of the group session is devoted to teaching new skills.  Co-leaders present material as though teaching a class, often utilizing Powerpoint presentations and providing handouts from the Skills Training Manual for Treating Borderline Personality Disorder. 
    When a skills training group first forms, they begin with the first module of treatment, mindfulness.  After completing this module, the group transitions into interpersonal effectiveness.  Upon completion of the interpersonal effectiveness module, the group reviews mindfulness skills before moving onto module three, emotion regulation.  Mindfulness is then reviewed again prior to beginning the fourth module, distress tolerance.  Generally speaking, a skills training group will complete two full cycles in a calendar year.  Clients are told to expect to remain in treatment for two years, quite long for an empirically supported treatment.
    The interpersonal effective module is fairly broad and involves a variety of disparate skills, so this article will serve as an introduction to the topic best supplemented by further reading of the materials published by Marsha Linehan and her colleagues (see our references page or online store for recommended products for suggested readings).  Borderline personality disorder (BPD), the disorder for which DBT was originally designed to treat, is characterized by stormy interpersonal relationships.  Many studies have examined this point empirically and found evidence supportive of this diagnostic criteria.  For example, Russell, Moskowitz, Zuroff, Sookman, and Paris (2007) found that individuals with BPD were more submissive and quarrelsome in interpersonal relationships than were individuals who did not meet criteria for a mental illness.  Additionally, Hill and colleagues (2008) found that, among DSM disorders (both Axis I and Axis II), BPD was the only disorder that specifically predicted dysfunctional romantic relationships and that individuals with BPD reported similar dysfunction in peer and work relationships.  Selby, Braithwaite, Joiner, and Fincham (2008) found that perceived emotional invalidation - the tendency to have one's emotional responses criticized and/or trivialized - partially explained the relationship between BPD and romantic relationship dysfunction.  So, given all of this evidence, the need for the development of more effective interpersonal skills appears quite clear.
     The skills that comprise the interpersonal effectiveness module are quite varied.  One key point that the group members are taught is that, in any interpersonal interaction, there are a variety of priorities that must be managed and how those priorities are attended to will, in large part, dictate the degree to which an individual feels like she effectively managed the encounter.  Specifically, Linehan points toward three types of effectiveness that must be considered in an interpersonal interaction:

1. Objectives effectiveness
2. Relationship effectiveness
3. Self-respect effectiveness 

    Objectives effectiveness refers to prioritizing the accomplishment of clear, objective goals (e.g., obtaining a raise).  Relationship effectiveness refers to the prioritizing of maintaining a conflict-free relationship (e.g., ensuring your boss still likes you).  Self-respect effectiveness refers to prioritizing acting within your own principles so as to ensure that you feel comfortable with how you approached the situation (e.g., standing up for yourself, even if it costs you the raise and leaves your boss angry).  In any situation, all three priorities need to be considered and, to some degree, rank-ordered.  Whichever priority is of greater importance to the individual in that particular situation needs to be the primary focus, as regardless of the outcome of the situation, if that priority is addressed effectively, the individual is likely to feel reasonably satisfied with his role in the interaction.
    One of the reasons this skill is particularly effective is that it forces individuals to consider their desired outcomes prior to taking action.  Individuals with any of the disorders DBT has been shown to treat effectively (BPD, bulimia, and binge eating disorder) are typically characterized by a tendency to act impulsively when upset.  As such, they often act without thinking about consequences due to an overpowering urge to reduce distress.  As a result, conflicts become more likely and relationships become strained (or, alternatively, relationships are destructively fostered through undue submissions when the individual does not consider how being passive will impact his self-respect).
    Identifying priorities is certainly a healthy tendency, but realizing this is important is not sufficient.  Additionally, clients must learn how to go about enacting this interpersonal approach in their own lives.  The interpersonal effectiveness module addresses this in a variety of ways, but I will focus on one particular set of skills - "DEAR MAN."  DEAR MAN is an acronym comprised of particular methods for successfully navigating a potentially difficult interpersonal interaction.  The components of DEAR MAN are as follows:

Describe
Express
Assert
Reinforce

(stay) Mindful
Appear confident
Negotiate

    To explain this skill, I will use a hypothetical example of Sarah, who approaches her roommate, Jessica about Jessica's refusal to wash her own dishes.  The first skill, describe asks Sarah to explain the situation to Jessica in concrete terms, without inserting her own interpretations or feelings (e.g., "Jessica, lately, I've noticed that you are piling your dishes in the sink rather than washing them."). 
    Express asks Sarah to explain how this situation makes her feel.  Notice, Sarah is asked to separate her feelings from the objective facts.  Additionally, Sarah is asked to explain how she feels rather than assuming that Jessica will just know on her own (e.g., "This is frustrating to me because a clean house keeps my stress levels down."). 
    The assert skill asks Sarah to clearly state her desired outcome (e.g., "What I would really like would be for us both to clean our dishes after we eat so they don't pile up and food does not have time to harden and become difficult to remove.").  In this skill, it is important to be mindful of your tone of voice and to remain calm and composed.
Reinforce asks Sarah to explain why her goals will be beneficial (e.g., "If we do this, I will feel significantly less stressed at night and will be much less likely to snap at you and be irritable.").  In doing this, Sarah provides motivation for Jessica to consider her proposal. 

The stay mindful skill reminds Sarah to keep her focus on her goal.  Oftentimes, in potentially uncomfortable interactions, the other individual will either try to shift the focus of the conversation by bringing up other topics (e.g., "Well, you haven't been getting me your share of the rent on time, so I don't think you're in a position to criticize me.") or intimidate the initiator of the conversation by raising their voice, making threats, or calling names.  If Sarah takes the bait, either fighting back by calling names or yelling or discussing the new topic, her goal becomes lost and unlikely to be accomplished.  As such, she needs to not engage with Jessica when she tries such tactics.  Instead, she is instructed to ignore inflammatory comments and to act like a "broken record" by consistently reiterating her point.  In group, Sarah will learn to do this tactfully, taking care not to appear hostile in her response (e.g., "It sounds like there are some things you'd like for me to do differently too, but we're discussing the dishes right now.  Why don't we resolve this first and then we can figure out a plan for the rent check.").
    The appear confident skill essentially preaches the mantra of "fake it until you make it."  The appearance of confidence can have a significant impact upon the way a person is seen and how he or she is responded to during a conversation.  If Sarah is looking at the ground and stumbling over her words, Jessica will be less likely to take her seriously.  If, on the other hand, Sarah maintains eye contact and appears composed, Jessica will be more likely to consider her points and respond with respect.
    The final DEAR MAN skill, negotiate, teaches Sarah to give in order to get.  In other words, DEAR MAN is a method for increasing the likelihood that a fair outcome will be attained in an interpersonal interaction.  It is not a tool for making unsightly demands or ignoring the needs of others.  As such, by using the negotiate skill, Sarah will acknowledge Jessica's perspective and work with her towards a resolution, perhaps even asking Jessica what she thinks would be a good solution.
    As you have likely noticed at this point, the interpersonal effectiveness module is heavily reliant upon the idea that interpersonal situations are more successful when an individual plans ahead and proactively considers the potential utility of each course of action.  There are several more skills in this module as well as more detailed descriptions of the skills we covered in this article and we encourage you to read further as well as to comment here on DBT interpersonal effectiveness skills.  In part three of this series, we will cover emotion regulation skills.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Dialectical Behavior Therapy Skills Part 1: Mindfulness

by Michael D. Anestis, M.S.

In a recent post on distress tolerance, I mentioned that we would be discussing dialectical behavior therapy (DBT; Linehan, 1993a; Linehan, 1993b) in a series of future posts.  Much like our ongoing series of posts on CBT and common factors across therapeutic modalities, the intention is to discuss DBT one component at a time so as to give as clear a description of the treatment as possible.  Without question, DBT is the most fulfilling approach to therapy in which I have been trained - I cherish the experiences I've had co-leading skills groups - but it is also the most complex, so I will make an effort to explain this from multiple angles and invite comments and questions regarding points of these articles that require further explanation.
    DBT, which has empirical support as a treatment for borderline personality disorder, bulimia nervosa, and binge eating disorder (Linehan, 1998; Safer, Lock, & Coutourier, 2007; Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan, 2001), requires that clients partake in individual therapy as well as group therapy, in which skills are taught and practiced with other clients.  The skills training is comprised of four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.  In today's article, I will focus on mindfulness, which is a pivotal facet of all phases of DBT.
    Defining mindfulness is fairly difficult, but at its core it involves learning to control your attention and keep your focus entirely on the present moment.  Every now and then, everybody finds themselves ruminating or worrying in response to stress.  We even do these things in the absence of stress at times.  Our focus shifts from what is in front of us to what happened earlier or what might happen when we leave the current situation.  Mindfulness skills in DBT are discussed as a way to take a step back when upset so as to allow intense emotional experiences to run their course naturally, enabling clients to make better behavioral decisions and remain calmer while responding only to what is directly in front of them.
    I know this seems fairly abstract, but bear with me because these skills can be applied in anyone's life, regardless of whether or not they meet criteria for a disorder for which mindfulness is an empirically supported treatment component.  Clients are taught mindfulness through a series of skills and exercises.  Marsha Linehan, in her Skills Training Manual for Treating Borderline Personality Disorder, explains the role of mindfulness in treatment as a way to find balance between reason and emotion in a state of mind she refers to as "wise mind."  In wise mind, she explains, individuals are not controlled by their emotions or reason, but instead they acknowledge the presence of both and synthesize them into a single, composed state of mind.  In wise mind, an individual does not try to reason away her emotions (e.g., "you shouldn't feel sad - other people aren't sad about this") or use emotions to blunt her reason (e.g., "I don't care what the consequences are right now, I'm sad and that's all that matters).  Balance requires that both sides be considered, allowing for a better resolution (e.g., "I feel sad right now, but I need to find a way to feel better that won't cause me bigger problems").  Linehan teaches clients that they can attain the balance of wise mind through the "what" skills and "how" skills. 
    The "what" skills include three distinct approaches: observing, describing, and participating.  Observing, although seemingly simplistic, is extremely difficult, as it involves simply observing your environment without using words to describe what you perceive.  The rationale for this is to teach clients to slow down their automatic thoughts and reduce their vulnerability to subsequent negative emotions.  Describing is the reaction to observing and involves applying words to your perceptions.  Linehan is careful to point out, however, that these words should describe only facts, not interpretations.  In other words, an effective description of the next lecture I will give in my Abnormal Psychology class would be: "the teacher is describing the symptoms and treatments of various personality disorders.  He is detailing the DSM criteria and explaining what he refers to as the strengths and weaknesses of each diagnosis."  If that description had read: "this lecture is shockingly boring and the teacher lacks the basic social skills required to speak to a room full of students," this would be less consistent with the goals of the describing skill, which aims to teach clients to see thoughts as thoughts rather than facts and to separate interpretations from actualities.  The participation skill teaches clients to fully engage in their current activity rather than allowing their mind to wander elsewhere.  Whereas observing and describing can, at least at first, seem somewhat bizarre to clients, this skills is one with which most readily identify, as we can all think of times during which we have been doing something, but our mind has been elsewhere.  Have you ever talked on your cell phone while driving and suddenly realized that you do not remember the last ten minutes of your drive?  Have you ever been in a conversation with somebody and realized that you had spent the previous minute replaying another conversation in your head and now have no idea what the person is talking about?  Has a movie ever reminded you of something, taken your mind back to a memory, and left you clueless as to what happened in the last scene?  In these examples and countless others, participation is lacking.  The individual is so focused on a scenario unfolding his head that he simply is not attending to the stimuli in front of him.  What's frustrating about this is that, as we ignore our environment and focus on the scenario in our mind, we often become increasingly upset.  Given that nothing in our environment is causing us to become upset and we are responding only to our own thoughts, this is obviously an unfortunate and unhealthy situation.  As such, the participation skill teaches clients to focus their attention only on what is in front of them.  When other thoughts enter their heads, the clients are taught not to judge themselves for losing focus, but rather to simply acknowledge that their mind had wandered and to bring their thoughts back to the current environment.
The "how" skills, which are methods by which clients can accomplish the goals of the "what" skills, consist of three components: the nonjudgmental skill, focusing on one thing in the moment, and being effective.  The nonjudgmental skill teaches us to dampen our natural tendency to apply evaluative labels to our experiences.  The rationale for this is that, quite often, our labels are based on distorted automatic thoughts, are vague, and leave us without any guidance as to how to resolve the situation.  In this sense, the skill is quite similar to cognitive restructuring, which we described in detail in a prior article.  Instead of thinking "I'm stupid," a student is trained to think "I received a failing grade on this test, and I am frustrated by that, so I need to meet with my teacher and change my approach in order to reach the final grade that I need."  In teaching clients to focus on one thing in the moment, the second "how" skill, DBT again emphasizes the importance of breaking ruminative cycles that are certain to increase the longevity and severity of our negative emotions.  In the third "how" skill, being effective, clients are taught to shift their focus away from how they wish things were, instead choosing to engage in behaviors that are the most likely to help them accomplish their goals.  The rationale behind this skill, much like several of the others, is to help the client prioritize proactive solutions to problems and to diminish the tendency to lose control of their thoughts and spiral into rumination.
    Okay, having explained the mindfulness skills as described in the Skills Training Manual for Treating Borderline Personality Disorder, I suspect that this topic still remains a bit more theoretical than most readers anticipated given the topics we have covered thus far on PBB.  That being said, let's try and consider what I described above in the context of every day life.  All of us can relate to times when we have been upset and become lost in our own thoughts.  Invariably, even when such thought spirals feel productive at the time, we eventually realize that we were exerting very little control over what we were thinking about at the moment.  Mindfulness teaches how to attain that control.  The best way for anyone to fully understand the meaning of mindfulness is through practice.  As such, I want to conclude this article by explaining a few quick mindfulness exercises.  Ideally, I would love for this to result in at least two types of responses.  First, responses from readers regarding their varying levels of success with the exercises - what went well, what did not.  Second, responses from readers regarding other mindfulness exercises worth trying.  Not everyone responds to each exercise the same way.  The key is finding something that works for you that you can apply in just about any situation when you start feeling upset.  Learning to do so will help you prevent overly powerful emotional spirals before they reach their peak.

1. Focus on breath:  In this exercise, often the first one taught in a group, your aim is to focus only on your breath. Feel the air as it passes down to your lungs.  Notice everything about the physical sensations associated with the passage of air with each breath.  Each time you complete a cycle of inhale/exhale, count it.  Start with one, count up to ten, and then reverse back down to one.  Here's the trick though, any time you have a thought other than a description of your breath and the number of breaths you have taken, start over again.  That includes thoughts like "this is hard," "I'm focusing on my breath right now," and "mindfulness is crazy."  Remember, we're being nonjudgmental here, so do not be critical of yourself.  Simply notice that a thought crept in and move your attention back to your breath.  It is extremely difficult if not impossible to accomplish a one to ten and back to one progression of counting, so the goal isn't really to finish, but rather to give you a neutral stimulus to focus on rather than your own emotionally charged thoughts.  After a few minutes of doing this (maybe even less), you'll likely feel less emotional and be in a better position to address whatever was making you upset.  There is nothing magical about your breath, but focusing on your breath instead of ruminating is a sure fire way to attain wise mind and thus put yourself in a position to make healthy behavioral choices.
2. Focus amidst distractions:  We often need to use mindfulness skills when the world around us is chaotic.  As such, this skill teaches you to chose a thought amidst stimuli competing for your attention.  Choose a song to play.  Before you start the song, decide on where you will focus your attention, but choose something other than the song.  In other words, I might choose to focus on an image in my head of the beach on Sanibel or on a box of tissues on the table in front of me.  As the song plays, maintain your focus on the thought you chose.  Observe and describe it, using only facts and withholding judgment.  Each time your thoughts wander, pull them back to your original thought rather than allowing the song to dictate your focus.
3. Mindfully attend to a pet:  If you have a pet, they will love this one.  Spend the next five minutes petting your animal.  Notice what its fur feels like, the pace at which it is breathing, the color of its eyes, or anything else about the pet that you notice.  Do not allow your mind to wander back to memories with your pet.  Keep your focus entirely on the sensations present in that moment.

    In all likelihood, as you attempt these skills, you'll find that it is exceptionally difficult to maintain complete control over your attention.  You'll notice things that you previously did not attend to, like the clicking of a clock, the sound of a fan, or the temperature of the surface on which your hand is resting. Now imagine how hard it would be to do this if you were upset.  Taking it one step further, imagine how difficult it is for somebody who has difficulties regulating their emotions in general.  These skills require patience and practice, so do not expect to notice changes overnight, but trust that mindfulness can offer impressive reductions in stress and an increased tendency to fully enjoy your surroundings.
    If you want to learn more about mindfulness, we suggest several resources.  Jonathan Kaplan runs a fantastic blog entitled Urban Mindfulness.  Additionally, Marsha Linehan's Skills Training Manual for Treating Borderline Personality Disorder and Cognitive-Behavioral Treatment of Borderline Personality Disorderand Thich Nhat Hahn's The Miracle of Mindfulness are all available through our online store for recommended products.  In our next DBT skills article, we will discuss the interpersonal effectiveness module, but we fully intend to devote more time to discussing mindfulness in future articles.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Common factors of therapy: Part 2, insight

by Joye C. Anestis, M.S.

When writing about catharsis as a common factor of therapy, I had a pretty easy time finding the appropriate research and coming to some conclusions.  Trying to write about insight, however, is another story.  It is incredibly difficult to find good research on the role insight in psychotherapy.  A lot of individuals have written theoretical articles about insight - defining it, discussing it, etc. - but very few have systematically examined it as a factor which cuts across therapies.

One of the difficulties in studying insight is the difficulty defining it and measuring it in a reliable manner.  Some clinical psychologists view insight as the achievement of understanding into the sources of one's problems and difficulties.  Others view it as the gaining understanding into the presence and symptoms of one's mental illness.  And once a construct definition can be agreed upon, the question then becomes: how do we measure it?  Is it more appropriate to get client ratings of insight, or are therapists the best assessors of client insight?  These basic questions have yet to be answered, really crippling the literature on insight.

Another complication inherent in a discussion of insight and the study of insight is the fact that different theoretical approaches view insight very differently.  For example, psychodynamic approaches to psychotherapy believe that insight is the endgame of therapy.  Through the use of psychodynamic techniques, the client will gain insight into the origins of their symptoms and, thus, be cured of them.  In essence, insight causes improvement (symptom alleviation).  In contrast,  cognitive conceptualizations imply that insight comes as a result of symptom alleviation.  Insight is not viewed as a goal or an active treatment component, but as a byproduct of improvement (insight is actually rarely discussed in the cognitive therapies).  Furthermore, some therapies emphasize insight into past events, and others focus on insight into current events.  These varying conceptualizations further muddy the research picture.  Actually, I question the inclusion of insight as a common factor present in all forms of therapy, if it is viewed differently in each type of therapy.  Do you have any thoughts on this?

In spite of these methodological problems, what do we know about the role of insight in different forms of psychotherapy? I was only able to find a handful of studies which examined the hypothesis that insight causes symptom reduction.  Kivlighan, Multon, & Patton (2000) found a significant linear increase in insight and corresponding decrease in target distress in time-limited psychoanalytic counseling.  It should be noted that the sample consisted of 12 subjects who sought counseling for "relationship difficulties".  In a review of the role of insight in bipolar disorder, McEvoy & Wilkinson (2000) note that insight improves with treatment (in this case, medication treatment). Eisen et al. (2001) found that insight improved as symptoms reduced in sample with obsessive-compulsive disorder. 

The remainder of the studies examine insight as a mechanism for treatment compliance.  For example, Rathod, Kingdon, Smith, & Turkingdon (2005) randomized patients with schizophrenia (n = 422) to a brief, insight-oriented cognitive behavioral therapy.  Results indicated a significant increase in total insight and, specifically, insight into treatment compliance (i.e., antipsychotic medication) in the individuals who received the intervention.  Thus, in this sample, insight led to better outcomes by improving treatment compliance. 

Even though insight is considered to be a common factor of therapy, and thus should be an area of treatment focus for proponents of the dodo bird hypothesis (the hypothesis that all therapies are equally effective), insight has received very sparse treatment and research consideration.  We don't know enough about the definition and function of insight to come to any firm conclusions.  To my knowledge, insight has not been examined as a factor in the majority of therapeutic styles, making the argument for insight as a common factor tenuous.  Additionally, most of the research I came across did not use the front-line treatment for a specific disorder.  I think it would be interesting to have some investigations into the role of insight in empirically supported treatments (e.g., is insight an important process, or even a process at all, in cognitive therapy for depression?).  The bottom line: at this point, it is unclear if insight should really be considered a common factor of therapy.  A significant amount of research is required before we can consider insight to be a curative factor in the therapeutic process.

Do you know of some studies that I missed?  If so, please send them along.  What do you think about insight as a common factor across therapies?  How about the definitional issues that arise in studying this construct?

Also, if you have a request for a common factor, send me an e-mail ([email protected]) & I'll be happy to oblige!

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Attentional training in social anxiety disorder: A novel computer-based treatment approach

by Michael D. Anestis, M.S.

I came across a study this morning with startlingly impressive findings.  What's more, the article was published in the most prestigious clinical psychology journal (Journal of Abnormal Psychology) and was written by several of my current colleagues at Florida State University and an FSU alum, and yet I did not know about it until just hours ago.  This goes to show just how difficult it is to keep up with all of the research transpiring in this field, even when it takes place in the same building as my own office.
    In this particular study, Brad Schmidt, Tony Richey, Julie Buckner, and Kiara Timpano (2009) investigated the potential utility of a computer-based intervention for social anxiety disorder (SAD) that aims to adjust the degree to which individuals with SAD attend to threat cues (e.g., facial expressions that might indicate others are evaluating them negatively).  The rationale for this particular study was based on a rich, although not universally consistent, literature indicating that individuals with SAD demonstrate an attentional bias towards threat (e.g., Amir, Freshman, & Foa, 2002; Rapee & Heimberg, 1997).   What this means is that individuals with SAD are hypervigilant towards threat, utilizing many of their attentional resources to scan their environment for evidence that they are currently being evaluated poorly.  Individuals with high levels of social anxiety have been shown to detect greater amounts of negative audience behavior relative to individuals with low levels of social anxiety (Valjaca & Rapee, 1998). 
    An argument could be made that attending to threat cues is an adaptive tendency.  After all, shouldn't we be aware of moments in which we are in danger?  If the question is phrased in this manner, the answer would be yes; however, this question misses the point.  Individuals with SAD are not attending to threats that put them in physical harm.  Instead, because this disorder is characterized by a fear of negative evaluation, the focus is on cues that, while likely to cause discomfort, are not truly representative of actual danger.  Additionally, constant hypervigilance towards threat serves to increase and sustain anxiety (Beck, Emery, & Greenberg, 1985).  So the actual result of this attentional bias is an overestimation of the likelihood and severity of threat as well as increased and prolonged negative mood.
    Schmidt and colleagues (2009), thus, set out to address the attentional biases of individuals with SAD by training them to control their attention and shift focus away from threat cues.  In this study, the authors places 18 individuals with SAD into a treatment condition and 18 individuals with SAD into a control (placebo) condition.  Both the treatment condition and the control condition consisted of a computer task that presented participants with a series of pairs of pictures, in addition to probes that prompted them to identify letters.  More specifically, participants were told to look at a screen while a series of photos were presented to them.  Prior to the presentation of each pair of photos, a fixation cross was displayed on the screen for 500ms.  Two photos were then presented on the screen, one immediately above the placement of the cross and one immediately below it.  Photos were either threat-based (a disgusted facial expression) or neutral (neutral facial expression).  Additionally, in both conditions, one of the photos was followed by a probe (either a letter E or a letter F).  When a probe appeared, the participant was told to indicate which letter had been presented.  Participants were instructed to perform this task as quickly as possible without sacrificing accuracy.
The difference between the two conditions was based on the placement of the probe.  In the treatment condition - individuals with SAD receiving attentional control training - the probe appeared in the place previously occupied by a neutral face in 80% of the pairings.  In this way, even though participants in this condition were not told to look away from disgusted faces, they learned that, when they saw disgusted faces, they should look elsewhere to find the probe. As a result, seeing a disgusted face became a cue to look elsewhere.  In the control condition, the probe appeared in the location previously occupied by the disgusted face as often as it appeared in the location previously occupied by the neutral face.
    Now, at first glance, the therapeutic value of this type of task may seem minimal.  How can looking at photos and identifying letters impact social anxiety?  Well, this is where data comes in handy, as it helps us get past strong but inaccurate gut reactions.  In this study, the authors measured SAD symptoms through self-report but also, more importantly, through a structured diagnostic interview, the most valid and reliable manner for reaching diagnostic decisions.  Symptoms were measured pretreatment, post-treatment, and at a 4-month follow-up.  Amazingly, the authors found that, at termination, 72% of individuals in the treatment conditions no longer met criteria for SAD compared to 11% of individuals in the control condition.  Additionally, these benefits were maintained at 4-month follow-up.  Even more astoundingly, only one participant in the treatment condition correctly guessed that he or she was receiving treatment.  In other words, every person in the study except one believed that they were in the no-treatment condition, so the belief that they were being treated can not account for these effects.
    Perhaps even more impressive than the magnitude of these findings was the amount of time it took to attain them.  Treatment consisted of eight 15-minute sessions, typically twice per week.  The average amount of time between pre- and post-treatment assessments was 36.8 days.  Additionally, these effects were attained with almost no contact with an actual therapist.  What this means is that the authors were able to help a substantial number of individuals with SAD remit from their illness in very little time entirely through a computer task that the individuals themselves believed was not even a treatment. 
    There are many benefits to research like this.  First, even though there are already empirically supported treatments for SAD (see Lora Rose Hunter's PBB article on cognitive behavioral group therapy for SAD), not every individual responds to the front line treatment or has access to clinicians trained to administer empirically supported treatments.  Secondly, creating effective, empirically supported online treatments might increase the degree to which individuals with SAD seek and attain proper treatment.
    Ultimately, this study accomplished several admirable goals.  First, it presented initial empirical evidence in support of a brief, inexpensive treatment for SAD that maintains treatment benefits well beyond the end of treatment.  Second, it provided an example of a thorough assessment approach utilizing scientifically tested tools (see our Assessment Tools page for more examples). Finally, this study is a prime example of the need to take a scientific approach to clinical psychology.  The most effective means for reducing symptoms of mental illness are not always the most philosophically appealing or intuitively obvious.  The reduction of symptoms for clients is more important than intellectual satisfaction for clinicians, and science and data are the most effective means for ensuring that such reductions remain our highest priority.
    To learn more about treatments for social anxiety disorder or methods for developing attentional control, please refer to our online store for recommended products.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

What are the risks of SSRIs for depression & untreated depression during pregnancy?

by Joye C. Anestis, M.S.

According to a new study in the American Journal of Psychiatry (Wisner et al., 2009), both the use of selective serotonin reuptake inhibitors (SSRIs; a common class of antidepressant medications) and untreated major depressive disorder had the same effects on the developing fetus.  In this prospective observational study, the researchers divided their sample of 238 women into 5 non-overlapping groups: no SSRI, no depression; continuous SSRI exposure (took SSRIs for the entire pregnancy); continuous depression, no SSRI; partial SSRI exposure (took SSRIs at some point during the pregnancy, with at least 1 full trimester without SSRIs); partial depression, no SSRI (depression at some point during the pregnancy, with at least 1 trimester of remission).  Among their many findings, they found that neither SSRI treatment nor unmedicated depression were related to minor or major psychical anomalies in the babies; however, the results indicated that both continuous depression & continuous SSRI exposure were related to premature births.  This study joins a growing literature demonstrating a three-fold increase in risk for preterm births for women treated with SSRIs during pregnancy, but it also adds to this literature by demonstrating a similar effect for untreated depression.

For many women, the issue of how to tackle psychiatric problems while pregnant is a significant concern.  Because the prevalence of depression in women is highest during the childbearing years (Kessler et al., 2003), the question of how best to manage antenatal depression becomes even more important (it occurs in 10% of pregnant women; Gotlib, Whiffen, & Mount, 1989; O'Hara, Zekoski, Philipps, & Wright, 1990).  What was most striking to me about the Wisner et al. study is that there was no mention of alternatives to medication for the treatment of depression.  This oversight was shocking considering that many studies have found psychotherapy  (specifically, cognitive therapy and cognitive behavioral therapy) and medications to be equally effective in the treatment of depression and the prevention of relapse (DeRubeis, Gelfand, & Simons, 1999; Dimidjian et al., 2006; Hollon et al., 2005). 

With this in mind, what do we know about alternatives to medication for pregnant women?  While the clinical psychology literature on antenatal depression is sparse, several studies have demonstrated treatment efficacy for interpersonal psychotherapy (IPT) with depressed, pregnant women & adolescents (Miller, Gur, Shanok, & Weissman, 2008; Spinelli, 1997; Spinelli & Endicott, 2003).  IPT is a brief treatment which focuses on interpersonal factors in the development and maintenance of mental illnesses (see Comprehensive Guide To Interpersonal Psychotherapy; comprehensive review of IPT available through our online store for recommended products).  At the outset of IPT, the patient chooses one domain of interpersonal functioning to focus on: role transitions, interpersonal disputes, grief, or interpersonal deficits.  The focus on interpersonal functioning, and especially the role transitions domain, seems like a logical choice for treating pregnant women, whose depressive symptoms may be related to transitioning from a single person to a mother. There is considerable empirical support for IPT for a number of mental illnesses, including major depressive disorder (e.g., Elkin et al., 1989) and bulimia nervosa (e.g., Fairburn et al., 1995).   Other forms of psychotherapy have not been systematically investigated in sample of pregnant women, but I'm not sure there is a reason to believe that psychosocial treatments known to be effective for depression in non-pregnant samples would operate differently in pregnant women.

Joye Anestis is a doctoral candidate at Florida State University.

It's just too much for me: The role of distress tolerance in problematic behaviors

by Michael D. Anestis, M.S.

    There are a variety of ways in which our emotions can cause us difficulties.  For some of us, affective lability - rapidly shifting emotional states - is the problem, leaving us in an unpredictable, frequently aversive state that feels difficult to control.  Others of us experience more frequent or more severe negative moods, so we encounter more powerful emotions more often than others.  For some of us, the problem is alexithymia - an inability to effectively identify our emotions, which leads to a broad sense of feeling "bad" that is difficult to regulate.  For others of us, the problem is anhedonia, an inability to feel positive emotions in response to things that previously felt pleasurable, which leaves us feeling numb, disconnected, and unmotivated.  There are several other ways in which our emotions can cause us problems and an entirely comprehensive list would be almost impossible.  Today, I will focus on one particular emotional variable, distress tolerance, which is defined as the degree to which an individual experiences emotions as overwhelming (Simons & Gaher, 2005).
    When I explain distress tolerance to a client or student, I tend to start with a bit of an odd metaphor.  I tell the person to imagine each person is a glass of water.  Each glass is uniform, holding the exact same amount of liquid, and each glass is sitting under a faucet that pours water out at the same rate.  Next, I tell the person to imagine that my glass of water starts with more water in it than any other glass.  Given this situation, even though my glass is being filled at the same rate with the same amount of water, mine will overflow more quickly than other glasses.  In this metaphor, my glass has low distress tolerance.  When an individual has low distress tolerance, it's not that he experiences more powerful emotions, more frequent negative emotions, or more confusing emotions.  The issue is simply that, what does not feel overwhelming to others feels overwhelming to him.  His glass already has more water in it, so it takes less to overflow.
    Fortunately, there is a lot of empirical research on distress tolerance that does not rely on my glass metaphor.  In this research, scientists have found that low levels of distress tolerance predict a host of problematic behavioral outcomes.  Women tend to have lower levels of distress tolerance than men, but low distress tolerance is equally destructive regardless of sex (Simons & Gaher, 2005), much like rumination.  Brandon and colleagues (2003) found that smokers with low distress tolerance were less able to sustain quit attempts than were smokers with moderate or high levels of distress tolerance.  Similarly, Daughters, Lejuez, Kahler, Strong, and Brown (2005) found that individuals with low distress tolerance receiving treatment at a substance abuse treatment facility were less able to sustain quit attempts than were individuals at that same facility with higher levels of distress tolerance.  Additionally, in a separate study, Daughters and colleagues (2005) found that individuals with low distress tolerance were more likely to drop out of a substance abuse treatment facility.  These findings make a lot of sense and go a long way towards explaining why overcoming addiction is more difficult for some individuals than others (although by no means explains it all).  Withdrawal is an extremely uncomfortable, distressing experience.  If an individual is already inherently less able to tolerate even moderate levels of distress, this experience becomes that much more difficult.
    Distress tolerance has been shown to be important in several other behavioral outcomes as well.  Daughers and colleagues (2005) found that pathological gamblers with low distress tolerance were less able to sustain quit attempts.  In a paper I co-wrote with Eddie Selby, Erin Fink, and Thomas Joiner (2007), we found that individuals with low distress tolerance were more likely to binge eat and purge than are individuals with higher levels of distress tolerance.  Nock and Mendes (2008) found that individuals with who frequently engage in non-suicidal self-injury (NSSI) also have low levels of distress tolerance, which is particularly problematic given the relationship between NSSI and the acquired capability for suicide.  Given all of these findings, it becomes readily apparent that not being able to tolerate negative emotions results in significant impairment.
So why would low distress tolerance motivate somebody to engage in such harmful behaviors?  The answer is similar to the information we discussed in a prior article on the functional model of NSSI.  When we hit a particular threshold of feeling upset, our priorities become almost entirely focused on immediately reducing our distress.  For most of us, this threshold is quite high - it takes a lot for us to act in a way that completely disregards potential long-term consequences.  When an individual has low distress tolerance, however, it takes less stress for them to reach their threshold - there is already more water in their glass.  There is compelling evidence that, if we believe a behavior has the ability to reduce our feelings of negative affect, we are more likely to engage in that behavior, even if it is unhealthy, (e.g., binge eating; Fischer & Smith, 2008).  There is also compelling evidence that some unhealthy behaviors have the ability to quickly reduce negative emotions (Smyth et al., 2008).  This is unfortunate because, as an individual learns that a behavior can quickly reduce feelings of negative affect, they become more likely to do it again the next time they reach that threshold.  If the threshold is low, they can quickly get stuck in a viscious cycle.
    Fortunately, researchers have developed empirically supported treatments that directly address distress tolerance.  Dialectical behavior therapy (DBT; Linehan, 1993a; Linehan, 1993b) is a form of cognitive behavioral therapy (CBT) that was originally designed to treat borderline personality disorder (BPD), which is characterized by highly labile emotions, difficulties regulating behavior when upset, stormy interpersonal relationships, and self-injury.  Several studies have indicated that DBT is an effective treatment for BPD (e.g., Linehan, 1998), which is an important and often misunderstood fact due to some particularly harmful and prevalent misinformation about that disorder.  DBT, which we will describe in more detail in future articles, includes a module that focuses entirely on teaching clients distress tolerance skills, ways to weather the storm when no healthy behavior is capable of changing the way they feel in that moment.  Such skills include radical acceptance - a skill that teaches individuals to shift their focus from the way they wish things were to the way they actually are, accepting reality and devising plans to attain the best possible outcome given their circumstances.  Recently, several researchers have demonstrated that DBT has empirical support as a treatment for both bulimia nervosa and binge eating disorder (Safer, Lock, & Coutourier, 2007; Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan, 2001).  More work needs to be done to demonstrate that DBT is an effective treatment for individuals whose distress tolerance has resulted in substace abuse or other problems; however, an important consideration to keep in mind is that such individuals may also meet criteria for BPD, bulimia, or binge eating disorder and thus benefit from DBT.
    Ultimately, it appears that low levels of distress tolerance can be highly dangerous, in that they are correlated with an increased use of harmful behaviors, but that distress tolerance is a good target for therapeutic interventions.  By understanding the mechanisms behind behaviors, whether this means distress tolerance, affective lability, or some other variable, researchers can be better equipped to design and test treatment protocols that have a greater likelihood of reducing rates of harmful behaviors.  Additionally, by understanding such mechanisms, it becomes clear how behaviors that might seem unrelated, such as binge eating, NSSI, and substance abuse, actually share important risk factors and, as such might respond to similar treatments.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

A Comment on ‘Distracted’: Is ADHD just a kid being a kid?

by Tracy K. Witte, M.S.

A recent NPR piece ("'Distracted' brings ADD debate to Stage;" Talk of the Nation) discusses an off-Broadway show starring, among others, Cynthia Nixon of Sex and the City fame.  Full disclosure -- I have not seen the play myself; rather, my commentary is intended for the discussion of the play contained in the above referenced Talk of the Nation episode.  In my opinion, this show did a disservice to the field of scientific clinical psychology in general and Attention-Deficit/Hyperactivity Disorder (ADHD) researchers and practitioners in particular.  The piece featured two of the main actors in the play (Cynthia Nixon and Josh Stamberg), who portray parents of a child diagnosed with ADHD.  The play is intended to be a lighthearted social commentary on the diagnosis of ADHD and the difficult decisions faced by parents of children with the disorder.  In principle, I think that it is a good thing to address mental health issues in works of art and literature; however, the discussion of the play - and potentially the play itself - seemed to ignore the notable advances in the field of attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment in recent years.
    ADHD is a diagnosis contained in the Diagnostic and Statistical Manual-IV (American Psychiatric Association, 2000) characterized by persistent inattention difficulties (e.g., having trouble maintaing attention in tasks or play activities, being easily distracted) and/or hyperactivity (e.g., fidgeting with hands or feet, behaving as if "driven by a motor").  Worldwide, the prevalence of ADHD is estimated to be between five and six percent (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007).  The diagnostic criteria for this disorder have evolved since its advent in the DSM-II (American Psychiatric Association, 1968).  The original diagnostic criteria focused mainly on hyperactivity.  The DSM-III (American Psychiatric Association, 1980) focused on the importance of inattentiveness in the diagnosis; thus, individuals could be diagnosed with attention-deficit disorder (ADD) with or without hyperactivity.  In the most recent version of the DSM (DSM-IV; APA, 2000), the name of the diagnosis has been changed to attention-deficit/hyperactivity disorder (ADHD), and an individual can be diagnosed with inattentive subtype (i.e., just inattention symptoms), hyperactive subtype (i.e., just hyperactivity symptoms), or combination subtype (i.e., both inattention and hyperactivity symptoms).  Lay persons often are confused about the nomenclature for ADHD, as it is often referred to in the popular press as "ADD."  To clarify, the most recent term for the disorder is ADHD; when people discuss "ADD," they are most likely using an older term for the same disorder.
    A common criticism of the diagnosis of ADHD is that it pathologizes a "kid being a kid."  Indeed, in the NPR piece, Neal Conan says "one of the great lines in the play is, you know, hey, attention deficit, short attention span, impulsiveness, risk-taking, isn't that a description of a 9-year-old boy?"  Now, I couldn't agree more that we should not pathologize a nine-year-old for not being able to sit still and listen to a reading of War and Peace.  If someone were to use such a criterion as evidence supporting an ADHD diagnosis, let me be the one to cast the first stone.  It is absolutely crucial, however, that the public understand that this is not what a responsible clinician is doing when assigning an ADHD diagnosis.  The DSM-IV definition of ADHD requires that the symptoms are "inappropriate for developmental level."  This means that the child exhibiting these symptoms must be impaired compared to other children his or her age.  Furthermore, according to the DSM, the impairment must exist in multiple areas of the child's life.  For example, if a child only experiences difficulty at school, the severity of the condition would not be sufficient to warrant an ADHD diagnosis.
    The gold standard for diagnosing ADHD includes:

• A physical exam to rule out a general medical condition
• An interview with the child, parent, and a teacher
• Child behavior rating scales completed by the parents and teachers of the child
• A review of school and health records
• A psychological test that does not involve self-report (Root & Resnick, 2003)

    One of the most popular types of non-self-report assessment instruments for ADHD is the continuous performance test (CPT).  CPT tasks are often conducted on a computer and require the tested individual to sustain his or her attention in order to be able to appropriately respond to various stimuli.  The benefit of using a non-self report instrument is that it is not as subject to demand characteristics, and it is more difficult for malingerers to provide false information.  It is crucial to obtain information from multiple methods and multiple sources in order to obtain diagnostic data that is as unbiased as possible (Achenbach, 2000).  The information from these sources should be analyzed by a trained clinician familiar with the diagnosis of ADHD.  When a diagnosis is carefully assigned using this relatively rigorous procedure (as is often the case), it is difficult to argue with its veracity.  Can ADHD be misdiagnosed?  Absolutely, however, when the above protocol is followed, the likelihood of misdiagnosis is greatly diminished.  I encourage interested readers to consult the Psychotherapy Brown Bag assessment tools page for further information on assessment measures for ADHD.
    Another issue brought up during the NPR piece was skepticism regarding whether ADHD is a real diagnostic entity.  For example, Cynthia Nixon said, "...even once we have the diagnosis, is this a real thing?...if it's a real disease, why isn't there one single antidote?  Why do we have to try this drug and thus drug and this drug?"  This comment is unfortunate and misinformed.  First, other "real" diseases, like cancer, do not respond uniformly to one single "antidote."  Second, there is evidence that ADHD runs in families and that people with ADHD exhibit frontal lobe deficits (see Campbell, 2000, ro a review of this topic).  These biologically-based variables provide compelling evidence of the construct validity of the diagnosis.
Regarding treatment for ADHD, a rigorous clinical trial run by the Multimodal Treatment Study of Children with ADHD (MTA Cooperative Group, 1999), utilized multiple outcome measures from multiple sources and conducted a 14-month follow-up.  Children with ADHD were randomly assigned to intensive medication management alone, behavioral intervention alone, or a combination of the two.  The outcome variables included severity of ADHD symptoms, parent ratings of symptoms, teacher ratings of symptoms, classroom observation, social skills, and academic achievement.  There were no significant differences between medication management and the combination treatment; however, both medication management and the combination treatment were significantly better than behavior management on all aforementioned outcome variables.  This study provides compelling evidence for the efficacy of medication in the treatment of ADHD.  It is notable that the medication not only ameliorated symptoms specific to ADHD but also other quality of life variables.  One caveat: the prevailing evidence supports the efficacy of intensive medication management (i.e., monthly visit and assessments by a physician).  When the children in the MTA study returned to being treated in the community, where the medication management was less intense, the benefits dissipated over time (Jensen et al., 2007).  Nevertheless, there was at least one subgroup of children in the MTA study (34% of the sample) who exhibited increasing benefits of medication treatment over three years (Swanson et al., 2007).  Thus, although medication may not work for everyone in the long run, it seems to certainly be effective in the short run and works for some children for up to three years.  Therefore, contrary to what the NPR piece seemed to imply, there is evidence for effective ADHD treatments that can drastically improve a child's functioning level in a variety of arenas.
    Finally, during the NPR piece, Cynthia Nixon says, "and I think that that is one of the big questions that the play is asking: in our incredibly fast-paced, multi-tasking world that we're in now, where we're constantly bombarded with stimulation, don't we all have attention deficit disorder?"  To put it bluntly, no.  I hope that the above discussion has convinced readers that ADHD is a real disorder with real psychological consequences (and effective treatments).

Tracy Witte is a doctoral candidate in the clinical psychology department at Florida State University.

Suicide in the military: Some thoughts on an emerging area of concern

by Michael D. Anestis, M.S.

    I came across two articles in the past 24 hours that both focus on a topic that has been a central component of my work over the past year: suicide in the military.  This topic has been garnering a significant amount of media attention recently as the data on soldiers and suicide have shown to be quite troubling.  In an article in the Journal of the American Medical Association (JAMA), Bridget Kuehn (2009) presented a concise summary of these statistics, as well as new efforts on the part of the military to study suicidal behavior in soldiers and to develop effective interventions. 

    Amongst the numbers Kuehn presented:

• Suicide rates amongst active-duty soldiers reached a 28-year high in 2008, with several cases still being investigated and likely to add to the total.
• The suicide rate in active duty solders in 2008 (likely to settle at approximately 20.2 per 100,000) surpassed that of civilians with similar demographics (19.5 per 100,000 in 2005), marking the reversal of a long-standing trend of lower rates in military populations relative to civilians.
• In 2005, males utilizing Department of Veterans' Affairs (VA) services had a suicide rate of 37.2 per 100,000 compared to 13.6 per 100,000 for females using VA services.

    In a separate article, CNN discussed the roles of multiple deployments and stress on suicide rates in the military.  Both articles point towards a variety of factors that are contributing to the vulnerability of soldiers to suicidal behavior.  For one, there is a stigma regarding seeking mental health treatment.  Not unlike the stigma in civilian populations, this situation leads individuals who recognize their own struggles to avoid seeking effective care because they fear repercussions.  Some fear seeking such treatment will preclude reaching certain career goals and others fear that they will be perceived poorly by others because of their symptoms.  Although some individuals do manage to handle such situations on their own, this invariably leads to a large number of individuals experiencing increasingly severe and dangerous symptomatology treatable only under effective clinical care. 

    Additionally, there is a higher demand than supply for effective mental health treatment services in this population.  Further complicating things, empirically supported treatments and systematic diagnostic assessment procedures have not been universally adopted, meaning that when care is available, it is not always necessarily based upon what has actually been shown to be effective.  This situation is by no means unique to the military, but rather represents a failure on the part of the field itself to effectively disseminate vital information as needed.

    Another vulnerability discussed in both articles is a tendency for soldiers to experience relationship difficulties.  This particular vulnerability dovetails with the discussion we had regarding Joiner's (2005) interpersonal-psychological theory of suicide on PBB the other day.  The theory indicates that individuals must have both the desire and capability for suicide before death by suicide is likely.  The desire component is comprised of two variables: thwarted belongingness and perceived burdensomeness.  Thwarted belongingness is characterized by an individual's sense that he or she does not have meaningful connections to other people.  Perceived burdensomeness is defined by an individual's sense that he or she does not make meaningful contributions to the world and that his or her presence serves as a liability to others.  In a paper I co-authored with Craig Bryan, Michelle Cornette, and Thomas Joiner (2009), we discussed a variety of ways in which deployed soldiers may develop these risk factors.  The loss of close friends during deployment or a failure to integrate socially with other soldiers while deployed could contribute to a soldier's sense of thwarted belongingness.  Additionally, returning home from deployment, some soldiers report that despite the knowledge that others care deeply for them, they feel disconnected because their love ones can not relate to their deployment experiences.  Such social detachment can also contribute to a soldier's sense of thwarted belongingness. 

    With respect to perceived burdensomeness, soldiers who are wounded while deployed and no longer able to perform functions they previously performed are likely to feel a sense of burdensomeness.  Additionally, difficulty re-integrating into civilian life after performing the important duties of a soldier can leave an individual feeling as though he or she is no longer useful.  All of these sensations are based on distorted automatic thoughts and misinterpretations of the environment, but they are compelling to the individual who experiences them and difficult to challenge without help.  In one of the only studies to date that has attempted to empirically measure the components of Joiner's (2005) theory in military populations, Brenner and colleagues (2008) found consistent themes of burdensomeness and thwarted belongingness along with a heightened tolerance of physical pain in deployed soldiers.

In each of the papers that have considered Joiner's (2005) theory in military populations, authors have been careful to note that there is no reason to expect that military service inherently increases an individual's vulnerability to the desire for suicide, but rather that there are certain types of experiences (e.g. loss of fellow soldiers) that would increase that risk.  In fact, there is reason to believe that military service serves as a buffer against the desire for suicide for many individuals by creating close-knit groups who perform overtly beneficial services.  The situation is different for the acquired capability for suicide, however.  In the paper I co-wrote with Bryan and colleages (2009), we argued that the nature of service in the military, even for those who do not see combat, serves as a vulnerability for the acquired capability, which is defined by an increased tolerance of physiological pain and a diminished fear of death and is developed through repeated exposure to painful and provocative events (for a more thorough description of this variable, consult our article on interpersonal-psychological theory of suicide).

    There is compelling evidence to support the idea that certain aspects of military service, including combat experiences and training in weapon usage, might serve to increase the acquired capability for suicide.  For one, male veterans in the general population have been shown to die by suicide at a significantly greater rate than male non-veterans in the general population.  Additionally, male veterans are 58% more likely to utilize firearms as their attempt method (Kaplan, Huguet, McFarland, & Newsom, 2007).  Nye and Bell (2007) found that the re-experiencing symptoms of PTSD - in which individuals experience visceral flashbacks often involving hallucinations - are the most predictive of suicide attempts in Vietnam war veterans.  By consistently re-experiencing painful and provocative events capable of inducing PTSD, it seems reasonable that an individual may experience an increase capability for suicide. 

    These studies are all indirectly related to Joiner's (2005) theory, but, in addition to impressively funded NIMH research sponsored by the military, a number of other studies are underway that will test these concepts more stringently and provide valuable data.  One of the psychologists directly involved in such work is Craig Bryan, a captain in the United States Air Force, who has written a valuable article on the integration of empirically supported treatments for Post-Traumatic Stress Disorder (PTSD) in military populations that will serve as the Psychotherapy Brown Bag featured article for April (publication date: 4/1/09).  Until then, we invite your thoughts on this topic.

    Why do you think suicide rates in the military have increased so drastically in recent years?  What do you think could be done?  What studies have you heard about that might provide a good basis for understanding this issue?  And remember, while we believe that a data-driven approach to understanding psychological phenomena and treatments is vital, ideas not yet tested by data are welcome too.  Such thoughts are simply seen as preliminary, in need of testing, and are a valuable initial step in the scientific process!

Mike Anestis is a doctoral candidate in the clinical psychology program at Florida State University.

Time magazine's opinions about DSM-V

by Joye C. Anestis, M.S.

Yesterday, in an excellent blog post chastising Senator Chuck Grassley's insensitive comment about suicide & his refusal to apologize for it, our friend Alicia at Celebrity Psychings made us aware of an interesting Time magazine article that we'd missed. Titled "Redefining Crazy: Researchers Revise the DSM," the article summarizes some talks at the recent American Psychopathological Association meeting to discuss DSM-V (read the article here).  In a frustrating oversight, there is no place to comment on the article on the Time website, only an option to write a letter to the editor...so I thought we could have a discussion about it here.  I am writing some of my comments about the article below.  Why don't you read it & leave your comments here?  The article is very short, so it shouldn't take long!

• First off, I find the title of the article to be offensive.  I thought we'd evolved a little past such labeling.
• The author, John Cloud, argues that one of the main problems with the current DSM is that it doesn't address cause.  This is a common critique of our current diagnostic taxonomy (see Clark, Watson, & Reynolds, 1995, for an excellent summary of the shortcomings of the DSM).  But Cloud does not offer compelling evidence to support this argument.  As an example, he describes an individual suffering from depression for many months as the result of job loss.  My thought on this is that an external cause is not necessary for diagnosis...depression following job loss and depression following an unknown stimuli both will respond to the same treatment, & that is what matters in a diagnostic system.  Furthermore, cause is not altogether ignored.  For each mental illness, the DSM requires a rule-out if the symptoms are caused by drugs, alcohol, or a medical condition.  Finally, I wonder if considering cause as a primary ingredient in the diagnosis of mental illness would move us away from the atheoretical goals of the modern DSMs.  Because so many theories exist about the causes of mental illnesses, I fear that including cause in the DSM, at this point in time, might work against the overall purposes.
• In making the point I mentioned above, the author asserts that, in the DSM "only perfect is considered normal," and doesn't offer evidence from the DSM to back this up.  This statement is not only inaccurate, but I think it's harmful.  It's not helpful for consumers of mental health services to hear that, unless they're "perfect," we'll consider them mentally ill.  By definition, the DSM characterizes mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (e.g., impairment in one or more important areas of functioning) or with a significanty increased risk of suffering death, pain, disability, or an important loss of freedom" (APA, 2000, p. xxxi).  Thus, we are not looking to label "imperfection," we are looking to help those who are significantly impaired or distressed by their behavior/symptoms.
• My criticism of this Time article is not to say that the DSM is without flaw, as that is far from the truth.  And hundreds of people are working toward creating a better system, one that's based on empirical data and not clinical lore.  Cloud refers to the push make diagnoses dimensional in nature, a very popular movement within the DSM researchers.  In fact, some studies have shown that some disorders might be best conceptualized as dimensions, whereas other disorders have been identified as taxa [natural, nonarbitrary categories; for just one example, see Haslam's (2003) of taxometric studies of personality disorders; for a good description of taxometrics, see Schmidt, Kotov, & Joiner (2004)].  I am excited to see what happens when it is published!

Do you agree with me?  Do you have other comments?  Read the article and let me know what you think about it - I am curious to hear your thoughts.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Joiner's interpersonal-psychological theory of suicidal behavior

by Michael D. Anestis, M.S.

    There are few, if any, more troubling phenomena in the world than suicide.  Recent data suggests that suicide is the 11th leading cause of death overall in the United States, 8th for males and 16th for females (American Association of Suicidology, 2005).  Each year, approximately 30,000 individuals die by suicide in the United States alone, which computes to an approximate total of 80 per day and one every 18 minutes.  For every completion, there are approximately 25 attempts, meaning there are approximately 750,000 suicide attempts annually in the United States (American Association of Suicidology, 2005).  This heart-breaking phenomenon reflects a significant amount of suffering among those who complete suicide and leaves in its wake an unfathomable number of mourners.

    Given the magnitude of the situation, the need for a theory capable of providing a framework within which to understand suicide and to develop systematic interventions would be impossible to overstate. In 2005, Thomas Joiner of Florida State University put forth such a theory, the interpersonal-psychological theory of suicidal behavior.  The theory states that, in order to die by suicide, an individual must develop high levels of three specific variables: a sense of thwarted belongingness, a perception of functioning as a burden on others, and the acquired capability for suicide.  The first two variables, thwarted belongingness and perceived burdensomeness, comprise the desire for suicide. 

    Evidence indicates that, when individuals die by suicide, they often feel disconnected from others.  This feeling can reflect a sense on the part of the individuals that nobody truly cares about them or, alternatively, it can reflect a sense that, while others might care, nobody can relate to them and understand their situation.  Both sensations leave individuals feeling intolerably isolated.  In reality, individuals who die by suicide rarely, if ever, truly lack others who care about them, but the dysfunctional automatic thoughts that are characteristic of mental illness skew the individuals' perceptions of the world around them.  The second description - the sense on the part of some individuals that, while others care, they can not relate to their experience - is a potential partial explanation for suicidality in returning veterans who re-enter civilian life after the experience of war.  In such cases, individuals can feel estranged from others who did not experience the same overwhelming events, regardless of how close they had been prior to its occurrence.

    Perceived burdensomeness, like thwarted belongingness, is generally driven by distorted automatic thoughts.  Individuals experiencing elevations in this variable have the sense that they are not making any worthwhile contributions to the world around them.  They not only feel as though they are not assets, but in fact believe that they are liabilities and that others' lives would be improved if they were to disappear.  Again, such beliefs are rarely, if ever, true, but they are nonetheless a common cognitive tendency on the part of individuals after experiencing particular types of events.  Losing a job, missing a promotion, transitioning into retirement, and failing a course are several examples of types of experiences that could prompt a sense of burdensomeness. 

    Both components of the desire for suicide are suitable targets for therapeutic interventions.  Cognitive behavioral approaches such as behavioral activation and cognitive restructuring can help such individuals increase the amount of positive experiences they have while diminishing the tendency to view their environment through distorted lenses.  Setting specific, graded goals with clearly defined paths towards accomplishing them can serve to increase an individual's sense of self-sufficiency.  An empathic and scientifically-minded therapist can help to make individuals feel as though somebody is listening and there are reasons to seek a better outcome.

    A somewhat more difficult point for intervention and a less familiar concept to the world at large is Joiner's (2005) concept of the acquired capability for suicide.  The interpersonal-psychological theory of suicidal behavior argues that, in order to enact lethal self-harm, an individual must habituate to physical pain and the fear of death.  Self-preservation is our natural instinct and this instinct is extremely strong.  In order to overcome this, an individual must become accustomed to pain and fear and be able to tolerate them in significantly higher than average doses.  This process of habituation occurs through repeated exposure to painful and provocative events. 

    Just as a loud, unexpected noise is frightening when first heard, but becomes less noticeable when it occurs repeatedly, physical pain becomes less pronounced over time when our body becomes accustomed to the experience.  A large collection of empirical studies have provided compelling evidence supporting this point.  For example, Nock and Prinstein (2005) found that individuals who frequently self-injure experience pain analgesia - the absence of pain - during self-injury episodes.  Additionally, a lack of pain during self-injury episodes has been shown to predict an individual's number of lifetime suicide attempts (Nock, Gordon, Joiner, Lloyd-Richardson, & Prinstein, 2006).  Orbach, Mikulincer, King, Cohen, and Stein (1997) developed a particularly compelling study that expanded further upon this idea.  They found that individuals admitted to an emergency room immediately following a suicide attempt exhibited higher pain threshold (when they first feel pain) and tolerance (when pain becomes too much to bear) than did individuals admitted to that same emergency room following accidental injuries.  Here, not only did the experience of pain appear to impact the manner in which pain was perceived, but the effect was stronger when individuals had intentionally self-inflicted pain.  In another study, Orbach and colleagues (1996) found that individuals with multiple past suicide attempts could tolerate more pain than could individuals with zero or one past suicide attempt. 

    These findings are all consistent with Joiner's (2005) idea that individuals must acquire the capability for suicide before a completed attempt is likely to occur.  This explains, in part, why there are so many attempts for every completion - most individuals who attempt have the desire, but not the capability for, suicide.  Repeated attempts, however, contribute to an individual's acquired capability.  Additionally, experiences that involve witnessing pain and violence, even in the absence of physical pain, are believed to be capable of contributing to the acquired capability, which might explain why physicians in emergency room settings and soldiers who witness injuries but are not hurt themselves are vulnerable to suicidal behavior.

    Recently, in addition to the findings mentioned above, a series of studies have been undertaken that have directly measured the acquired capability for suicide using a self-report measure entitled the Acquired Capability for Suicide Scale (Bender, Gordon, & Joiner, 2007).  Van Orden, Witte, Gordon, Bender, and Joiner (2008) found that the number of previously experienced painful and provocative events predicted individuals' levels of the acquired capability.  Additionally, individuals with higher scores on the measure of the acquired capability demonstrated higher levels of physiological pain tolerance and had a greater number of prior suicide attempts.

    So why are theories such as Joiner's (2005) interpersonal-psychological theory of suicidal behavior so important?  By understanding the underlying mechanisms that leave individual's vulnerable to suicide, researchers and clinicians can design optimally effective treatment interventions that aim to quickly diminish the symptoms that contribute to risk.  Additionally, understanding the variables that increase risk allows for systematic risk assessments that take the guess work out of determining whether an individual is in imminent danger.  Also, by clarifying the true nature of suicide risk, we can hopefully diminish the pervasive reach of misinformation on this topic.  Suicide, as it turns out, does not need to be a mysterious and poorly understood phenomenon.  It is capable of being understood through research just like any other health concern and the efforts put forth by the researchers mentioned above and countless others contributing to this cause will serve to bring clarity and hope to a behavior that has troubled mankind since its inception.

    If you or anyone that you know appears to be experiencing suicidal thinking or behaviors, please contact 1-800-273-TALK immediately.  Trained professionals are available 24 hours per day, 7 days per week and their help is both anonymous and free.

    If you would like to learn more about the interpersonal-psychological theory of suicidal behavior, please refer to Thomas Joiner's Why People Die by Suicide and Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd's The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients, both of which are available through our online store for recommended products.

Mike Anestis is a doctoral candidate in the clinical psychology program at Florida State University.