May 25

Malingering: When Psychiatric Conditions are Faked

Malingering involves the intentional production or display of false or grossly exaggerated physical or psychological symptoms, with the goal of receiving a specific benefit or reward such as money, an insurance settlement, disability status, evasion of legal consequences or release from incarceration, or avoidance of work, jury duty, the military, or other types of service. Psychologytoday.com

Some cases of malingering are relatively easy to detect, but some can be especially tricky for mental health professionals (and/or physicians) to identify. Such cases of malingering can lead to abuse of the system, with unnecessary tests and interviews being performed and time taken away from other clients and patients.

Malingering is a condition not listed in the DSM-5. However, “It is similar to, but distinct from, factitious disorder, in which an individual fakes symptoms of physical or mental illness but without a concrete motive or expectation of reward. Malingering is also distinct from somatic symptom disorder, in which someone experiences actual psychological distress due to imagined or exaggerated symptoms” (psychologytoday.com).

It may go without saying that individuals who do have ulterior motives for showing up at your therapy door don’t really want or need your help of the therapy kind; what they want is to manipulate you so that they get something else—something they presumably feel they can’t get otherwise.

A couple examples from pop culture: 1) Corporal Max Klinger (actor Jamie Farr) on the old TV show M*A*S*H (1972-83). His plan for getting out of the Army involved trying to prove that he was psychologically unfit. He couldn’t achieve his goal, though, and eventually gave up.

2) Liz Lemon, played by Tina Fey on the more recent TV sitcom 30 Rock. Her goal was to escape jury duty. See below:

A malingerer presenting at a mental health setting could also be driven by such motives as getting out of work, obtaining disability insurance, and seeking drugs.

Reportedly, research has shown, though, that a person who fakes symptoms of mental illness can actually start to believe the illness is real (Scientific American). Put into action, this means Klinger would start to really believe, for example, that he can fly (in his pink bathrobe and slippers), while Liz Lemon would settle into the delusion that she’s a Star Wars character.

On a more positive note, psychologist Elizabeth Loftus is quoted in the above-cited article as envisioning “therapeutic potential in the new study”…

…musing on a hypothetical strategy she calls ‘feigning good,’ which could motivate patients by helping them believe in improved cognitive skills and diminished symptoms of illness. ‘Should clinicians be prescribing a form of feigning? You wouldn’t want patients to feign anxiety, but maybe they could feign the opposite. Maybe they could feign crystal clear concentration.’

May 18

“Whole Again” After Abuse: Jackson McKenzie Quotes

Contained within Jackson McKenzie’s 2019 Whole Again: Healing Your Heart and Rediscovering Your True Self After Toxic Relationships and Emotional Abuse are strong quotes to help you heal. The following are some I’ve selected.

Note: References to C-PTSD below are about complex PTSD. See this link or this one if you’re unfamiliar with the diagnosis.

You’re so preoccupied with trying to make sure you’re reasonable and seeing all perspectives that you fail to throw in the towel when people are blatantly mistreating you. Oftentimes you notice something seems “off” for the longest time, but you feel guilty and dismiss it because the person is nice to you, or because they aren’t rejecting you.

…(T)he best gaslighting victims are those who doubt themselves.

Their partner can say and do unacceptable things on a daily basis, which the codependent will try to explain and understand (“they had a difficult childhood!”). But the moment codependents make a single mistake, they berate themselves for it, obsess over it, and wonder if they’re crazy. For this reason, they come up short in relationships, over and over again. Because they’re unable to recognize that the balance is skewed, and unable to recognize that they’re not getting what they deserve from a healthy relationship. Their self-doubt keeps things forever skewed in their partner’s favor.

How to Win Against an Abuser? I get this question all the time, and my answer is always the same: Don’t try to win. As soon as we engage in this win/lose mentality, we abandon our hearts and forget what’s really important: vulnerability and love. Yes, absolutely you should remove toxic people from your life, but it should be from the perspective of self-love, not “winning.” As long as we maintain this false illusion of control, we’re still connected to the person in our psyches. A hallmark of C-PTSD is fantasizing about gaining some power over an otherwise powerless situation.

If at any point your forgiveness process convinces you to invite an abuser back into your life (or even talk to them), this is not the kind of forgiveness we’re looking for. It will actually impede your own progress.

People cannot go from abusing and manipulating you one day, to magically being healed a week later. This is simply impossible. Especially when this change occurs as a response to possible abandonment or rejection, there’s just no chance this is authentic change.

Codependent forgiveness is this fantasized tear-filled beautiful reconciliation where everything is magically cured by love and compassion. As with most codependent issues, it’s focused on other people. Their problems. Their childhood. Their past. You think you understand them so much, maybe even more than they understand themselves! You make up excuses and reasons for them, your heart melts, you take them back, and then they hurt you again.

C-PTSD sufferers who experienced abuse may engage in mental arguments with their abusers long after the abuse has ended. Most people with C-PTSD experienced ongoing abuse from someone (or multiple people) who repeatedly betrayed their trust, and blamed them for this betrayal. They were made the scapegoat of someone else’s shame, which eventually caused them to absorb this shame themselves.

Dysfunctional Healing Approach: C-PTSD causes the sufferer’s thinking to become very rigid and analytical. This was (at some point) a necessary survival skill in order to identify threats and stay safe. However, once the threat is over, those with C-PTSD may still have a lot of trouble “feeling” emotions, and may end up trying to “think” them instead. As they begin recovery, they are likely to use this same analytical and rigid thinking against themselves, embarrassed or impatient by their inability to get in touch with their own feelings. They are also likely to have an extremely negative reaction to the idea of forgiveness, equating that with “letting them win,” and seeing forgiveness as something that abusers use to keep hurting victims.

May 10

“Toxic Positivity” a Trend That’s Got to Go

In the midst of a rising tide of social hatred, a seeming countertrend, toxic positivity, has also infected this culture. As defined by mental health professionals Samara Quintero, LMFT, CHT, and Jamie Long, PsyD, thepsychologygroup.com, this phenomenon is defined as:

…the excessive and ineffective overgeneralization of a happy, optimistic state across all situations. The process of toxic positivity results in the denial, minimization, and invalidation of the authentic human emotional experience.

What, then, is positivity without toxicity? Dani DiPirro, blogger at Positively Present:

Positivity is about assessing the situation, understanding your feelings, looking to see if there’s anything you can do to make the situation better, and, if there’s not, doing what you can to make the most of whatever the situation is. It’s not about pretending. And it’s definitely not about happiness.

A new book by therapist Whitney Goodman, Toxic Positivity: Keeping It Real in a World Obsessed with Being Happy, expands on this topic. From the publisher:  

Every day, we’re bombarded with pressure to be positive. From ‘good vibes only’ and ‘life is good’ memes, to endless advice, to ‘look on the bright side,’ we’re constantly told that the key to happiness is silencing negativity wherever it crops up, in ourselves and in others. Even when faced with illness, loss, breakups, and other challenges, there’s little space for talking about our real feelings—and processing them so that we can feel better and move forward.

But if all this positivity is the answer, why are so many of us anxious, depressed, and burned out?

Five essential points Goodman makes in Toxic Positivity (per nextbigideaclub.com):

  1. Positivity can hurt. “…Positivity itself isn’t toxic. It becomes toxic when used at the wrong time and with the wrong topics. Toxic positivity denies an emotion…”
  2. Complaining effectively“’Having a place to vent’ is actually one of the most common reasons people ask to work with me…To eliminate complaining is not the answer—what matters is improving how you complain…”
  3. Listen, understand, validate, and empathize. “…When you don’t know what to say to someone who is struggling, strive to include these four ingredients in your communication…”
  4. Intent matters. Impact matters more. “…I want you to know that there’s no perfect thing to say. Everyone has their own preferences and sensitivities…”
  5. Stop trying to be happy. “…I know, it sounds counterintuitive, but research shows that the more people see happiness as a goal, the less happy they are…Instead of pursuing happiness, I want you to pursue fulfillment through a value-driven life. A value-driven life makes room for the fact that living in accordance with our values doesn’t always mean feeling happy, but it is in alignment with who we are and what we want.”

“She goes on to argue that relentless encouragement to look on ‘the bright side’ can be a form of gaslighting,” states the Publishers Weekly review, “and even that toxic positivity perpetuates oppressive systems and prejudice (‘discrimination with a smile’). Further elaboration: 

 She backs it all up with copious amounts of research, examples from clients she’s worked with (unfortunately, though, too few of them), and her own life experiences….In a genre dominated by the upbeat, Goodman’s realism both stands out and takes the edge off; as she says, ‘It’s OK if you don’t always say the right thing; you’re not a Hallmark card.’ Goodman matter-of-factly challenges genre status quo, while maintaining respect for its readers.

May 04

“Can’t Just Stop” All Kinds of Compulsions

While extreme compulsions often appear odd, irrational, pitiable and self-destructive, our emerging understanding of compulsions implies something quite different: Even the craziest-looking compulsions are adaptive, even pragmatic, and all too human. A compulsion is at once psychological balm and curse, surface madness (or at least eccentricity) and profound relief. Sharon Begley, author of Can’t Just Stop (Wall Street Journal)

Behaviors such as OCD, hoarding, exercise, shopping, video-gaming, hyper-conscientiousness, and even hyper-do-gooding—which can all be responses to anxiety—are examined in Can’t Just Stop: An Investigation of Compulsions by science journalist Sharon Begley (1956-2021).

Compulsions “are repetitive behaviors that we engage in repeatedly to alleviate the angst brought on by the possibility of harmful consequences,” states Begley. Examples of compulsions of varying levels of severity are offered (Wall Street Journal):

There’s the woman who hit the treadmill so compulsively that she could do little else—and all because, every moment that she wasn’t exercising, the thought of fat cells proliferating in her body drove her nearly mad with anxiety. There’s the actor who was so certain he suffered from a dire illness that he compulsively pressed his doctors to give him CT scans, over and over, to assuage his angst. And there are the millions of us who feel compelled to check our phones before we get out of bed in the morning and constantly throughout the day, because FOMO—the fear of missing out—fills us with so much anxiety that it feels like fire ants swarming every neuron in our brain.

Publishers Weekly notes that Begley’s research and writing “demystifies compulsive behavior, exploring its history and manifestations and the many difficulties its sufferers face in finding appropriate diagnoses and treatment.”

Selected Quotes from Can’t Just Stop

The saddest thing I came to understand in researching and reporting this book is that so many of our behaviors draw us into them not because they bring joy but because they promise to quiet anxiety. But the most heartening thing was the realization that the ability of compulsive behaviors to quiet anxieties great and small is one of the greatest gifts our brains can give us.

For compulsions, according to a growing body of scientific evidence, are a response to anxiety. Suffused and overwhelmed by anxiety, we grab hold of any behavior that offers relief by providing even an illusion of control.

We cling to compulsions as if to a lifeline, for it is only by engaging in compulsions that we can drain enough of our anxiety to function.

Selected Reviews of Can’t Just Stop

Joel Gold, MD: “At once fascinating and compassionate, funny and informative, this volume should be on the bookshelf of every psychiatrist, and on the nightstand of anyone who enjoys absorbing and incisive writing.”

Gary Greenberg, therapist and author: “Sharon Begley has done us all a service, writing about compulsion without writing about disease and offering a new perspective on a phenomenon that is common if not universal. People troubled by their own compulsive behavior will appreciate her nuanced and balanced approach and perhaps come away with a new understanding of themselves.”

Publishers Weekly: “Begley’s final chapter on brain function in the compulsive mind contains fresh insight that could fundamentally alter how we think of, and treat, mental illness going forward.”

Apr 27

“The Unexpected Joy of Being Sober”: Selected Quotes

The consumer reviews of Catherine Gray‘s The Unexpected Joy of Being Sober (2018) have shown that her book is highly relatable among avid “quit lit” readers. Thus, the publisher seems to get it right: “Whether you’re a hopelessly devoted drinker, merely sober-curious, or you’ve already ditched the drink, you will love this book.”

Below are selected quotes from The Unexpected Joy of Being Sober, many of which are Gray aptly quoting others.

As Annie Grace says, ‘We protect alcohol by blaming addiction on a person’s personality rather than on the addictive nature of alcohol…The concept of addictive personality lets us close our minds to the fact that alcohol is addictive, period. (Also see this Minding Therapy link.)

Nothing good ever happens in a blackout. I’ve never woken up and been like, “What is this Pilates mat doing out?” AMY SCHUMER

I didn’t have a drinking problem as such. I was great at drinking! It was the stopping. I had a stopping problem.

If I quit eating cake, would people make jokes about me ‘not being able to handle cake’? No. I don’t think so. If I quit imbibing cheese because I wanted to commit suicide after eating cheese, would people ask, ‘Can’t you just have a little bit of cheese? Just one piece of cheese?’ *Pleadingly offers up the cheese* HAVESOMECHEESE.

As much as we try to separate alcohol from other drugs by saying ‘alcohol and drugs’ (which makes no actual sense: it’s like saying ‘foxgloves and flowers’ or ‘BMWs and cars’), alcohol is a drug.

My top sober reads are: Unwasted: My Lush Sobriety by Sacha Z Scoblic, Blackout by Sarah Hepola, This Naked Mind: Control Alcohol by Annie Grace, Dry by Augusten Burroughs and Kick the Drink…Easily by Jason Vale. [See previous blog posts on Blackout and This Naked Mind.]

Everything is interconnected. Gratitude improves sleep. Sleep reduces pain. Reduced pain improves your mood. Improved mood reduces anxiety. It’s a daisy-chain of benefits.

The eternally epic Anne Lamott says, ‘There is almost nothing outside of you that will help in any kind of lasting way, unless you’re waiting for an organ. You can’t buy, achieve or date serenity and peace of mind. This is the most horrible truth, and I so resent it. But it’s an inside job.’ (Watch Anne’s TED talk on the 12 truths she’s learned, it’s glorious.)

Addiction is now often regarded as a spectrum. ‘It isn’t an issue of “sensible drinker” and “dependent drinker”,’ says Dr. Julia Lewis. ‘People often don’t realize that everyone has their own “tipping point” along that spectrum, whereby the dependence will suddenly start running away with them.’