The Pursuit of Happiness

Psychologists and therapists have traditionally focused on alleviating misery–-making anxious people less anxious, angry people less angry, and psychotic people less psychotic–-and assumed that happiness was a byproduct. Researchers in a relatively new subfield of psychology believe that reducing suffering is not enough and that increasing happiness should be a separate and equally important objective.

Positive psychology is the study of positive emotion and human strengths, with the goal of identifying and building strengths, nurturing talent, and improving quality of life in relatively untroubled people. Positive psychology researchers study the traits and habits of happy people and, based on their findings, design interventions to increase happiness.

So what makes us happy?

·     Strong interpersonal relationships make us happy. The people in the highest percentiles of happiness are extremely social, have rich and meaningful friendships, are in a romantic relationship, and don’t spend a lot of time alone.

·     Knowing and using our personal strengths makes us happy. Positive psychology therapy clients complete questionnaires that identify their strengths and are assigned to, for example, use their key strengths in new ways three times per week. If your two greatest strengths are patience and teaching, things like helping your niece learn to read and showing your dad how to use HTML increase happiness. Likewise, couples in therapy with a positive psychologist are assigned to go on a “strengths date,” i.e., a date during which both partners get to use their strengths.

·     Meaning (using your strengths in the service of a greater good or to belong to a larger community) and engagement (the ability to get lost in what you’re doing, whether it’s stock trading, parenting, or making music) make us happy. Pleasure (the experience of positive emotion), on the other hand, is less relevant to happiness. 

The implications of positive psychology findings are considerable. People seeking happiness through pleasure can consider pursuing engagement and meaning instead. The known relationship between happiness and outcomes like better health and longer life can have a significant positive impact on larger systems such as health care and the economy. Finally, positive psychology is an exciting and validating option for future mental health professionals (ahem) who are less interested in severe mental illness and very interested in helping well people improve their quality of life.  

Personality Disorders

DSM personality disorders are fascinating and controversial because they suggest that a person’s personality--by nature multifaceted, unique, and shaped by experience--can be maladaptive and inappropriate to the point that it constitutes a disorder. According to the DSM, a personality disorder is an enduring, inflexible, and pervasive pattern of experience and behaviour that deviates markedly from the expectations of the person’s culture; is manifested in terms of cognition, emotion, interpersonal functioning, and impulse control and leads to significant distress or impairment. The ten DSM personality disorders are divided into three clusters.

Odd or Eccentric: A person with a schizoid personality is a loner, detached or aloof, with a restricted range of emotions. A person with a paranoid personality is distrustful and suspicious, and frequently and unjustifiably perceives others as deceitful or disloyal. A person with antisocial personality disorder is popularly known as a psychopath or sociopath: manipulative and lacking in empathy or conscience. A person with a schizotypal personality is odd or eccentric, with unusual or peculiar beliefs or behaviour.

Dramatic, Emotional, or Erratic:  Borderline personality disorder is characterized by emotional instability, poor self-image, dramatic shifts in mood, fear of abandonment, and tumultuous interpersonal relationships. A person with a narcissistic personality is grandiose, selfish, entitled, and intolerant, with a strong need for admiration. A person with a histrionic personality is theatrical, flashy, emotional, and uncomfortable when not the centre of attention.

Fearful or Avoidant: A person with an avoidant personality fears criticism, avoids social interaction, and is risk-adverse and sensitive to rejection. A person with a dependent personality is needy and submissive, very sensitive to criticism or disapproval, and needs a lot of reassurance and help making decisions. A person with an obsessive-compulsive personality is focused on efficiency and productivity, and may be considered a perfectionist or a workaholic.

Each personality disorder is described by 7 to 9 traits, most of which are not independently pathological. Lots of people people are, for example, impulsive and fail to plan ahead, or show restraint within intimate relationships out of fear of shame or ridicule, without having an antisocial or avoidant personality disorder, respectively. Further, a personality disorder is not necessarily immediately obvious. You could be dating someone for three months before you realize that he is intolerant of your opinions, expects special treatment from waiters and customer service representatives, and frequently and tangentially mentions his Harvard PhD in conversation with strangers–-helping explain why he has a hard time sustaining a relationship.

Therapists can use a strong or otherwise unusual personal reaction to a given client as a clue to the possibility of a personality disorder, and can convert the reaction into a therapeutic intervention by telling the client about it (e.g., “I feel personally responsible for your well-being to an unusual extent” or “I feel like nothing I could do would allow me to gain your trust”). If the client says it’s not the first time he or she has received that particular feedback, the therapist can ask something like, “What do you think it’s like for others to feel so much responsibility for you?” or “How has your difficulty with trust affected your marriage?” to help the client gain insight about how his or her personality impacts his or her relationships.

Personality disorders don’t come out of nowhere, and can constitute a valid response to a maladaptive early environment. If you were consistently misled and betrayed as a child, paranoia is a reasonable response. If you were an adored and overprotected child who was never criticized and who never faced a tough decision or problem on her own, dependence is to be expected. The emotional instability and fear of abandonment common among individuals with borderline personality disorder are the natural outcomes of alternating abuse, invalidation, and neglect. This developmental perspective on personality disorders can be validating for clients and helpful in maintaining patience and empathy in therapists who work with people with personality disorders. The therapist’s job is then to guide the client to an understanding of the impact of the behaviour pattern on the client’s current relationships and to help the client replace dysfunctional patterns with more adaptive and appropriate behaviour.

Activity Scheduling

When you’re sad, bored, lonely, or otherwise unhappy, people often suggest that you get out of the house, join a group, do something nice for yourself, or some variation on that theme. It’s intuitive that engaging outwardly or doing something that you enjoy feels good, but this type of activity has been found to be so effective in improving mood that psychologists working with depressed clients implement mandatory participation in rewarding and pleasurable activities or in activities that increase feelings of mastery. An empirically validated treatment for depression, activity scheduling was developed thirty years ago after research demonstrated that depressed people find fewer activities pleasant and engage in pleasant activities less frequently than do non-depressed people. 

Clients are provided with a blank weekly calendar and are asked to pencil in, for example, 15 minutes of rewarding or pleasurable activity twice per day. The activity has to be realistic: a severely depressed client is unlikely to suddenly join a sports team or redecorate the kitchen. A realistic pleasurable activity might be 15 minutes of reading a magazine and sipping a hot drink. An activity that promotes mastery might be as simple as watering the plants, completing a small errand, or merely showering and shaving. For a depressed client whose life is very busy (with unpleasant or unrewarding activities), a pleasurable activity might be an afternoon coffee break during which the client stops working and listens to his or her favourite music for 15 minutes. Clients are asked to monitor their mood on a graph so that they can observe the mood shifts that correspond with activity.

The non-depressed-person version of activity scheduling is personal projects. A personal project is a hobby, venture, or activity that makes you feel happy, fulfilled, or accomplished–-things like learning to knit, joining a pub ‘trivia night’ team, building a bookshelf, writing a blog, training for an athletic event, learning to play an instrument, designing a software program, and volunteering. The parallel between activity scheduling for depressed people and personal projects for well people is obvious, and provides an intriguing perspective on the role of personal projects in quality of life. Psychology research supports the prescription of enjoyable and rewarding activities as an anti-depressant for depressed clients; it doesn’t seem far-fetched to bet that personal projects increase fulfillment and improve quality of life in well people. 

Intermittent Reinforcement

Some people (ahem) check their personal email an absurd number of times per day. Sitting in front of a computer all day, it’s hard to resist checking for new messages, even if you just checked five minutes ago. In fact, it’s almost impossible. Why?

I think I know, and I think I learned it in Intro to Psych in 1999.

In the 1950s, behavioural psychologists experimented with learning by rewarding caged rats with a food pellet every time the rats pressed a lever. Although the rats initially only pressed the lever randomly or by mistake, they quickly learned the relationship between behaviour and reward and responded with frantic lever-pressing. In psych terms, the food reinforced the lever-pressing behaviour, that is, made it more likely to be repeated. Real-life examples of this kind of conditioning include rewarding your child with a new toy when he makes his bed or your company rewarding every two years of service with a pay increase. Toys and pay raises increase bed-making and company loyalty, respectively.

What does this have to do with email checking? Well, once the rats had clearly learned the relationship between lever-pressing and food, researchers started experimenting with the timing and probability of the reward. They wanted to know what would happen if they gave a rat a food pellet every third time it pressed the lever rather than every single time. Or if they provided food every 60 seconds no matter how many times the rat pressed the lever in the past minute. Or if the reward was completely random, that is, independent of timing and frequency of the behaviour. These variations are called reinforcement schedules. To their surprise, the researchers found that the most successful reinforcement schedule was intermittent reinforcement, that is, random and inconsistent reinforcement. This finding has since been widely replicated, in animals and humans, across situations and types of reward. 

Let’s go back to email checking now. You arrive at work in the morning and check your personal email first thing. You have a bunch of new messages. When you check again 15 minutes later, you have two more new messages. The next three times you check, there’s nothing. After lunch, still nothing. But an hour later, in mid-afternoon, you sign in again and bingo–you’re rewarded with 3 new messages! Yessss!! You feel pleased and validated because all your hard email-checking work paid off. You read your messages, respond or delete, and return to work. But 15 minutes later you have the urge to check your email again. You're in the clutches of email's inherently intermittent reinforcement!

Question: Is it disturbing or reassuring to realize that your personal behaviour is governed by basic principles of learning theory that apply to all people? And, um, all rats.

Twilight Zone

Seasonal Affective Disorder (SAD) is a mood disorder in which people whose mental health is stable for most of the year experience depressive symptoms during the winter months. But what about the short-term anxiety, disorientation, or melancholy that you feel in the winter around 4pm when the light starts to change? At first I thought it was just me, but the fleeting depressive state that occurs at dusk is a legitimate phenomenon (although not included in the DSM) and it has a name. It's called Hesperian depression, after the moment when the Greek God Hesperus, the evening star, rises in the sky. 

I've discovered that the best way to combat Hesperian depression is to be doing something at that time other than staring out the window at the darkening sky. For me, the best thing is to go for a run, but a phone call to a friend, a coffee break, or some other quick and pleasant distraction will also do the trick. By the time you're done, darkness will have fallen completely, Hesperus' rise will be complete, and that uncomfortable twilight period will be over.

The DSM

First published in 1952, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the diagnostic reference manual used by psychologists, psychiatrists, and other mental health clinicians in North America. The manual lists all the different depressive disorders, anxiety disorders, substance-related disorders, psychotic disorders, eating disorders, impulse control disorders, sexual and gender identity disorders, and personality disorders, among others. Each disorder is described by a set of diagnostic criteria.

What’s good and bad about the DSM?

Let's start with the good. First, the manual creates a common language for professionals. If I tell my client’s GP that the client has panic disorder, the doctor knows what I’m talking about. Second, a DSM diagnosis provides validation for clients; if you think you’re going crazy, it can be a relief to hear that your problem is a documented phenomenon. Third, DSM criteria are helpful in recruiting participants for psychiatric research. When you read an ad for individuals who experience recurrent and persistent intrusive thoughts or impulses and repetitive behaviours that they perform in response to an obsession, you’re reading the DSM criteria for obsessive-compulsive disorder.

What are the problems with the DSM? One of the biggest criticisms is that a DSM diagnosis is stigmatizing--a valid point. For example, if you have a major depressive episode documented in your medical file, your insurance carrier might consider you a suicide risk and raise your life insurance rate. If your file says that you have a personality disorder, some therapists may hesitate to accept you as a client. For this reason, as psychology interns, we are taught to be very careful what we write in client files.

A second criticism of the DSM is that it’s categorical and the diagnostic thresholds are arbitrary. I’ll use the diagnostic criteria for post-traumatic stress disorder (PTSD) as an example. You might have experienced a traumatic event and responded with intense fear, helplessness, or horror (criterion A). You may re-experience the event through flashbacks, nightmares, or memories (criterion B) and avoid people or places associated with the trauma (criterion C). But if you don’t experience arousal symptoms such as angry outbursts and sleep disturbances (criterion D), according to the DSM, you don't have PTSD. Without a DSM diagnosis, you may be denied access to specialized treatment, and your insurance company may decline to reimburse your therapy fees.

A final point to consider about the DSM is that the inclusion of a given condition constitutes an indicator of how that condition is viewed by society. Infamously, homosexuality was included in the DSM up until the 1980s. Today, there is heated debate about whether or not Gender Identity Disorder (the feeling that your physical gender does not match your true gender) is a real disorder and if so, whether or not the DSM should change the name to the less pejorative “Gender Incongruence.”

The edition in current use is DSM-IV-TR (text revision), published in 2000, but DSM-V is to be published in 2012. In preparation, working groups at the American Psychiatric Association are making decisions about such proposed additions as binge eating disorder, Internet addiction, and premenstrual dysphoric disorder.

Stay tuned.

What's the difference?

What's the difference between a psychologist and a psychiatrist?

A psychiatrist is a person who went to medical school and chose to specialize in psychiatry rather than pediatrics, oncology, or another medical specialization. Psychiatrists are doctors and they can prescribe drugs. In contrast, a psychologist is a person who completed a PhD in psychology (although in Quebec prior to 2006, a psychologist could be granted a license with a master's degree).

The reason it's confusing is that both professionals do mental health research, see patients in clinic or hospital settings, and teach in universities. And, although therapy is usually the province of psychologists, some psychiatrists conduct therapy as well. 

What's a psychotherapist, then? Enter further complication. Until recently, the title “psychotherapist” was not protected in Quebec and no regulations governed its practice. Any psychologist, psychiatrist, doctor, nurse, social worker, sexologist—or for that matter, any software developer, construction worker, or event planner—could advertise himself or herself as a therapist. However, the term "psychotherapist" became regulated in 2012, and the right to practice psychotherapy and the use of the title psychotherapist is now restricted to psychologists and members of certain other professional orders. This legislation is good news for the public because it prevents individuals who are not adequately trained from providing psychotherapy.

Sometimes when I tell people I'm a psychologist, they say "Oh wow, I bet you're reading my mind right now!" This is a whole other level of confusion wherein psychologists are mistaken for psychics.

In sum, psychiatrists are doctors; psychologists are PhDs; psychotherapists (in Quebec) are psychoeducators, nurses, guidance counsellors, social workers, and occupational therapists, among others; and no one can read your mind. Now go forth and impress mental health professionals with your advanced understanding of the differences between professions!