Our New Offices at the Institute

The Briggs Institute has opened, and we are now seeing clients at our new offices at the Doctors Pavilion in Midtown Nashville. Speaking on behalf of the whole clinical team, we are all feeling very fortunate that we get to spend our days practicing marriage and family therapy in a space that is this beautifully designed and comfortably appointed.

As pre-licenced clinical fellows at The Briggs Institute, we are able to provide high quality relationship and mental health care services from this facility at a price that is well below that of many other therapists ($60 to $95 per session), and we remain connected to academia through supervision by core faculty at Lipscomb University, which means our work is informed by cutting-edge scientific research that most private practice therapists can’t easily access.

The Institute really is a special place, and therapy here is an exceptional value.

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The Question of Internet Addiction


As the unity of the modern world becomes increasingly a technological rather than a social affair, the techniques of the arts provide the most valuable means of insight into the real direction of our own collective purposes
. ~ Marshall McLuhan

It’s a shame that Marshall McLuhan didn’t live long enough to see the Internet come into existence. I’d love to have heard what he’d have to say about its impact on society. After all, we live in a world where interpersonal communication has been suddenly and fundamentally transformed more than it ever has been in the history of the human experiment. Children learn to interact with touch-screens before they learn to talk, the boundaries of couplehood are established by an adjustment of relationship status on social media, and a family’s generation gaps are now defined by the technologies that separate them. The Internet has become inseparable from our identities and our relationships. It has connected us — and disconnected us — in ways that we are just now beginning to understand.

Internet Addiction Defined

The most widely used definition of Internet Addiction is “the inability of individuals to control their Internet use, resulting in marked distress and/or functional impairment in daily life.”

Some researchers describe Internet Addiction in terms similar to substance-based addiction, but others are hesitant to even use the word addiction at all, instead preferring instead to use terms such as “pathological,” “problematic,” “maladaptive,” or “excessive” to describe what are essentially the same types of Internet behavior. To quote Dr. Ronald Pies:


The term pathological use of electronic media (PUEM) is less emotionally “loaded” and more encompassing than internet addiction. PUEM would permit incorporation of problems related to new electronic technologies without endlessly multiplying psychiatric diagnoses.

All of these terms reflect a slightly different interpretation of the nature of Internet Addiction, and while academics could argue endlessly about the semantics, everyone agrees that pathological use of the Internet, whether problematic or truly addictive, is a serious problem worthy of clinical study.

The Controversy of Internet Addiction

After years of deliberation, the American Psychiatric Association chose not to formally include Internet Addiction in the latest DSM. Instead, a condition titled “Internet Gaming Disorder” was identified in Section III as a “condition warranting more clinical research and experience before it might be considered for inclusion in the main book as a formal disorder.”

Essentially, the APA gave researchers a wink and a nod. They left the door open for a whole range of behavioral addictions, and the single most relevant controversy surrounding Internet Addiction still remains whether it should have been included in the DSM-V as a formal diagnosis.

Dr. Pies recognizes the gravity of the condition, but does not believe it merits inclusion:


So-called internet addiction should not be written off as another attempt by psychiatry to “medicalize” unfortunate or self-destructive behaviors. We already know that some individuals exhibiting severe overuse of the internet are in danger of serious emotional and physical complications. However, in my view, it is too soon to consider IA a full-fledged and discrete mental disorder.

On the other hand, Dr. Block believes quite simply that, “Internet addiction appears to be a common disorder that merits inclusion in DSM-V.” As Beard & Wolf put it, “The debate over the existence of Internet Addiction will probably continue for some time. Regardless of whether or not the term ‘Internet Addiction’ is used, there are people developing a harmful dependence on the Internet.”

Internet Addiction Programs

A number of clinical programs have been developed in recent years to address problematic use of electronic media, most notably, The Center for Internet Addiction founded by Dr. Kimberly Young.

In the following TED Talk, Dr. Young explains how in 1995, she became interested in Internet Addiction as a result of her friend’s husband becoming addicted to AOL chat rooms:

Dr. Young initially developed an eight-point questionnaire that assessed Internet Addiction by modifying the criteria for compulsive gambling. Based on the findings of that first questionnaire, as well as the criteria used to diagnose compulsive gambling and alcoholism, she created a more comprehensive diagnostic instrument now referred to as the Internet Addiction Test, which is still widely used by researches and clinicians today.

In 2009, Dr. Young opened the first hospital-based Internet Addiction treatment center in the United States that offers a voluntary, 10-day in-patient program for people who have been diagnosed with severe Internet Addiction. A few other treatment centers dedicated to Internet Addiction have also established themselves, most notably the reSTART Program, which claims to be the nations first retreat center program specializing in problematic Internet, video game, and technology use.

Internet Addiction Resources

Beyond clinical programs, there are a number of resources available for professionals working in this area. For instance, Dr. Young’s Center for Internet Addiction collaborated with the Zur Institute to offer a Certificate Program in “Psychology of the Web,” featuring special courses on Internet Addiction, Internet Sex Addiction, Online Gaming, and Cyberbullying. Dr. Young also offers enterprise and organization-level program development for agencies, hospitals, schools, and clinics that are considering opening an Internet Addiction recovery program.

The similarly named (but totally unaffiliated) Center for Internet and Technology Addiction founded by Dr. David Greenfield also offers a training series for mental health professionals that will help them gain a thorough understanding of the theory underlying compulsive Internet and digital media behavior, including online sexual and gaming addiction, as well as compulsive use of social media and texting.

A Treatment Philosophy

After twenty years of steady development, researchers and clinicians working in the field of Internet Addiction have established a fascinating body of work, but there is still much to be discovered about the nature (and the limits) of this disorder.

Therapists working with clients who need help for problematic use of electronic media would need to be competent in addiction treatment, but they would also need a specialized understanding of clinical assessment, the various types of Internet Addiction, and treatment and recovery strategies that are unique to the field.

In a larger sense, though, therapists need to recognize that whether problematic or beneficial, our use of the Internet now affects every aspect of our daily lives. In order to offer the highest level of care, therapists need to stay fluent in the latest media and technology trends, especially with regard to the new and varied ways in which people communicate. After all, our media and technology not only define us, but they are the very things we use to define ourselves.

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Tales of a Misophoniac

If I’m ever forced to listen to your open-mouthed chewing noises — if you’re munching your popcorn behind me in a movie theater, if you’re smacking your gum next to me in an elevator, or if you’re slurping your soup in front of me in a restaurant — you can rest assured that while I may be smiling politely, beneath the surface I am a boiling cauldron of rage and disgust silently wishing that I could duct tape your face shut.

I’m terribly sorry for reacting that way, but I really can’t help myself. You see, I have misophonia, a psychiatric disorder in which certain aversive human sounds trigger impulsive aggression and extreme negative emotion.

Yes, misophonia is a real thing.

It may not be listed in the DSM-5, but Arjan Schröder and his colleagues at the University of Amsterdam certainly think that it deserves to be. In a 2013 study, they suggested that misophonia should be classified as a discrete psychiatric disorder on the Obsessive-Compulsive spectrum. They identified the most common irritants as eating sounds, including lip smacking and swallowing; breathing sounds, such as nostril noises and sneezing; and hand sounds, such as knuckle-cracking and pen clicking. (Oof. Just thinking about that list turns my spine to glass.)

Like most people who suffer from misophonia, I lived with symptoms long before I heard of the condition, and I was relieved to discover that not only did it have a name, but I wasn’t alone. There are plenty of people out there like me who also have to suppress the urge to literally rip the throat out of a noisy swallower like Patrick Swayze at the end of Road House.

Of course, as a psychotherapist, dealing with misophonia can be a bit tricky. Clients can be the source of irritating sounds, and while I’m ashamed to admit it, sometimes I have to consciously set aside my negative emotions and remind myself to remain professional. Then again, the condition can also be a source of special bonding if I realize that a client is a fellow sufferer. I can offer an informal diagnosis, and together we can explore possible cognitive-behavioral treatment methods.

Misophonia is still poorly understood, and people are hesitant to talk about what feels like an aggressive overreaction to something as harmless as chewing sounds, but as someone who knows all too well what it feels like, I take the condition seriously.

If you live in Tennessee and want to discuss your therapeutic options for dealing with misophonia, feel free to contact me. I’m more than happy to chat with you.

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Help I'm Alive ~ Metric

Help I’m Alive: Coping With Panic Attacks

Come take my pulse, the pace is on a runaway train. Help, I’m alive. My heart keeps beating like a hammer. Beating like a hammer.

~ Metric, “Help, I’m Alive”

The first time I experienced a panic attack was at the age of 23.

I awoke violently from a deep sleep, unable to breathe. The center of my chest was being crushed by an invisible anvil. I was consumed with a profound sense of dread. Each shallow, gulping breath felt like the one that would stop my heart from beating. Every instinct of urgency and distress screamed at me that I was about to die.

My freaked-out girlfriend drove me straight to the hospital where an incredulous ER doctor kept asking me what I had taken. It was Saturday morning at 3AM, and she gave one glance at my chart (no history of anxiety) and one look at my girlfriend (purple hair and a lip ring), and absolutely refused to believe that I wasn’t on some kind of recreational drug. (I wasn’t.)

By that time, I didn’t feel like I was dying anymore. My body was a pile of cold gelatin and I was sitting in a puddle of my own sweat, but I knew how to breathe again, and I was pretty sure that I would live to see the sunrise.

The doctor hooked me up to an EKG only to find that my heart was perfectly fine. Normal sinus rhythm. I wasn’t having a heart attack. She practically rolled her eyes when she told me. Clearly, she had better things to do, but I was okay with that. I’d much rather her reaction be dismissive than concerned.

She told me that I’d probably had a panic attack. I asked the doctor what caused it and she half-shrugged, too indifferent to even bother saying “How the hell would I know?”

They discharged me from the ER and my girlfriend drove us home. We were both exhausted, our nerves were shot, but we were still able to catch a few more hours of sleep. We woke up the next morning as if nothing had even happened, the only evidence of the previous nights emergency was the hospital admissions bracelet I was still wearing as a souvenir.

When I spoke with my father later that afternoon, he told me that my grandmother had suffered panic attacks all her life. So had my uncle. It was a thing in my family, and I’d never even known.

Since that night, I’ve averaged about 1 or 2 full-blown panic attacks per year. They’re still terrifying, but I’ve learned healthy ways to effectively cope with them, and their intensity and frequency are to the point now where I don’t even consider them a problem.

The Physiology of a Panic Attack

As an expression that’s entered our everyday language, having a panic attack can mean different things to different people. Nevertheless, it’s a clinical term with a very specific set of criteria.

Let’s crack open the DSM-5 to get a clear definition:

A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

 

  1. Palpitations, pounding heart, or accelerated heart rate.
  2. Sweating.
  3. Trembling or shaking.
  4. Sensations of shortness of breath or smothering.
  5. Feelings of choking.
  6. Chest pain or discomfort.
  7. Nausea or abdominal distress.
  8. Feeling dizzy, unsteady, light-headed, or faint.
  9. Chills or heat sensations.
  10. Paresthesias (numbness or tingling sensations).
  11. Derealization or depersonalization (feelings of detachment from reality or oneself).
  12. Fear of losing control or “going crazy.”
  13. Fear of dying.

For those of you who’ve lived through a panic attack, you don’t need a dry list of symptoms to understand that wet, visceral fear — the kind of fear that might keep you alive in the face of actual danger, but absent any threat, can cripple you with physical symptoms that are terrifyingly real.

When I woke up in the midst of a full-blown panic attack, my sympathetic nervous system had already triggered my fight-or-flight response. Though it acted with the best of intentions, I had been betrayed by my own brain, specifically, a little almond shaped cluster of nerves called the amygdala.

The amygdala is the brain’s throbbing hub of fear and aggression, so it’s no surprise that this primal cluster of nerves is closely associated with the pathogenesis of panic attacks.*

The ultimate irony is that our amygdalae want to keep us safe. Their processes are specifically designed to keep us out of danger, but when they’re falsely cued by an emotional or environmental trigger —something you see, smell, hear, taste, or feel — a cascading chain of hormonal and physiological reactions lead to an attack of irrational and uncontrollable panic.

Seeking Treatment for Panic Attacks

People seeking treatment for panic attacks often want to jump right to medication. Selective serotonin reuptake inhibitors (SSRIs), for example, are frequently prescribed for people who suffer from persistent panic attacks and anxiety. Benzodiazepines are occasionally prescribed to manage acute symptoms.

Useful though it may be, medication has its limits, and only psychotherapy can address the underlying behavioral and psychological triggers that ramp up a threat response into a full-blown panic attack.

I highly recommend you watch this video about therapy and panic attacks. It’s good stuff.

The first time I went to see a therapist was for help with my panic disorder, and while my underlying causes were different than the ones in the video, the process itself was remarkably similar.

As a psychotherapist who knows all too well what it feels like to experience the crippling terror of a panic attack, I have unique understanding of what my clients are going through when they seek treatment for panic attacks and panic disorder.

If you live in Tennessee and would like to discuss your therapeutic options for dealing with panic attacks, feel free to contact me. I’m more than happy to discuss them with you.

Here’s a cocktail party fun-fact: the amygdala is also associated with right-wing politics. A 2011 study correlated political orientation with brain structure, so if you’ve ever wondered why conservative politics are so fear-based while liberal politics are more fact-based, it’s because liberalism is associated with increased gray matter, whereas conservatism is associated with increased amygdala size. One might say that millions of swollen amygdalae — and a collective lack of grey matter — are directly responsible for Donald Trump’s presidency.

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Using the Term “On the Spectrum”

A few years ago, our culture collectively stopped using the word “retarded” as an ableist slur, but lately, the phrase “on the spectrum” has caught on as common slang to describe someone as socially inept. It’s even made it to the Urban Dictionary:

On the spectrum

A phrase used to describe a person with social tics and/or awkwardness usually associated with autism or Asperger’s Syndrome.

“Sheldon Cooper is such a funny character… he’s definitely on the spectrum, though.”

Since this is Autism Awareness Month, it’s worth learning the actual definition of autism. Here are the abbreviated diagnostic criteria for Autism Spectrum Disorder as defined in the DSM-5:

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following:

  1. Deficits in social-emotional reciprocity,
  2. Deficits in nonverbal communicative behaviors used for social interaction, and
  3. Deficits in developing, maintaining, and understanding relationships.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following:

  1. Stereotyped or repetitive motor movements, use of objects, or speech.
  2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior.
  3. Highly restricted, fixated interests that are abnormal in intensity or focus.
  4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.

To be fair, there are people who are critical of the DSM definition. The Autistic Self-Advocacy Network prefers to define autism as a “neurological variation” characterized by “different sensory experiences,” “non-standard ways of learning and approaching problem solving,” and “deeply focused thinking and passionate interests in specific subjects.”

However we choose to define autism, we have to be careful how we use the term. From TV shows like The Big Bang Theory to movies like 21 Jump Street, socially awkward characters are being labeled as autistic, and that’s not a healthy trend. By using autism to describe people who have trouble socializing, communicating, or empathizing, we insult people who fit the actual diagnosis, and we spread misinformation about autism in general.

We can’t let “on the spectrum” become a cheap pop-culture reference, or worse, the next ableist slur.

 

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Powers of Ten (Reckoner Redux)

I was a child in the early 80s when I first saw Powers of Ten. It melted my tiny little brain. I was on a grade school field trip to a science museum, and they had it playing on a continuous loop at one of the exhibits. My friends couldn’t drag me away. I stood there and watched it over and over again, totally enraptured. It’s the first time I can remember ever having had such a profound experience, and I’ll never forget that warm, dizzy feeling of wonder mixed with existential terror.

If you haven’t seen the original, I highly recommend it. Of course, astro and quantum physics have come a long way since 1977. So has computer animation. Parts of the film don’t stand the test of time, but there’s also something enduring about it. There’s a certain kind of poetry embedded in the concept, and that poetry is enhanced when you strip away the original soundtrack.

That’s why I made a redux version. I prefer it that way — just the visuals and the synchronicity of Radiohead’s Reckoner. Without all that noodling music and educational voiceover it becomes an emotional journey rather than a science lesson, and that’s so much more powerful.

Every once in a while, I like to watch it again and catch that terrifying jolt of my cosmic unimportance. It lubricates my sense of scale. It keeps me grounded. It reminds me that humanity is a fleeting and fragile experiment, the sum total of which won’t even register in the grand scheme of all that unimaginable vastness.

I consider it a mindfulness exercise. Watching Powers of Ten has the effect of mediation. I walk away buzzing ever so slightly, awakened to experience, in a state of open attention to the present moment. It leaves me keenly aware of my place in the world — that I am at once the center of my own universe and at the same time utterly insignificant — and for some reason, I find great freedom in that.

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We Are Fine ~ Sharon Van Etten

We Are Fine: The Gift of Mindfulness

It’s okay to feel. Everything is real. Nothing left to steal.
‘Cause we’re alright.
We’re alright.

~ Sharon Van Etten, “We Are Fine”

Mindfulness is the act of consciously focusing the mind in the present moment without judgment and without attachment to the moment. When mindful, we are aware in and of the present moment. We are open to the fluidity of each moment as it arises and falls away.

Mindfulness practice is the repeated effort of bringing the mind back to awareness of the present moment, without judgment. It includes the repeated effort of letting go of attachment to current thoughts, emotions, and circumstances.

Mindfulness is not a place we get to. Mindfulness is a place we are. It is the going from and coming back to mindfulness that is the practice. It’s just this breath, just this step, just this struggle. Mindfulness is just where we are now, with our eyes wide open, aware, awake, attentive.

~ Excerpted from Mindfulness Skills Teaching Notes by Marsha Linehan

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That’s Just What We Do Here

On this otherwise average weekend tucked neatly between Memorial Day and the 4th of July, a man in America committed suicide. Of course, it wasn’t enough for the man to simply kill himself. He was a violent narcissist filled with so much rage that he decided to walk into a crowded nightclub full of people he hated out of self-loathing and fear and open fire with a high-powered assault rifle loaded with hundreds of rounds of ammunition, all of which he purchased legally.

In the coming days, the news outlets will ritualistically publish every juicy scrap they can uncover about this man — he’s a Muslim, a homophobe, a wife beater, an all-around asshole — and in the end, we will all nod and solemnly agree that whatever else he was, he was also “mentally unstable,” and with that, we will collectively wash our hand of any responsibility we might have as a society for this uniquely American atrocity.

That’s normal now. That’s just what we do here.

Today’s mass shooting is so apple pie American I can’t even stand it. Every few days, an angry man filled with narcissistic rage (yes, it’s always a man) decides to commit suicide by mass shooting, and occasionally the body count is high enough that we are all forced to pause and reflect.

And since this is an American ritual, the red team is ready with their petulant defense of the Second Amendment, and the blue team is ready with their outrage and exhaustion, and no one listens to anybody, but we all tune in as the President gives the same empty speech, sending the same empty thoughts and prayers to the same families of the victims in Orlando and Blacksburg and Charleston and Colorado Springs and San Bernadino and Newtown and Aurora…

…I suppose I could keep listing cities, but what would be the point? It’s the same damn speech every time, the same tired news coverage, and the same $30,000,000 spent by the NRA every year to keep even the slightest restrictions from being placed on anything with a trigger, because heaven forbid that a wife-beating asshole who’s been questioned three times by the FBI should have the slightest delay in purchasing assault weapons designed and built for no other purpose than urban warfare.

It’s the same story over and over, and like clockwork we label him as “mentally unstable,” and then suddenly it’s all just one man’s fault. We absolve ourselves of any culpability because that man meets a list of diagnostic criteria, and we conveniently ignore all the systemic failures that consistently lead us back to this same tragic set of circumstances.

We should be ashamed of ourselves for allowing this to become so normal. We should each feel guilty for this particular ritual, because we are all at fault. We let it become part of the American experience. It’s been baked into the apple pie, and it isn’t going to stop. It can’t, not until we collectively acknowledge that the man with the gun isn’t the only one who’s mentally unstable. His instability is endemic. We are all a little bit crazy to keep putting up with this shit. We are all somewhat to blame.

I certainly feel my share of the guilt. It’s enough to make me donate money and time. It’s enough to make me write my congressman. It’s enough to make me never vote for another candidate who isn’t an advocate for sensible gun control legislation. And since I’m being a wide-eyed dreamer, wouldn’t it be nice if we decided as a country to prioritize the funding of mental health care services? Wouldn’t it be wonderful if our mentally ill population was properly cared for instead of stigmatized? Wouldn’t it be great if treatment was readily available for anyone who needed it?

I know, I know. Don’t be silly.

That’s not what we do here.

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The Post-Millennial Normal

Today in our DBT consultation team, we were discussing impulsivity in teenagers and how that plays into the enormous social pressure they feel to curate an online identity. With regard to certain adolescent behaviors that might be considered inappropriate or even illicit, Dr. Vaughn offered the following bit of wisdom:

Be careful not pathologize normal behavior. A red flag isn’t always a symptom. We don’t want to label everything as problematic when some things should just be considered normal teenage risk-taking behavior.

Of course, she wasn’t excusing problematic behavior. She was merely recognizing that it requires a certain level of savvy in order to tell the difference. After all, the post-millennial generation currently going through adolescence are digital natives who never knew a world before social media, and a huge part of their identity formation takes place online and in public. They are the first generation in history to face immediate and sometimes serious consequences for behavior that previous generations took for granted.

They have Instagram, Snapchat, and a myriad of other formats — all digital, ubiquitous, and often impossible to permanently erase. At most, previous generations had Polariods — analog, singular, and simple to destroy. An impulsive decision to document illicit behavior with a Polaroid is infinitely less precarious than the same decision on Snapchat.

The technology gap between the generations has to be acknowledged. Their normal is not our normal, and when assessing adolescents, it’s absolutely critical to contextualize their behavior by their peer’s standards and not our own. Otherwise, we run the risk of pathologizing normal teenage risk-taking behavior which can damage the therapeutic relationship and lead to inefficient treatment.

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Refusing Patients On Religious Grounds

Governor Haslam just signed HB 1840, making it legal in Tennessee for mental health professionals to refuse treatment to patients based on their sincerely held religious beliefs.

I’ve been fighting against this bill since it was introduced in January, and to be honest, I never thought it was actually going to become law. Quite frankly, I thought the governor was better than this. He was savvy enough to veto that ridiculous bill making the Bible the official state book, but I guess he felt the need to throw a bone to all the ignorant wingnuts in the Tennessee legislature. It’s a real shame, because HB 1840 is a hateful piece of legislation that encourages discrimination, protects small-minded bigots, and erodes the ethics of my profession.

The sad irony is that none of us wanted this. Across the state, every professional association of psychologists, counselors, and therapists fought hard to defeat this bill, but a tiny group of suspiciously well-funded conservative Christians decided that they knew better than the people who actually do this for a living, and now we’ve all been dragged over to the wrong side of history. I still consider it an honor to call myself a therapist, but today I’m ashamed to call myself a Tennessean.

In light of that shame, I want to extend myself to anyone across the state who might read this. If you are struggling with issues of sexuality or spirituality and you feel like you can’t speak freely with your church or local counselor for fear that you might be refused treatment, please reach out to me. I will do everything I can to help you find the mental health resources you need, wherever you happen to be.

Nobody should ever have to worry that they might be refused mental health care for being open and honest about their sexual orientation, gender identity, or religious doubts, and any therapist who would use this disgusting law to put their own sanctimonious objections ahead of a patient’s well being doesn’t deserve to have a license.

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