Psychotherapy Meets the 21st Century
Nancy J. Smyth, PhD, Dean & Professor, University at Buffalo
“Photographs do not explain, they acknowledge.” –Susan Sontag
Last month, the Oxford Dictionary made the word “selfie” not only an official word, but their word of the year for 2013. Defining selfie as “a photograph that one has taken of oneself, typically one taken with a smartphone or webcam and uploaded to a social media website” the OD made explicit what has implicitly grown to be the norm of our world; a world of smartphones, self pics and social media.
Many psychotherapists and social workers have and will continue to decry this as another sign the the “narcissism” of our age. Selfies have become synonymous with the millenials, the dumbing down of the populace by the internet, and sometimes even stretching to how Google is making us stupid. My chosen profession has historically played fast and loose with calling people and cultures narcissistic. Karen Horney coined the term “the neurotic personality of our time” in the 1930s, initially in part as a critique to the Freudian critique of Victorian modesty. Kohut’s groundbreaking work on “tragic man,” and the healthy strands of narcissism in human life was co-opted within years by Lasch (1979) to describe the then-current “culture of narcissism.” In short, even though narcissism has been a part of human being at least since Narcissus gazed into the water in Greco-Roman times, we continue to see it as perennially on the uprise.
Joanna Pappas, Epic MSW Student
This dovetails with each generation’s lament that the subsequent one has become more self-absorbed. And yet, as Sontag points out, by making photography everyday, “everybody is a celebrity.” Yep, that’s what we hate about the millennials, right? They think everything is an accomplishment, their every act destined for greatness. But as Sontag goes on to say, making everybody a celebrity is also making another interesting affirmation: “no person is more interesting than any other person.”
Jonathan Singer, Assistant Professor, Temple University
Why do many of us (therapists in particular) have a problem then with selfies? Why do we see them as a “symptom” of the narcissism of the age? Our job is to find the interesting in anyone, after all. We understand boredom as a countertransference response in many cases, our attempt to defend against some projection of the patient’s. So why the hating on selfies?
I think Lewis Aron hits on the answer, or at least part of it, in his paper “The Patient’s Experience of the Analyst’s Subjectivity.” In it he states the following:
I believe that people who are drawn to analysis as a profession have particularly strong conflicts regarding their desire to be known by another; that is, they have conflicts concerning intimacy. In more traditional terms, these are narcissistic conflicts over voyeurism and exhibitionism. Why else would anyone choose a profession in which one spends one’s life listening and looking into the lives of others while one remains relatively silent and hidden?
(Aron, A Meeting of Minds, 1996, p. 88)
In other words, I believe that many of my colleagues have such disdain for selfies because they secretly yearn to take and post them. If you shuddered with revulsion just now, check yourself. I certainly resemble that remark at times: I struggled long with whether to post my own selfie here. What might my analytically-minded colleagues think? My patients, students, supervisees? I concluded that the answers will vary, but in general the truth that I’m a human being is already out there.
Mike Langlois, PvZ Afficianado
Therapists like to give themselves airs, including an air of privacy in many instances. We get hung up on issues of self-disclosure, when what the patient is often really looking for is a revelation that we have a subjectivity rather than disclosure of personal facts. And as Aron points out, our patients often pick up on our feelings of resistance or discomfort, and tow the line. One big problem with this though is that we don’t know what they aren’t telling us about because they didn’t tell us. In the 60s and 70s there were very few LGBT issues voiced in therapy, and the naive conclusion was that this was because LGBT people and experiences were a minority, in society in general and one’s practice in specific. Of course, nobody was asking patient’s if they were LGBT, and by not asking communicating their discomfort.
What has this got to do with selfies? Well for one thing, I think that therapists are often similarly dismissive of technology, and convey this by not asking about it in general. Over and over I hear the same thing when I present on video games–“none of my patients talk about them.” When I suggest that they begin asking about them, many therapists have come back to me describing something akin to a dam bursting in the conversation of therapy. But since we can’t prove a null hypothesis, let me offer another approach to selfies.
All photographs, selfie or otherwise, do not explain anything. For example:
People who take a selfie are not explaining themselves, they are acknowledging that they are worth being visible. Unless you have never experienced any form of oppression this should be self-evident, but in case you grew up absolutely mirrored by a world who thought you were the right size, shape, color, gender, orientation and class I’ll explain: Many of our patients have at least a sneaking suspicion that they are not people. They look around the world and see others with the power and prestige and they compare that to the sense of emptiness and invisibility they feel. Other people can go to parties, get married, work in the sciences, have children, buy houses, etc. But they don’t see people like themselves prevailing in these areas. As far as they knew, they were the only biracial kid in elementary school, adoptee in middle school, bisexual in high school, trans person in college, rape survivor at their workplace.
So if they feel that they’re worth a selfie, I join with them in celebrating themselves.
As their therapist I’d even have some questions:
In addition to exploring, patients may find it a useful intervention to keep links to certain selfies which evoke certain self-concept and affect states. That way, if they need a shift in perspective or affect regulation they can access immediately a powerful visual reminder which says “This is possible for you.”
Human beings choose to represent themselves in a variety of ways, consciously and unconsciously. They can be whimsical, professional, casual, friendly, provocative, erotic, aggressive, acerbic, delightful. Are they projections of our idealized self? Absolutely. Are they revelatory of our actual self? Probably. They explain nothing, acknowledge the person who takes them, and celebrate a great deal. If there is a way you can communicate a willingness see your patient’s selfies you might be surprised at what opens up in the therapy for you both.
Melanie Sage, Assistant Professor, University of North Dakota
In other posts I have written about Huizinga’s concept of play. Rather than as seeing selfies as the latest sign that we are going to hell in a narcissistic handbasket, what if we looked at the selfie as a form of play? Selfies invite us in to the play element in the other’s life, they are not “real” life but free and unbounded. They allow each of us to transcend the ordinary for a moment in time, to celebrate the self, and share with a larger community as a form of infinite game.
It may beyond any of us to live up to the ideal that no one is less interesting than anyone else in our everyday, but seen in this light the selfie is a renunciation of the cynicism I sometimes see by the mental health professionals I meet. We sometimes seem to privilege despair as somehow more meaningful and true than joy and celebration, but aren’t both essential parts of the human condition? So if you are a psychotherapist or psychoeducator, heed my words: The Depth Police aren’t going to come and take your license away, so go out and snap a selfie while everyone is looking.
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Recently I had the great opportunity to be a scholar-in-residence at The University at Buffalo’s School of Social Work. For three days I met with students, faculty and staff to speak about emerging technologies ranging from Twitter to video games. During one morning, Dean Nancy Smyth and I sat down for a series of informal discussions around various topics, and the University was kind enough to let me share these videos with you. If you want to learn more about how I can come to your institution to do the same thing, please contact me.
How to Use Social Media and Technology to Develop a Personal Learning Network:
http://www.youtube.com/watch?v=zb74jYN0k5Y&feature=share&list=UUQG8usDJjq8OjMgtNDQC6fg
If I Don’t Use Social Media and Technology in Social Work Practice What Am I Missing?
Social Work is Changing: Integrating Social Media and Technology Into Social Work Practice
http://youtu.be/FQWUMTxXVus
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Like other art forms, video games can be both a mirror and a candle held up to our culture, at times reflecting it and at times revealing things about it. Normally I direct my posts primarily at people: therapists, gamers, educators, parents. But today I want to include the company that produces World of Warcraft as well. We have a crisis regarding thinking, and although I don’t think WoW created it at all, it has reflected it in a recent game mechanic change.
I am referring to a change mages that happened recently, where the spell Evocation was replaced by Rune of Power. For people not familiar with the game, here’s a simple explanation. Mages cast spells, but spells require an energy called mana, which gets used up gradually as you cast spells. How much mana you start with depends on your character’s intellect, and once you have used up your mana, you can’t cast any more spells until it is replenished. To replenish it you can either wait and it will gradually return (not the greatest idea in combat,) or eat and drink (not possible while you are in combat.) Or you could in the older days cast Evocation, which meant you stood in place as the spell was going, gain 15% of your total mana instantly and another 45% of your total mana over 6 sec. Move or get attacked, and the spell broke.
This recently was replaced with Rune of Power, which places a rune on the ground, which lasts for 1 min. While standing within 5 yds of it, your mana regeneration is increased by 75% and your spell damage is increased by 15%. You have to keep remembering to replace it every minute, but that’s not the problem. It may even be an easier game mechanic, but that’s not the problem either. My problem with it is how it reflects our dysfunctional attitude about thinking, and specifically our tendency to think of thinking as separate from doing something.
We live in a culture where people frequently worry about things, and in fact have ruminations that are intrusive. Many people report feeling hijacked by their minds with worrying or intrusive thoughts. And yet at the same time, few of us seem to mark our time and set it aside specifically for thinking. We schedule appointments to do things, but thinking isn’t one of them. We treat thinking, which is intangible, as if it can occur in the same space as doing other activities that are more observable and tangible. And then we are surprised when our minds rebel and hijack our thinking with thoughts and feelings that come unbidden, when all along we have been failing to cultivate the practice of intentional, mindful thinking about things.
This is where I think Blizzard and Wow initially had it right with Evocation. It was acknowledging an important truth, that Thinking IS doing something, and when done intentionally it occupies time and has benefits. Sure you weren’t able to do other things while casting Evocation, but isn’t that the point? In the real world, when you want to think deeply and seriously about something, you really do need to be intentional about it, and make a space in your day to do it. Rune of power definitely embraces the multitasking model, which encourages you to set up a rune and then go about your other business while keeping half an eye on it to know when to refresh. Multitasking is not inherently a bad thing, but there are times and places that intentional thinking may be more appropriate and less anxiety-provoking.
Part of helping patients learn to manage worrying is often to help them set up a specific time for worrying about things. This “worry time” can be a placeholder in the day or week which the patient uses when an intrusive worry enters into their thinking: They can dismiss it by deciding to put that on the agenda for the scheduled worry time. This is a way of training your mind to be intentional about what you choose to think about and when. But implicit in this is the idea that training your mind to think about things intentionally is a learned skill.
You can apply this to many different aspects of your life and work. If you are growing your private practice, when was the last time you set aside an hour to think deeply about your business plan or clinical focus. I’m not talking about daydreaming here, I’m talking about sustained intentional thought. Clinically, do you set aside supervision time to think deeply about patients? As students do you take 15 minutes after each article to think specifically about the reading? As parents, when was the last time you said to your co-parent, let’s make a time to think together about how our child is doing in life at home and school. Classroom teachers, when was the last time you asked students to take 5 minutes and think quietly about the classroom topic?
Another challenge here is the confusion of tongues around the concept of thinking. Self-help gurus often exhort us to stop thinking about things and JUST DO IT. But I don’t think they are talking about intentional thinking, I think they are talking about reactive or intrusive thinking. Procrastination is reactive thinking, worrying can be intrusive thinking. Those are often roadblocks to success, but the form of thinking I have been referring to is perhaps better described as a form of concentration meditation. Concentration meditation has come to be seen by many of us as concentrating on an image, or a candle, or chanting, or a revered object, but that is not necessarily the case, and in fact it is limiting.
What if your idea is the revered object? What if your thought process about your work, child, patient, class is worthy of your undivided attention? What if you were to schedule a specific time to think about a certain project?
If you are one of those detractors who say, “I just don’t have time to think,” I don’t buy it. Thinking time is not a luxury item, although it may be a learned discipline to set aside a few minutes at a time to do it. So please take a second and schedule a time on your calendar to think about an idea that is important to you. Schedule a time to hold your random worries and thoughts and show up at that appointed time to seriously consider them. I suspect this will free up more mental space and time than you may imagine.
And please Blizzard, bring back Evocation. I miss it, and the important life lesson in mindfulness it has to teach us.
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Nobody wants to be irrelevant, and many mental health practitioners want to try out new technologies like Apps, but how to choose? Currently the App Store in iTunes makes available 835,440 different Apps, of which approximately 100,000 are categorized as lifestyle, medical or healthcare & fitness. And Android users have just about as many to choose from according to AppBrain, which says there are a whopping 858870 as of today. With so many to look at, how can a clinician keep current? Hopefully we can help each other.
Instead of writing the occasional “Top 10 Post,” I’m setting up a site for you to visit and review different Apps. I’ll review some too, and hopefully by crowd sourcing we can get a sense of what are some of the best. I’ll need Android users to weigh in heavy, as I will be test-driving Apple products alone.
Why have I decided to do this? Several reasons, the complicated one first:
1. Web 2.0 is interactive. We forget that, even those of us who are trying to stay innovative. We keep thinking we need to get on the podium and deliver lectures, information, content. And to a degree that is true, but we can easily slide back to the old model of doing things. That’s what you see in a lot of our well-intentioned “Top 10 App” posts and articles. Recently I found myself trying to explain on several occasions why doing a lecture or post on the best Apps for Mental Health didn’t sit right with me. Part of it was because Apps are put out there so fast, and then surpassed by other apps, that it becomes a bit like Project Runway: “One day you’re in, the next day you’re out.”
I was getting trapped behind that podium again, until I realized that we don’t need another post about the top 10 mental health apps, we need an interactive platform. I need to stop acting as if I’m the only one responsible for delivering content, and you need to break out of the mold of passive recipient of information. I’m sure that many of my colleagues have some suggestions for apps that are great for their practice, and I’m hoping that you all share. Go to the new site, check out some of the ones I mentioned, and then add your own reviews. Email me some apps and I’ll try ’em and add them to the site. Let’s create something much better than a top 10 post with an expiration date, let’s collaborate on a review site together. Which brings me to:
2. I want to change the world. That is the reason I became a social worker, a therapist, and a public speaker. I think ideas motivate actions, and actions can change the world. The more access people have to products that can improve their mental health, the better. By creating a site dedicated solely to reviewing mental health applications, we can raise awareness about using emerging technologies for mental health, and help other people improve their lives. Technology can help us, which brings me to:
3. Technology can improve our mental health. Yes, you heard it here. Not, “we need to be concerned about the ethical problems with technology X,Y or Z.” “Not, the internet is making us stupid,” or “video games are making people violent,” but rather an alternate vision: Namely, that emerging technologies can allow more people more access to better mental health. Let’s start sharing examples of the way technology does that. There are Apps and other emerging technologies that can help people with Autism, Bipolar, Eating Disorders, Social Phobias, Anxiety, PTSD and many more mental health issues. I can’t possibly catalog all those alone, so I’m hoping you’ll weigh in and let me know which Apps or tech have helped you with your own struggles.
Is this the new site, Mental Health App Reviews, a finished product? Absolutely not. What it will be depends largely on all of us. This is how crowd sourcing can work. This is how Web 2.0 can work.
If you want to contribute, just email me at mike@mikelanglois.com with the following:
and I’ll take it from there. Please let me know if you are a mental health provider and or the product owner in the email as well.
You can also contribute by reviewing the Apps below that you use. Be as detailed as possible, we’re counting on you! And while you’re at it, follow us on Twitter @MHAppReviews
Recently, I had a discussion with a student about social media, and the fact that I usually start off a comment on a blog with “great post!” She noted two things: First, that it rang false to her initially, making her wonder if I even read the posts people write; and second, that despite this initial impression she found herself commenting anyway. So let me define what a great post is.
A great post is one that captures your interest and keeps the thoughtful discourse going.
Now many of my academic readers are going to vehemently disagree. They may disagree with this blog post entirely, and you know what? If they comment on it, I’ll publish the comment. Because the comment keeps the discourse going.
Also recently, I was explaining my pedagogy to colleagues who were questioning my choice to assign a whole-class group assignment for 25% of the student grade. The concern was that by giving the class a grade as a whole I would run the risk of grade inflation. This is a real concern for many of my peers in academia and I respect that, and as someone who believes in collaboration I intend to balance advocating for my pedagogical view with integrating the group’s discerning comments and suggestions. In my blog however, let me share my unbridled opinion on this.
I don’t care about grade inflation.
Really, I don’t. I went to a graduate school which didn’t have grades, but had plenty of intellectual rigor. I am more concerned with everyone having a chance to think and discuss than ranking everyone in order. That is my bias, and that is one reason I like the internet so much.
The old model of education is a meritocracy, which according to OED is:
I think that Education 2.0 has many of us rethinking this. Many of our students were indoctrinated into that view of education that is decidedly meritocratic. I suspect this was part of what was behind my student’s skepticism about “great post!” My role as an educator in a meritocracy is to evaluate the merit of these comments and ideas, rank them and award high praise only to those which truly deserve it. By great posting everything I demean student endeavors.
One of my colleagues Katie McKinnis-Dietrich frequently talks about “finding the A in the student.” This interests me more than the finite game of grading. Don’t get me wrong, I do offer students choices about how to earn highest marks in our work together, I do require things of them; but I try hard to focus more on the content and discourse rather than grades.
I frequently hear from internet curmudgeons that the internet is dumbing down the conversation. The internet isn’t dumbing down the conversation: The internet is widening it. Just as post-Gutenberg society allowed literacy to become part of the general population, Web 2.0 has allowed more and more human beings to have access to the marketplace of ideas. We are at an historic point in the marketplace of ideas, where more intellectual wares are being bought and sold. More discernment is certainly required, but the democratization of the internet has also revealed the internalized academic privilege we often take for granted. Every ivory tower now has WiFi, and so we can experience more incidents of our sneering at someone’s grammar and picking apart their spelling. What is revealed is not just the poor grammar and spelling of the other, but our own meritocratic tendencies.
Detractors will pointedly ask me if I would undergo surgery performed by someone who had never been to medical school, and I will readily admit that I will not. But how can we reconcile that with the story of Jack Andraka, a 15 year-old who with no formal training in medicine created a test for pancreatic cancer that is 100 Times More Sensitive & 26,000 Times Cheaper than Current Tests. In fact, if you listen to his TED talk, Jack implicitly tells the story of how only one of the many universities he contacted took him seriously enough to help him take this discovery to the next level. Meritocracy in this case slowed down the process of early intervention with pancreatic cancer. One side of this story is that this test will save countless lives; the darker side is how many lives were lost because the meritocracy refused to believe that someone who hadn’t been educated in the Scholastic tradition could have a real good idea.
I am urgently concerned with moving education further in the direction of democracy and innovation. Any post that gets me thinking and interacting thoughtfully with others is a great post. On a good day I remember this.
But like many academics and therapists and educators and human beings brought up in a meritocracy, I have my bad days. Like many of you, I fear becoming irrelevant. I resist change, whether it be the latest iOS or social mores. Last night I caught myself reprimanding (internally) the guy wearing a baseball cap to dinner in the restaurant I was in.
We still live in a world where only students with “special needs” have individualized education plans– quite frankly, I think that everyone should have an individualized education plan. I think our days of A’s being important are numbered. There are too many “A students” unemployed or underemployed, too many untenured professors per slot to give the same level of privilege in our educational meritocracy. Digital literacy is the new frontier, and I hope our goal is going to be maximizing the human potential of everyone for everyone’s sake. Yes this is a populist vision, I think the educational “shining city on the hill” needs to be a TARDIS, with room for the inclusion of all. I also think that those of us who have benefited from scholastic privilege will not give this privilege up easily. We desperately want to remain relevant.
I know it is risky business putting this out in the world where my colleagues could see it. I know this will diminish my academic standing in the eyes of many. I know my students may read it and co-opt my argument to try to persuade me to give the highest grade. But if I believe in discourse and collaboration I’ll have to endure that and walk the walk.
I’m not saying that every idea is a good one. What I am saying, what I believe that has changed my life for the better is something I find more humbling and amazing about the human being: Not every idea is a good one, but anyone, anyone at all, can have a good idea.
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GamerTherapist blog is on vacation and will return with new posts after Labor Day. In the meantime, here is a reader favorite:
At its heart, diagnosis is about exerting control. Clinicians want to get some sense of control in understanding a problem. We link diagnosis to prognosis to control our expectations of how likely and how much we will see a change in the patient’s condition. Insurance companies want to get a handle on how much to spend on who. Schools want to control access to resources and organize their student body. And with the current healthcare situation, the government is sure to use diagnosis as a major part of the criteria in determining who gets what kind of care.
Therapists and Educators do not like to think of ourselves as controlling people. But we often inadvertently attempt to exert control over our patients and entire segments of the population, by defining something as a problem and then locating it squarely in the individual we are “helping.”
This week has been one of those weeks where I have heard from several different colleagues about workshops they are attending where the presenters are linking Asperger’s with Gaming Addiction: Not in the sense of “Many people on the Autism Spectrum find success and motivation through the use of video games,” but rather in the sense of “excessive gaming is prevalent in the autistic spectrum community.”
This has always frustrated me, for several reasons, and I decided its time to elaborate on them again:
1. Correlation does not imply Causation. Although this is basic statistics 101 stuff, therapists and educators continue to make this mistake over and over. Lots of people with Asperger’s play video games, this is true. This should not surprise us, because lots of people play video games! 97% of all adolescent boys and 94% of adolescent girls, according to the Pew Research Center. But we love to make connections, and we love the idea that we are “in the know.” I can’t tell you how many times when I worked in education and clinics I heard talk of people were “suspected” of having Asperger’s because they liked computers and did not make eye contact. Really. If a kiddo didn’t look at the teacher, and liked to spend time on the computer, a suggested diagnosis of Autism couldn’t be far behind. We like to see patterns in life, even oversimplified ones.
2. Causation often DOES imply bias. Have you ever stopped to wonder what causes “neurotypical” behavior? Or what causes heterosexuality for that matter. Probably not. We usually try to look for the causation of things we are busily pathologizing in people. We want everyone to fit within the realm of what the unspoken majority has determined as normal. Our education system is still prone to be designed like a little factory. We want to have our desks in rows, our seats assigned, and our tests standardized. So if your sensory input is a little different, or your neurology atypical, you get “helped.” Your behavior is labeled as inappropriate if it diverges, and you are taught that you do not have and need to learn social skills.
Educators, parents, therapists and partners of folks on the Austism Spectrum, please repeat this mantra 3 times:
It is not good social skills to tell someone they do not have good social skills.
By the same token, technology, and video games, are not bad or abnormal either. Don’t you see that it is this consensual attitude that there is something “off” about kids with differences or gamers or geeks that silently telegraphs to school bullies that certain kids are targets? Yet, when an adolescent has no friends and is bullied it is often considered understandable because they have “poor social skills and spend too much time on the computer.” Of course, many of the same kids are successfully socializing online through these games, and are active members of guilds where the stuff they hear daily in school is not tolerated on guild chat.
Let’s do a little experiment: How about I forbid you to go to your book discussion group, poker night, or psychoanalytic institute. Instead, you need to spend all of your time with the people at work who annoy you, gossip about you and make your life miserable. Sorry, but it is for your own good. You need to learn to get along with them, because they are a part of your real life. You can’t hide in rooms with other weirdos who like talking about things that never happened or happened a long time ago; or hide in rooms with other people that like to spend hours holding little colored pieces of cardboard, sort them, and exchange them with each other for money; or hide in rooms where people interpret dreams and talk about “the family romance.”
I’m sure you get my point. We have forgotten how little personal power human beings have before they turn 18. So even if playing video games was a sign of Asperger’s, we need to reconsider our idea that there is something “wrong” with neuro-atypical behaviors. There isn’t.
A lot of the work I have done with adults on the spectrum has been to help them debrief the trauma of the first 20 years of their lives. I’ve had several conversations where we’ve realized that they are afraid to ask me or anyone questions about how to do things, because they worried that asking the question was inappropriate or showed poor social skills. Is that really what you want our children to learn in school and in treatment? That it is not ok to ask questions? What a recipe for a life of loneliness and fear!
If you aren’t convinced, please check out this list of famous people with ASD. They include Actors (Daryl Hannah,) bankers, composers, rock stars, a royal prince and the creator of Pokemon. Not really surprising when you think about innovation.
3. Innovation is Dangerous. Innovation, like art, requires you to want things to be different than the way they are. Those are the kids that don’t like to do math “that way,” or are seen as weird. These are the “oversensitive” ones. These are the ones who spend a lot of time in fantasy, imagining a world that is different. These are the people I want to have over for hot chocolate and talk to, frankly.
But in our world, innovation is dangerous. There are unspoken social contracts that support normalcy and bureaucracy (have you been following Congress lately?) And there are hundreds of our colleagues who are “experts” in trying to get us all marching in lockstep, even if that means killing a different drummer. When people try to innovate, they are mocked, fired from their jobs, beaten up, put down and ignored. It takes a great deal of courage to innovate. The status quo is not neutral, it actively tries to grind those who are different down.
People who are fans of technology, nowadays that means internet and computing, have always been suspect, and treated as different or out of touch with reality. They spend “too much time on the computer,” we think, until they discover the next cool thing, or crack a code that will help fight HIV. Only after society sees the value of what they did do they get any slack.
Stop counting the hours your kid is playing video games and start asking them what they are playing and what they like about it. Stop focusing exclusively on the “poor social skills” of the vulnerable kids and start paying attention to bullies, whether they be playground bullies or experts. Stop worrying about what causes autism and start worrying about how to make the world a better place for people with it.
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Last week I was speaking to a colleague whose partner is a gamer. She was telling me about their visit to his mother. During the visit my colleague was speaking to his mother about how much he still enjoys playing video games. His mother expressed how concerned she had been about his playing when he was young. “It could have been worse though,” she’d said, “at least he wasn’t into drugs.”
This comparison is reminiscent of the homophobic one where the tolerant person says, “I don’t mind if you’re gay, as long as you don’t come home with a goat.” The “distinction” made actually implies that the two things are comparable. But in fact they are not.
Our culture uses the word addiction pretty frequently and casually. And gamers and opponents of gaming alike use it in reference to playing video games. Frequently we hear the comments “gaming is like a drug,” or “video games are addictive,” or “I’m addicted to Halo 3.” What muddies the waters further are the dozens of articles that talk about “proof” that video games are addictive, that they cause real changes in the brain, changes just like drugs.
We live in a positivistic age, where something is “real” if it can be shown to be biological in nature. I could argue that biology is only one way of looking at the world, but for a change I thought I’d encourage us to take a look at the idea of gaming as addictive from the point of view of biology, specifically dopamine levels in the brain.
Dopamine levels are associated with the reward center of the brain, and the heightened sense of pleasure that characterizes rewarding experiences. When we experience something pleasurable, our dopamine levels increase. It’s nature’s way of reinforcing behaviors that are often necessary for survival.
One of the frequent pieces of evidence to support video game addiction is studies like this one by Koepp et al, which was done in 1998. It monitored changes in dopamine levels from subjects who were playing a video game. The study noted that dopamine levels increased during game play “at least twofold.” Since then literature reviews and articles with an anti-gaming bias frequently and rightly state that video games can cause dopamine levels to “double” or significantly increase.
They’re absolutely right, video games have been shown to increase dopamine levels by 100% (aka doubling.)
Just like studies have shown that food and sex increase dopamine levels:
This graph shows that eating food often doubles the level of dopamine in the brain, ranging from a spike of 50% to a spike of 100% an hour after eating. Sex is even more noticeable, in that it increases dopamine levels in the brain by 200%.
So, yes, playing video games increases dopamine levels in your brain, just like eating and having sex do, albeit less. But just because something changes your dopamine levels doesn’t mean it is addictive. In fact, we’d be in big trouble if we never had increases in our dopamine levels. Why eat or reproduce when it is just as pleasurable to lie on the rock and bask in the sun?
But here’s the other thing that gets lost in the spin. Not all dopamine level increases are created equal. Let’s take a look at another chart, from the Meth Inside-Out Public Media Service Kit:
This is a case where a picture is worth a thousand words. When we read that something “doubles” it certainly sounds intense, or severe. But an increase of 100% seems rather paltry compare to 350% (cocaine) or 1200% (Meth)!
One last chart for you, again from the NIDA. This one shows the dopamine increases (the pink line) in amphetamine, cocaine, nicotine and morphine:
Of all of these, the drug morphine comes closest to a relatively “low” increase of 100%.
So my point here is twofold:
1. Lots of things, not all or most of them drugs, increase the levels of dopamine.
2. Drugs have a much more marked, sudden, and intense increase in dopamine level increase compared to video games.
Does this mean that people can’t have problem usage of video games? No. But what it does mean, in my opinion, is that we have to stop treating behaviors as if they were controlled substances. Playing video games, watching television, eating, and having sex are behaviors that can all be problematic in certain times and certain contexts. But they are not the same as ingesting drugs, they don’t cause the same level of chemical change in the brain.
And we need to acknowledge that there is a confusion of tongues where the word addiction is involved. Using it in a clinical sense is different than in a lay sense– saying “I’m hooked on meth” is not the same as saying “I’m hooked on phonics.” Therapists and gamers alike need to be more mindful of what they are saying and meaning when they say they are addicted to video games. Do they mean it is a psychological illness, a medical phenomenon? Do they mean they can’t get enough of them, or that they like them a whole lot? Do they mean it is a problem in their life, or are they parroting what someone else has said to them?
I don’t want to oversimplify addiction by reducing it to dopamine level increase. Even in the above discussion I have oversimplified these pieces of “data.” There are several factors, such as time after drug, that we didn’t compare. And there are several other changes in brain chemistry that contribute to rewarding behavior and where it goes awry. I just want to show an example of how research can be cited and misused to distort things. The study we started out with simply found that we can measure changes in brain chemistry which occur when we do certain activities. It was not designed or intended to be proof that video games are dangerous or addictive.
Saying that something changes your brain chemistry shouldn’t become the new morality. Lots of things change your brain chemistry. But as Loretta Laroche says, “a wet towel on the bed is not the same as a mugging.” We need to keep it complicated and not throw words around like “addiction” and “drug” because we want people to take us seriously or agree with us. That isn’t scientific inquiry. That’s hysteria.
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Not too long ago, I was learning how to fire a sniper rifle in Call of Duty. It wasn’t going very well. I kept firing (which you do by holding down the right-hand trigger) and missing. Or I would use the scope, which you do by holding down the left-hand trigger; and then try to find my target so slowly that I’d get shot long before seeing it. To make thing more complicated, my patient Gordon** was trying to teach me the difference between “hardscoping” which meant to press and hold down the left trigger, and “quickscoping” which was more like a quick tap and release of the scope.
The key to success, I was told, was to locate the target, quickscope it for a second to take aim, and then fire. The source of my failure was that I’d see the target and not bother to scope at all, and just fire. At first I didn’t even know I was doing that. I thought the scope was going up, and it was, but it was going up a split second after I was firing and not before. After several fumbled attempts Gordon said, “you have to not fire and learn to push the scope first instead.” I suddenly realized that he was teaching me about impulse control.
Because many parents and therapists are reluctant to play video games, in particular first-person-shooters, they only tend to see them from outside the experience. What they learn from seeing that way is that FPS are full of violence, mayhem, blood and noise. Is it any wonder then that they grow concerned about aggression and the graphic nature of the game? It’s all that is really available to them unless there is a strong plot line and they stick around for that.
But as someone who has been playing video games for years I can tell you things are different from within the experience. And one of the most counterintuitive things I can tell you from my experience is this: First Person Shooters can help you learn impulse control. It takes a lot more impulse control to not fire at a target the second you see it. It takes a lot more impulse control to wait and scope. And because all of these microdecisions and actions take place within the player’s mind and the game experience, outside observers see violence and aggression alone and overlook the small acts of impulse control the player has to exert over and over again.
Any therapist who has worked with adolescents, people with ADHD, personality disorders and a host of other patient types understands the importance of learning impulse control. That act of mindfulness, that ability to create a moment’s space between the situation and the patient’s reaction to it is necessary to help people do everything from their homework to suicide prevention. In addition, there is always a body-based aspect to impulse control, however brief or small, and so to create that space is to forge a new and wider relationship between mind and body.
All of this was going on as we were playing Xbox. Over and over again, I was developing, practicing impulse control from behind that virtual sniper rifle. Again and again I was trying to recalibrate my bodily reflexes and sensations to a new mental model. Don’t fire. When my kill score began to rise, it wasn’t because my aim had gotten better, it was because my impulse control had.
Meanwhile, for the past two weeks I have been practicing making omeletes.
In particular, I have been learning how to make an omelette roulée of the kind Julia Childs makes below (you can skip to 3:30 if you want to go right to the pan.)
This type of omelette requires the ability to quickly (in 20-30 seconds) tilt and jerk the pan towards you multiple times, and then tilting the pan even more to flip it. Doing this over the highest heat the movement needs to be quick and reflexive or you end up tossing a scrambled eggy mess onto the burner. I can’t tell you how tense that moment is when the butter is ready and you know that once you pour in the egg mixture there is no going back. To jerk the pan sharply towards you at a tilt seems so counterintuitive, and this is an act of dexterity, meaning that your body is very involved.
In a way an omelette roulée requires impulse control just like Call of Duty in order to learn how to not push the pan but pull it toward you first. But just as importantly, making this omelette requires the ability to take risks. It can be scary to make a mess, what happens if the eggs fly into the gas flame?!
Let me tell you, because I now know what happens: You turn off the flame, wait a minute and wipe off the messy burner. And then you try again.
Adolescents, all people really, need to master both of these skills of impulse control and risk-taking. To do so means widening the space in your mind between situation and action, but not let that space become a gaping chasm impossible to cross. Learning impulse control also happens within experience, not in a special pocket universe somewhere apart from it. Learning risk-taking requires the same. And at their core they are bodily experiences, which may be what Freud meant when he said that the ego was first and foremost a body ego.
When I worked in special education settings, I was often called on to restrain children in crisis. Afterwards we would usually do a postvention: “What was happening?” “How could you do things differently next time?” We were looking at their experience from the outside, constructing a little pocket universe with words, as if we understood what had been going on in the experience, in the body and psyche of the child. I doubt these post-mortems taught impulse control.
I wonder what might have happened if we had risked throwing some eggs on the fire and encouraged the kids to play first person shooters or other video games. If my theory is right, then we would have been cooking.
**Not his real name. Name, age, gender and other identifying information have been altered to preserve confidentiality.
Mike is on vacation until September, which means that he has started talking in the third person at the end of blog posts. It also means that the next new post will be next month. He’ll repost an old fave or book excerpt to tide you over in the meantime.
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“European commerce during the Dark Ages was limited and stifled by the existence of a multitude of small kingdoms that were independently regulated and who suppressed the movement of goods across their borders through a confusing and inconsistent morass of taxation, tariff, and regulation. This forced merchants to find another solution to move their goods, one that would avoid the strangulation that resulted from this cumbersome regulatory model. These merchants chose to move their goods by sea without being subject to the problems that were created by this feudal and archaic design, a move that changed the world. The little kingdoms took hundreds of years to catch up.”
–Harris, E., & Younggren, J. N. Risk management in the digital world.
Keeping up with policy is not my favorite thing: But if I am to continue to be a consultant to therapists building their business and an educator on integrating technology into social work practice, it is part of the prep work. So when a recent client asked me a question about licensure and online therapy in our Commonwealth of Massachusetts I surfed on over to our Division of Professional Licensure to take a look. Good thing I did, and a lesson for all of you thought leaders and innovators out there, regardless of what state you live in.
There wasn’t much about technology, except for the interesting fact that the past several Board Meeting minutes made mention of a Committee discussion open to the public on “E-practice policy.” I assumed (correctly it turns out) that this meant that the Social Work Board was formulating a policy, so I reached out to the Division and asked some general questions about what it was going to look like. The answer was prompt and pretty scary.
The representative stated in her email to me that the “Board feels as if the use of electronic means should be employed as a last resort out of absolute necessity and it is not encouraged. The social worker would have the burden of proof that electronic means were employed as a last resort out of absolute necessity.”
I have several concerns about this.
Before elaborating on them, I want to explain that my concerns are informed by my experience as a clinical social worker who has used online therapy successfully for several years, as well as an educator nationwide on the thoughtful use of technology and social work practice. I have had the opportunity to present on this topic at a number of institutions including Harvard Medical School and have created the first graduate course on this topic for social workers at Boston College. In short, this issue is probably the most defining interest and area of study in my career as a social work clinician, educator and public speaker.
I also am a believer in regulation, which is why I have been licensed by the Board of Licensure in Oregon, and am in process of similar applications in several states, including CA, and NY, so that I may practice legitimately in those jurisdictions. I am a very concerned stakeholder in telemedicine and here are only a few of my concerns about a policy of “extenuating-circumstances-only-and-be-ready-to-prove-it:”
The NASW policy which I believe she is referring to was drafted 8 years ago in 2005. For context, it was drafted 5 years before the iPad in 2010, 2 years before the iPhone in 2007, and 4 years before the HITECH act in 2009. In fact, the policy I reference says nothing about limiting technology such as online therapy to “last resort;” rather it encourages more social workers and their clients to have access to and education about it. That professional organizations may be lagging behind the meaningful use and understanding of technology is not the Board’s fault. But to rely on those policies in the face of recent and evidence-based research is concerning. If the Board does wish to be more conservative than innovative in this case, I’d actually encourage it to consider the policy adopted by the Commonwealth’s Board of Allied Mental Health Professionals at http://www.mass.gov/ocabr/licensee/dpl-boards/mh/regulations/board-policies/policy-on-distance-online-and-other.html which in fact does not make any mention of setting a criteria of extenuating circumstances or potentially intimidate providers with the requirement of justification.
I hope the Board listens to my concerns and input of research and experience in the respectful spirit that it is intended. I am aware that I am commenting on a policy that I have not even seen, and I am sure that the discussions have been deep and thoughtful, but I know we can do better. As a lifetime resident of Massachusetts, I know we take pride in being forward thinkers in public policy. Usually we set the standard that other states adopt rather than follow them. I invited the Board to call upon me at any time to assist in helping further the development of this policy, and reached out to state and national NASW as well. I hope they take me up on it, but I am not too hopeful. I had to step down from my last elected NASW position because I refused to remove or change past or future blog posts.
If you practice clinical social work or psychotherapy online, it’s 3:00 AM: Do you know what your licensing boards and professional organizations are doing? Are they crafting policies which are evidence-based and value-neutral about technology, or are they drafting policies based on the feelings and opinions of a few who may not even use technology professionally?
This is a big deal, and you need to be involved, especially if you are pro-technology. The research from Pew Internet Research shows that people age 50-64 use the internet 83% of the time, about 10% less than younger people; and only 56% of people 65 or older do. These older people and digital immigrants are often also the decision-makers who are involved in policy-making and committees.
If you don’t want to practice online, you may bristle at this post. Am I saying that older people are irrelevant? No. Am I saying that traditional psychotherapy in an office is obsolete? Absolutely not. But I am saying that there is a backlash against technology from people who are defensive and scared of becoming irrelevant, and fear does not shape the best policy. Those of us with experience in social justice activism know that sometimes we need to invite ourselves to the party if we want a place at the table.
And with government the table is often concealed behind bureaucracy and pre-digital “we posted notice of this public hearing in the lobby of the State House” protocols. My local government is relatively ahead of the curve by posting minutes online, but I look forward to the day when things are disseminated more digitally, and open to the public means more than showing up at 9:30 AM on a work day. If they allow videoconferencing or teleconferencing I will gladly retract that.
At its heart, divisions of professional licensure are largely about guildcraft: They regulate quality for the good of the whole guild and the consumers who purchase services from guild members. They establish policies and sanction members of the guild as part of establishing and maintaining the imprimatur of “professional” for the entire guild. They develop criteria both to assure quality of services and to regulate the number of providers allowed in the guild with a certain level of privileges at any time: LSWs, LCSWs, and LICSWs are the modern-day versions of Apprenctice, Journeyman and Master Craftsman. This is not to say guilds are bad, but it is to say that we need more of the senior members of the guild to advocate for technology if they are using it.
Too often the terms “technology” and “online therapy” get attached to term “ethics” in a way that implies that using technology is dangerous if not inherently unethical. That’s what I see behind the idea that online therapy should only be used as a “last resort.” We thought something similar about fire once: It was mysterious to us, powerful and scary. So were books, reading and writing at one point: If you knew how to use them you were a monk or a witch.
Technology has always been daunting to the keepers of the status quo, which is why you need to start talking to your policymakers. Find out what your licensing boards are up to, advocate, give them a copy of this post. Just please do something, or you may find your practice shaped in a way that is detrimental to your patients and yourself.
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References
Birgit, W., Horn, A. B., & Andreas, M. (2013). Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. Journal Of Affective Disorders, doi:10.1016/j.jad.2013.06.032
Funderburk, B. W., Ware, L. M., Altshuler, E., & Chaffin, M. (2008). Use and feasibility of telemedicine technology in the dissemination of parent-child interaction therapy. Child Maltreatment, 13(4), 377-382.
Harris, E., & Younggren, J. N. (2011). Risk management in the digital world. Professional Psychology: Research And Practice, 42(6), 412-418. doi:10.1037/a0025139
Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., Crow, S., Lancaster, K., Simonich, H., et al. (2008). A randomized trial comparing the efficacy of cognitive–behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face. Behaviour Research & Therapy, 46(5), 581-592.
Nelson, E., Barnard, M., & Cain, S. (2006). Feasibility of telemedicine intervention for childhood depression Routledge.
Trief, P. M., Teresi, J. A., Izquierdo, R., Morin, P. C., Goland, R., Field, L., et al. (2007). Psychosocial outcomes of telemedicine case management for elderly patients with diabetes. Diabetes Care, 30(5), 1266-1268.
