Part Two: Dovetailing Dialectical Behavior Therapy (DBT) and Emotional Intelligence

Dialectical Behavior Therapy (DBT) but First a Disclaimer

The following post is entirely my own interpretation of DBT, and I am solely responsible for the content. I am in no way authorized as a spokesperson for the field of DBT.

In the immediately preceding post, I listed ten mental health skills areas, five derived from emotional intelligence and five derived from dialectical behavior therapy (DBT). That post focused on emotional intelligence and this one on DBT. However, this post is not about providing or consuming DBT. Instead I introduce the four skill sets of DBT along with dialectical thinking teased out as an additional skill set. To be sure, dialectical thinking is the sauce that permeates the four skill sets of DBT, and its separation is not authorized. I do so to highlight it as a mental health skill.

Marsha Linehan is the architect of DBT. She conceived the intervention as a manualized intervention for persons who live with borderline personality disorder. DBT, however, can enhance the mental health of everyone. In my own practice, I present the principles of DBT in psychoeducational doses to my patients as part of individual therapy.

Dr. Linehan’s principles can be found in her seminal book, Cognitive-Behavioral Treatment of Borderline Personality Disorder. As extraordinary as that book is, the one I recommend for beginners is DBT Made Simple by Sheri Van Dijk. You can use this post as an introduction to DBT vocabulary and then turn to Van Dijk for an in-depth look. After that, please get Linehan’s original book. Read it and keep it for reference.

Five Mental Health Skill Sets Gleaned from DBT

1. Dialectical thinking

Dialectical thinking is the ability to see validity on all sides of issues, including controversial ones, and simultaneously accept the contradictions.

Dialectical thinking asks us not to judge the intrinsic worth of people, situation, and objects. We are, however, allowed to judge whether we like or don’t like certain people, situations, and objects. Caveat: Our likes and dislikes are usually best kept to ourselves.

Dialectical thinking is a tough sell because we humans have evolved to prefer negativity and its attendant divisiveness. Social media and much of traditional media make fortunes with snarkiness, trolling, condemnation, and AI programmed polarization.

After noticing the negative, mentally healthy people immediately seek all relevant sources of data before concluding anything. These highly functioning people have cultivated the ability to tolerate ambiguity and to be patient with complexity.

(Dialectical thinking is not one of the four sanctioned DBT skill sets. Instead it is the foundation of DBT, just look at the name, dialectical. For the purpose of this post, I discuss it as a skill to help newcomers to DBT.)

2. (1) Mindfulness

Traditionally, mindfulness is the ability to be in the moment while suspending judgment about external and internal stimuli.

My preference, however, is to define mindfulness as the ability to return immediately to the present as necessary. Mindfulness allows sojourns to the past and to the future while keeping the path clear to the present. Mindfulness should be largely joyful, not a prison sentence to present time.

The measure of mindfulness is willful, focused attention. We scan the environment and then proactively choose what to observe.

Lack of mindfulness has three traps. Ironically, the first is getting stuck in the present. This can be a form of dissociation called depersonalization/derealization disorder (DDD). The real problem with DDD is not the surreality or the outside observer perspective but the being stuck. The second trap is getting stuck in the past and is called rumination, a core component of depression. ((Note: The rumination in depression can be so severe that the future is often blank, i.e. hopeless.)) The third trap is getting stuck in the future and is called catastrophizing, a core component of clinically significant anxiety.

Therefore, the skill set of mindfulness is essential for modulating anxiety and depression and keeping them within healthy bounds. ((The concept of anxiety and depression as health promoting may surprise you. A topic for a future post.))

Pointers on achieving mindfulness

Mindfulness is predicated on a physically and mentally healthy lifestyle and is not a standalone skill. Competence in mindfulness comes as one develops all the skills of DBT and emotional intelligence.
Managing the consumption of media, both social and traditional, is basic to mindfulness.
Mindfulness operates in the background but requires frequent conscious daily doses of a few seconds to a few minutes.
There are many mindfulness skill building exercises. The one I recommend for beginners is physiological coherence breathing (PCB).

3. (2) Distress Tolerance

Distress tolerance is the ability to acknowledge our upsetting emotional reactions to negative people, objects, and situations while acknowledging the positive and neutral aspects of our current context.
Distress tolerance is the ability to withstand emotional reactions and delaying responding until all appropriate data are in.
Distress tolerance is recognizing that the present is not our future or our past.
Distress tolerance is mindfulness in action: Experiencing the moment without attempting escape unless unacceptable harm could result.

Opportunities for developing distress tolerance

Physical exercise for 30 minutes a day in addition to routine labor such as household chores, shopping, etc. The 30 minutes can be divided into exercise snacks as short as 2 minutes.
Twenty minutes three times a week of physical exercise harder than you want such as running, swimming, spinning (not leisurely bike riding), stair climbing, wheelchair workouts, rowing, etc. according to the limbs available to you.
Not automatically looking at your digital devices when standing in a queue, stopped for a traffic light, or in a waiting room. ((The waiting room is a tough situation. If alone, I will refrain from my phone for five minutes. If others are present, I will look at my phone right away to avoid becoming a distraction to others.))

4. (3) Emotional Regulation

Our emotional reactions serve as suggested default responses. Emotional regulation is the ability to respond to challenges, big or small, in pro-self and prosocial ways whether or not they are in agreement with our emotional reactions.

This is a tall order because evolution by natural selection (EBNS) has selected for obeying emotional reactions without question. What had worked in the wild is now an obstacle to self-actualization in civilization.

Emotional regulation is a proactive effort to be aware of our emotional urges and their triggers. Our mental health demands that we study these urges, accept them as part of ourselves, and carefully choose our responses to the challenges of life while taking our emotional reactions into account as only one source of information.

Our individual schemas of reality begin in our heads and cause us to have expectations: Expectations of ourselves, of others, and of the physical world. When our expectations are contradicted, emotional reactions automatically flood our thinking, our desires, our central and peripheral nervous systems, and our internal organs and glands with the result of blinding us to context.

So, emotionally regulated people deal with challenges by thoughtful, analytic responding after considering all the available data beyond the restricted context of emotional reactions. Often the best solution to a challenge is the one suggested by an emotional reaction, but only after considering the range of responses available. All important decisions of life (partners, living arrangements, careers, significant purchases, etc.) should be rooted in emotional reactions but carried out only after analyzing the consequences.

5. (4) Interpersonal Effectiveness

Interpersonal effectiveness is the ability to cooperate with others so that all parties get more from the cooperation. In my experience, the ability to compromise is the essential skill of interpersonal effectiveness. Let me explain: Compromise has dual outcomes, gain and loss. Mentally healthy people are grateful for the gain, and their gratitude overcomes the loss. On the other hand, those people who have growth edges in interpersonal effectiveness are determined never to lose anything, tangible or intangible. The obsession of never relinquishing is just that, an obsession which interferes with mental health.

The willingness to compromise is in line with recent findings that people older than 65 with dispositional gratitude and without a single-minded attitude of loss avoidance are more satisfied.

Please look at the section on Sociability in Part One of this two-part post for more ideas on interpersonal effectiveness.

Endnotes

Writing this post has given me new appreciation into Dr. Linehan’s formulation of DBT. Specifically, interpersonal effectiveness rests on emotional regulation, which rests on distress tolerance, which rests on mindfulness, and all that combined rests on dialectical thinking.
We can use the skills in this post and in Part One prophylactically, similarly to daily physical workouts. Will power and healthy practices cultivated daily are a rehearsal for the inevitable violations of our naïve expectations. If we do not exercise our will power and healthy habits daily, they will not be available to us in the throes of urgent situations and temptations.
Consult a therapist as needed. Life is so complicated that we can’t see everything. The best of parents and schools cannot prepare us for everything. Psychotherapy is an opportunity for lifelong learning, although working with a therapist need not be lifelong.

Good mental health,

Dr. Michael DeCaria

(The featured image is a clematis growing through an wooden fence a few blocks from my house. I was thrilled that Millcreek City chose this photo for inclusion in its 2022 calendar. Photograph by the author)

Psychotherapy and Psychology

Breathing for Physiological Coherence.

Introduction

If you are reading this post, you are, of course, breathing. But are you breathing in a way that supports your mental health?

It turns out that physiological coherence breathing (PCB) can magnify the mental health skills of mindfulness, distress tolerance, and emotional regulation. So, what is a technique for breathing?

Technique

A respiration set is 12 respiration cycles, each lasting 10 seconds for a total of 2 minutes.

A respiration cycle lasts 10 seconds: one inhalation for 5 seconds and one exhalation for 5 seconds.

The timing reminder of the five second intervals can be visual, auditory, or tactile depending on the sensory pathways available to you.

For beginners I recommend one set in the morning and another in the evening.

What to Expect

The skills of mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness increase gradually along with your competence in PCB.
Mental health functioning requires much more than PCB, but PCB is an effective way to start.
Many people are skilled in PCB without ever having heard of it because PCB develops naturally in tai chi, yoga, religious prayer especially antiphonal, athletic pursuits, and similar activities.
Once you have achieved some competence in PCB, you will find yourself using it often without awareness.

Why Physiological Coherence Breathing Works

Our brains do not have an off switch; they are always on. Even when we sleep. Instead, our brains operate in different functional states governed by different neural networks. The first of these to be named was the default mode network (DMN). When the DMN is operating we are thinking of ourselves in relationship to others, to the past, and to the future.

The DMN is critical to our surviving, but getting stuck in it can have had adverse consequences. Two of these are getting stuck in the past, rumination, and getting stuck in the future, catastrophizing. Rumination is a core cause of depression, and catastrophizing is a core cause of anxiety. ((Anxiety and depression are normal and useful conditions that contribute to the quality of life. Both can become pathological, but that is the subject of a future post.))

Physiological coherence breathing switches off the DMN and switches on the rest and digest network (RDN). This latter network allows the renewal of our physical and psychological systems and is mediated by the vagus or tenth cranial nerves. The pair of vagus nerves originate at the bottom of the brainstem and coordinate the heart, lungs, internal organs, and many muscles of the face. Physiological coherence breathing is associated with the coordination of brain and organ functioning along with facial expressions.

We humans may have a brain center that monitors respiration rate. Rapid respiration alerts the sympathetic nervous system for the classic fight, flight, freeze, or fawn defensive activities. Slow respiration energizes the parasympathetic nervous system and the RDN.

Endnotes

A school of thought says that physical and mental health rests on four things:
1. Healthy air
2. Healthy water
3. Nutritious food
4. Physical movement
This post supplements the two-part post on emotional intelligence and dialectical behavior therapy (DBT).
An easy add-on to PCB is to allow the muscles of the face, especially around the eyes and cheekbones, to relax while doing the breath work. Recall that the vagus nerve regulates some muscles of the face.

Good mental health,

Dr. Michael DeCaria

(The featured photo is sunrise through Millcreek Canyon in the Wasatch Mountains with Grandeur Peak on the left. Photograph by the author.)

Psychotherapy and Psychology

Part One: Dovetailing Emotional Intelligence and Dialectical Behavior Therapy (DBT)

Introduction

Marsha Linehan’s dialectical behavior therapy (DBT) in 1993 and Daniel Goleman’s emotional intelligence in 1995 significantly advanced psychology. Dr. Linehan formulated a new cognitive behavioral treatment (CBT) for borderline personality disorder, and Dr. Goleman presented a structural outline of highly functional human behavior. Although the two psychologists came from two different philosophical directions, the former clinical and the latter global, their overlapping findings give us a vocabulary for describing mental health skills.

Dictionary definitions of mental health include meeting thresholds of self-acceptance, positive regard for others, and social functioning. Emotional intelligence and DBT go beyond dictionaries with operational definitions of mental health components.

Together, emotional intelligence and DBT each have five skill areas for a total of ten.

Emotional intelligence:

Self-awareness
Self-regulation
Motivation
Empathy
Socialization

Dialectical behavior therapy:

Dialectical thinking
Mindfulness
Emotional regulation
Distress tolerance
Interpersonal effectiveness

Below I introduce emotional intelligence and its five skills sets. Dialectical behavior therapy and its skills sets follow in another post.

Emotional Intelligence ((A proper introduction with an in-depth understanding of emotional intelligence is best left to Goleman’s publications and talks. My intent is to provide an outline along with highlights that speak to me.))

Emotional intelligence is the ability to recognize emotions in yourself and in others and then use that knowledge to enhance your life and your communities.

Daniel Goleman’s book, Emotional Intelligence: Why It Can Matter More than IQ, is a monumental achievement. The book is one of the few found in both my hardcopy and virtual libraries. The information is so dense that I have read the book three times. If you are a mental health professional or a layperson who wants to be an increasingly effective human being, Dr. Goleman’s book is essential. Here are the five components:

1. Self-awareness

Self-awareness has three abilities:

Acknowledging our different emotions
Recognizing what causes them
Accepting them, i.e., not judging ourselves negatively for having them.

Here is one dictionary definition of emotion: a conscious mental reaction (such as anger or fear) subjectively experienced as strong feeling usually directed toward a specific object [person or situation] and typically accompanied by physiological and behavioral changes in the body. ((“emotion.” 2022. In Merriam-Webster.com. Retrieved February 3, 2022, from https://www.merriam-webster.com/dictionary/emotion. (Author’s addition in brackets) ))

Emotions are complex, and what we call a particular emotion is just the most prominent one mixed up with others. For this reason “emotional episodes” may be more descriptive than “emotions.” Emotional episodes evolved as templates of behavior over evolutionary time to aid animals and us to increase the odds of survival by reacting without thinking. The quality of self-awareness asks us to change without thinking to with thinking.

Here is a list of basic emotional episodes common to people in all cultures: ((This is only one of several lists of emotions that philosophers and scientists have proposed. All such lists are controversial. Nevertheless, this is one that I find the most useful in the clinical setting.))

Fear
Anger
Sadness
Joy
Disgust
Surprise
Embarrassment
Shame
Guilt
Pride of accomplishment

2. Self-regulation

Regulating emotional experiences means accepting the experiences and then behaving in an informed way to modulate them. When we can name an emotional experience, we can feed it or starve it by our actions and inactions.

Evolution by natural selection (EBNS) has resulted in a numerous evolved psychological mechanisms (EPMs). Some of these are urges accompanied by mental and physical discomfort, sometimes extreme, if not acted on. Some EPMs such as an exaggerated fear of spiders or the urge to eat stale food rather than throw it away are silly. Other EPMs, such as the urge to take one’s own life when jilted by a lover or to go to war over national pride, are tragic.

Some common characteristics of emotional episodes:

They have either an approach valence or an avoidance valence. Often, to our consternation, both valences operate simultaneously.
They exist in a temporal context that may be eons old.
They are about our beliefs and about our interactions with the environment.
They can be occasions of great learning.
They are our first response to challenges that violate our expectations.

Obstacles to self-regulation of emotional episodes

Emotional episodes cannot be quickly turned off by will power. If they could, they would be useless.
Emotional episodes are complex.
Emotional episodes are like icebergs: They operate in the unconscious long before awareness.
As a consequence of evolution by natural selection, an emotional episode can be in full operation before cognitive controls kick in.
Our expectations are often based on a desire for coherence of belief rather than the truth.

Strategies for self-regulation of emotional episodes

The regulation of emotional episodes is to prevent escalation of the episodes and not to stop them in their tracks.
Live life daily in synchrony with your circadian rhythm.
I referenced will power in the above bullet list. Although will power cannot turn off an emotional experience, it can be part of a preventive strategy limiting escalation, e.g., anger need not become rage.
Engineer your life to reduce nasty surprises and to maximize joyful surprises.
Know the valence of your emotional episodes and act oppositely. For example, anger is an approach emotion. When you feel angry, withdraw from the focus of the anger and observe the larger picture. Sadness is an avoidance emotion. When you feel sad, embrace the focus of the pain.
Foster expectations of life based on accepting reality.

3. Internal Motivation

Internal motivation is the ability to act consistently in the best interests of yourself and of your communities even if your actions may be unpopular. Internal motivation is not deliberately contrarian; it is informed by foresight, the ability to see the beneficial effects of present behavior in the future.

Internal motivation is a skill set consciously sought after and built on a widely based experiential and academic learning. Acquiring and maintaining internal motivation is an active process.

Internal motivation is not closing yourself off from the voices of others. It means acting in accord with all the data available to you including knowledge received from others. In my view of emotional intelligence, internal motivation requires us to be a citizens of our communities. Cult leaders and their followers may have internal motivation to exploit the common good for their selfish purposes, but that brand of motivation is not emotional intelligence.

Motivation and self-regulation rely on each other.

4. Empathy

Empathy consists of two pieces: (a) the prosocial ability to recognize and distinguish emotional episodes in other people and (b) the ability to recognize how other people’s current situations relate to their emotional episodes.

A note on language: English in all its varieties has a confusing vocabulary around empathy. A few examples are sympathy, compassion, and empathic concern. Then there are the adjectives empathetic and empathic. I will leave it to linguists to sort through the semantics and the varieties of national English and ESL, and I will use empathy as defined above.

Empathy and morality

I subscribe to the school that empathy is the source of morality defined secularly. Empathy is also the source of ethics. Societal institutions such as governments and religions are corrupted by relying only on persons with economic and political power for financing. The result is that governments often forego their Lockean duties to secure basic human rights for all its citizens. Similarly, followers of religion sometimes substitute professed beliefs and solidarity practices for the entirety of a moral code.

Empathy and forgiveness

I do not subscribe to the school that forgiveness is something to attain at all costs. Forgiveness, however, is a wonderful experience, and we should be open to it finding us. I have been able to forgive others when I have realized their capabilities had been taxed by the extraordinary demands often placed on them precisely because of those capabilities.

5. Socialization

We demonstrate socialization by contributing ideas to the conversation, by managing teams, and by working through conflicts. Ultimately, socialization is getting along with others and is the ultimate test of emotional intelligence. We prepare ourselves for socialization by cultivating self-awareness, self-regulation, internal motivation, and empathy.

Contributing to the conversation

Intelligently. We learn to distinguish details; learn to distinguish important from unimportant detail; learn to focus on the important and set aside the unimportant; learn to compare and contrast; and finally learn to rank order.
Humbly. We may or may not be the smartest person in the room. The smartest person is rarely smart enough, anyway. All ideas stimulate other ideas until a viable plan emerges given the resources and time constraints.
Generously: Knowledge is power: Give it away. Mentor others and let the credit go to them. Adam Grant details how doing so allows your communities to prosper and you along with them.

Managing teams

Managing teams is about letting the members work for each other and for you as a leader. Most humans are more motivated by peer relationships than by causes. Treating all the members of the team as fellow humans will contribute to repeated successes over time. I admire the principle of Stoic philosophy that teaches us to live each moment as a gift to ourselves and to others rather than focusing primarily on outcomes. Outcomes matter but they are secondary to each team member’s individual humanity.

Working through conflicts

Because evolution by natural selection (EBNS) has resulted in humans being easily inclined to intrasexual competition, conflicts are inevitable. Emotionally intelligent people utilize self-awareness to check their own urges to compete unnecessarily, and they utilize empathy to recognize urges in others to compete unnecessarily. Emotionally intelligent people are skilled in emotional regulation and in deescalating techniques when unnecessary urges to compete are felt.

Endnote

Thank you for reading this post. If you are new to the details of emotional intelligence, even this little introduction may require a repeated reading. I have read Goleman’s book three times (as mentioned above) and discovered new insights each time. I wonder how many more await me on another reading. I very much welcome your comments. Another post will follow soon on dialectical behavior therapy.

Best regards,

Dr. Michael DeCaria

(The featured image is of a nearly full Moon rising over the the Wasatch Mountains of Utah. Photograph by the author.)

Psychotherapy and Psychology

Trauma: Posttraumatic Stress Disorder (PTSD)

Introduction

This post is the second on trauma and focuses on posttraumatic stress disorder (PTSD). The first post provided an a overview of trauma.
I became interested in treating PTSD in 1991. I had heard a report that 75,000 American veterans of the War in Vietnam had committed suicide from the official end of the war in 1975 to 1991. The figure shocked me because it was much greater than 58,000, the official American military death toll from the war itself.
As I started providing services for patients living with PTSD, I soon realized that most of my patients were not veterans. Instead they were civilian survivors of maltreatment at the hands, often literally, of parents, of other family members, of intimate partners, and of other trusted adults. Other patients had developed PTSD from motor vehicle accidents, crimes perpetrated by strangers, and wars in their residential areas. Still other patients were first responders, and, yes, many were military veterans.
This post is based on my clinical experience of serving patients with PTSD.

What is posttraumatic stress disorder (PTSD)?

A mental condition

sometimes occurring in persons who have experienced extreme, often catastrophic, challenges that have shattered two core beliefs: the ability to care for themselves and their certainty that the world is safe ((A recent patient told me: “I don’t trust anything – I have lost the ability to trust myself.”)) and
having many other characteristics (listed directly below).
It is important to note that:
- PTSD is only one kind of adverse traumatic mental condition that can result from an extreme challenge, and
- not all persons who experience extreme challenges develop PTSD.

What are some of the characteristics of PTSD?

The traumatic reaction lasts more than 30 days.
Unwanted, intrusive reexperiencing of the traumatic episode (e.g.., flashbacks, distressing dreams)
Avoiding or attempting to avoid actual or similar environmental reminders of the challenge
Attempting to avoid emotions associated with the traumatic experience (i.e., anxiety itself)
Intense psychological and physical distress when avoiding reminders is not possible
Withdrawing from emotional life, i.e., dissociation
Isolating from social support systems
Pervasive shame
Marked weakening of the basic mental health abilities of mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. ((Some readers may recognize that these skills, along with dialectical thinking, make up the core of dialectical behavior therapy (DBT).
Anniversary reactions

What is the DSM-5® and what does it say about PTSD?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a publication of the American Psychiatric Association.
The United States uses the DSM-5 exclusively as the official list of psychiatric disorders and their descriptions.
The DSM-5 has rigid, enumerated lists of criteria for every listed disorder, and patients must meet a set number of criteria for their behavior to meet a diagnosis.

What are the DSM-5 criteria for PTSD? ((This list is only an incomplete summary of the DSM-5 criteria. Accurate diagnosis of PTSD requires a qualified mental health provider.))

The DSM-5 specifically limits the diagnosis of PTSD to trauma resulting from three specific types of challenges: “Exposure to actual or threatened death, serious injury, or sexual violence….” ((DSM-5))
Intrusive symptoms such as distressing memories, distressing dreams, flashbacks, emotional distress and/or physiological reactions to internal or environmental reminders of the original challenge
Strong motivation to avoid any reminders of the original challenge
Extremely negative evaluation of one’s personal abilities
Belief that the world is overwhelmingly dangerous
Increases or decreases in arousal and activity levels related to the unresolved trauma.
The traumatic symptoms must last last longer than one month and “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” ((DSM-5.))

What is the ICD-10 and what does it say about PTSD?

The ICD-10 Classification of Mental and Behavioural Disorders (ICD-10) is a publication of the World Health Organization (WHO).
The DSM-5 is closely modeled on the ICD-10 (just as the DSM-IV was modeled on the ICD-9).
Almost all mental health practitioners outside the United States use the ICD-10.
Here is the ICD-10 diagnostic description for PTSD (F43.1): (PTSD) arises as a delayed and/or protracted response to a stressful event or situation (either short-or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone (e.g. natural or man-made (sic) disaster, combat, serious accident, witnessing the violent death of others or being the victim of torture, terrorism, rape, or other crime).
The ICD-10 then has several paragraphs highlighting possible symptoms without the enumerated list of the DSM-5. The ICD-10 has a more elastic feel for clinicians matching behavior to diagnoses. ((As with the DSM-5, all ICD-10 diagnoses including PTSD must be left to qualified mental health providers.))

Are the DSM-5 and the ICD-10 too restrictive?

In my opinion they are too restrictive because challenges besides death, injury, and sexual violence can result in pervasive, debilitating traumatic reactions.
The DSM-5 and the ICD-10 do recognize the traumatic reactions to other challenges and call them adjustment disorders.
But adjustment disorders are “lightweight” diagnoses, and American insurance companies often limit paying for treatment.

What are some challenges besides death, injury, and sexual violence that can result in PTSD-like reactions?

Being subjected to distant, rejecting, and self-absorbed parenting during childhood and adolescence
Experiencing microaggressions based on externally imposed membership in a less privileged category of society
Experiencing infidelity in an intimate relationship
Loss of social status (through change of relationship status, job loss, financial setbacks, aging, etc.)

What is complex PTSD (C-PTSD)?

C-PTSD is not included in the DSM-5 or the ICD-10.
C-PTSD is a subset of PTSD characterized by the extreme severity of symptoms and/or the chronic reexperiencing.
Hypothesis: The people most likely to be targeted for chronic adverse challenges are the members of society with the least access to political, financial, and cultural power.
Recommendation for future editions of the DSM and ICD: Broaden the criteria for PTSD so that
- more people who live with the condition can receive treatment and
- societal practices that allow PTSD to develop in the first place can be highlighted and eliminated.

What are the risk factors for PTSD?

Failure of self-soothing skills
Failure of social support systems (e.g., family, ecclesiastical, school, business, and government) ((These two failures coincide with my view that self-soothing and peer relations are the two primary developmental goals for children and adolescents.))

Summary

PTSD is an interaction between the degree of the challenge and the vulnerability of the person experiencing the challenge.
Not all persons who experience extreme, even catastrophic, challenges will develop PTSD.
Society plays an outsized role in setting up conditions conducive to individuals acquiring PTSD.
Governments could do much more to pressure the other institutions of society (family, religion, school, and business) to promote a more inclusive society.
PTSD is not the only possible outcome of a traumatic experience.
PTSD is not always curable, but it is almost always treatable.

Good mental health,

Dr. Michael DeCaria

(The featured image is a pond at the International Center, an industrial park just west of the Salt Lake International Airport. Photograph by the author.)

Psychotherapy and Psychology

Trauma: An Overview

What is psychological trauma?

A mental condition resulting from a challenge that shatters two core beliefs: Our ability to care for ourselves and our certainty that the world is safe
Note that trauma refers to the mental condition and not to the challenge. The challenge is extrinsic and the trauma is intrinsic.

What are some challenges that can result in trauma?

Being subjected to distant, rejecting, and self-absorbed parenting during childhood and adolescence
Personally experiencing near death or witnessing the death or near death of another
Personally experiencing serious injury or the threat of such; similarly witnessing serious injury or the threat of such to another
Experiencing sexual violence or witnessing sexual violence to another (Note: The threat of sexual violence is in itself sexual violence.)
Experiencing microaggressions based on externally imposed membership in a less privileged category of society
Experiencing infidelity in an intimate relationship
Loss of social status (through change of relationship status, job loss, ageing, etc.)

How long can trauma last?

From twenty-four hours to a lifetime
The duration of a trauma is affected by the duration of the challenge.
- A trauma can result from a discrete challenge such as a motor vehicle accident (MVA) or
- from a long-term challenge (e.g., ongoing parental maltreatment or the aggressions and microaggressions perpetrated by societal groups with economic and political power against members of communities with less access to such powers.)

Can trauma ever have positive outcomes?

Yes, under the following conditions:
- The trauma is induced by a discrete challenge.
- The trauma reaction lasts less than 30 days.
- The target of the challenge has adequate skills of emotional regulation.
- The target of the challenge has adequate social support.
As a result, the target of the challenge:
- heals back stronger and smarter, and
- experiences joy, the reward of having negotiated the trauma successfully.

Does vulnerability to trauma have individual differences?

Yes, some people demonstrate two overlapping qualities when challenges confront them:
- Hardiness: The ability to place distress in context while determining the appropriate response
- Resilience: The ability to regain confidence in the ability to care for the self
Psychological science has identified three attitudes of people who demonstrate hardiness and resilience:
- Commitment: Joining with others rather than isolating
- Control: Actively working to change what is happening rather than passively accepting the outcome
- Incorporation: Being open to new learning and establishing a new normal regardless of the final outcome of the challenge
People are born with more or less hardiness and resilience, but everyone can proactively work to increase these two skill sets through psychotherapy and other mentoring.

Can trauma ever have negative outcomes?

Yes,
- When constant or quickly repeating challenges do not permit recovery
- When sufficient skills of distress tolerance are lacking
- When a caring social network is lacking
Sadly, Nietzsche’s aphorism, “That what does not kill me makes me stronger,” is not reliably true.

What are some negative outcomes of trauma?

Shame: Feeling public disapproval because “I should have been smarter and stronger.”
Depression
- Uncontrolled rumination or catastrophizing
- Lethargy
- No longer enjoying what was once pleasurable (anhedonia)
Anxiety
- Generalized anxiety disorder (GAD)
- Social anxiety: Significant ongoing negative comparisons with others
- Separation anxiety disorder
Dissociation: Depersonalization, derealization, or both
Unwanted, intrusive memories
Phobias
Emotional dysregulation resulting from insufficient resilience
Distress intolerance from insufficient hardiness
Poor impulse control and high risk behaviors (e.g., spending binges, alcohol and other substance use, gambling, promiscuous sex, etc.)
Posttraumatic stress disorder (PTSD)
Attention-deficit/hyperactivity disorder (ADHD or ADD)

Dear Readers,

This is the first of two posts on psychological trauma. The second post will offer more detail about posttraumatic stress disorder (PTSD).

Good mental health,

Dr. Michael

(Featured image is in the Netherlands: A potato farm in North Holland province as seen from the North Sea Canal. Photograph by the author)

Psychotherapy and Psychology

Anger and Its Management

Introduction

This post is the outline of a presentation for my colleagues at the Center for Human Potential (https://c4hp.com.)
The presentation begins with a scientific overview of emotional episodes in general and then transitions to anger episodes in particular.

Emotional Episodes in General

What are emotional episodes?

Complex, coordinated responses of an individual’s physiological, cognitive, motivational, behavioral, and subjective systems to situations that have challenged individuals over evolutionary time. ((Paraphrased from Nesse R. M. & Ellsworth, P.C. (2009). Evolution, Emotions, and Emotional Disorders. American Psychologist, Vol 64, 129-139.))

Why emotional episodes?

Emotions are all consuming bodily experiences. The single word emotion does not connote the full force of an episode.
Emotional episodes are like symphonies involving all the players in the orchestra, but the mood changes according to the key. For example, C major is innocent and happy and D# minor is deep despair.

Where have emotional episodes come from?

Evolution by natural selection (EBNS).

What are the obstacles to managing emotional episodes?

They are the body’s first response to a challenge.
They are enormously complex.
They are like icebergs: They are largely opaque to consciousness, and they can be operating in the unconscious long before awareness.
As a consequence of EBNS, emotions have a head start over the cognitive controls of the prefrontal cortex (PFC).
But the PFC is limited by ontological and cultural EBNS.
- Limits of ontological EBNS. Hint: We are not blank slates.
- Limits of cultural EBNS. Hint: Marvin Harris’s cultural materialism.

What are the common characteristics of emotional episodes?

They cannot be quickly turned off by will power. If they could, they would be useless.
They have either an approach valence or an avoidance valence. Sometimes both valences operate simultaneously.
They exist in a temporal context that may be eons old.
They are about our beliefs and about our interactions with the environment.
They can be occasions of great learning.

Is life a maelstrom of sequential and co-occurring emotional episodes?

Is our emotional life a herd of wild horses over which we have some but limited control?

What is a list of basic emotional episodes?

Fear
Anger
Sadness
Joy
Disgust
Surprise
Embarrassment
Shame
Guilt
Pride of accomplishment

Anger in Particular

What is anger?

An approach-valenced emotional episode that arose to manage impending death and challenges to our core beliefs.
Grades of anger include: Irritation, frustration, and rage.
Closely related to: Fear, disgust, shame, narcissistic pride.

Are anger and violence the same?

No, anger is an emotional episode and violence is an action.

Principles of Anger Management

Anger is always about ourselves

A major component of anger as an approach emotion is that projects blame.
The morality of an aggravating stimulus is independent of our anger.

Life is full of interruptions, complications, and mistakes, often of our own making.

Sometimes we must be prepared to lower our expectations…
…And mourn the loss of our higher expectations.

We can engineer our lives to reduce, but not eliminate, episodes of anger.

Buy the best automotive batteries available and change them every five years.

We can inoculate ourselves from anger.

By respecting our biology through respecting its circadian rhythms.

Actions to take during episodes of anger.

Acknowledge that you are experiencing an episode that has been chosen for you by your ancestors including the nonhuman ones over evolutionary time.
Stop and think and wait: Average time is 30 minutes for men and 5 minutes for women for the PFC to come on line.

Forget everything you have ever heard about venting anger.

Anger is a self-energizing emotion. It is not a gas in an enclosed space.

Conclusion

Anger episodes in particular, and emotional episodes in general can define who we are.
But through conscious effort we can cultivate wisdom and emotional intelligence to create a modicum of freewill. Please watch for future posts on these subjects.

Thank you,

Dr. Michael DeCaria

(The photograph: Franklin’s and California Gulls devouring an insect hatch near the shore of the Great Salt Lake – June 2021.)

Psychotherapy and Psychology

The Key to Diagnosing Autism Spectrum Disorder in Adults: Theory of Mind

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental disorder. It poses life altering challenges, both for those who live on the spectrum((I never say somebody “has autism” or is “autistic.” Instead, I talk about “living on the spectrum” or “living with autism.”)) and for those who care about them.
If you provide psychotherapy to adults, you will discover patients who live on spectrum.
Often patients who do not live on the spectrum((Sometimes people not on the spectrum are referred to as “neurotypical.”)) have spouses, children, parents, friends, work supervisors and others on the spectrum.
It is important that all providers of psychotherapy for adults be competent in diagnosing ASD in adults for two reasons:
- Your patients who live on the spectrum can learn about their assets, growth edges, and limitations so as to better manage their social relationships, social communications, and their emotional reactions.
- Patients not on the spectrum can exercise empathic concern for those people on the spectrum.((Of course, ethical psychotherapists do not diagnose people who are not their patients and, therefore, have not given informed consent to be diagnosed. A delicate line exists between helping our patients understand others’ situations and not enabling our patients to wield a diagnosis of autism like a light saber.))
Diagnosing ASD in adults is straightforward((Please note that this post is about adults. Please leave the diagnosing ASD in children and younger adolescents to specialists in psychology (e.g. child psychologists, school psychologists, or some neuropsychologists), pediatricians, or child neurologists.)) for any licensed psychotherapists who has learned the basics about ASD.
Because this post is not a comprehensive overview of ASD, please pay close attention to the ASD diagnostic criteria and the accompanying discussion in the DSM-5™ (American Psychiatric Association, 2013).

The problem

As useful as the DSM-5 overview of ASD is, it does not explicitly acknowledge theory of mind (ToM) deficit.
Theory of mind, or more accurately the lack of theory of mind, is implicit in ASD; the disorder cannot exist except in the absence of theory of mind.

Theory of Mind

ToM has two equal parts:

1. The awareness of the mental states of others, specifically, what other people believe (cognitions), what other people feel (emotions), and what other people want (intentions).
2. The awareness that the mental states of others can be different from one’s own mental states.

Examples of theory of mind deficits

Deeply held belief in the accuracy of one’s own assessments of others’ mental states. Profound resistance to altering one’s own beliefs in spite of contrary objective evidence.
Personal identity firmly tied to one’s own beliefs no matter how illogical in the larger context.
Unconsciously ascribing one’s own mental states, especially negative ones, to others. Often quick to see hostility in others where none exists.
Narrow framework of subjective reality divorced from logic and science.

Diagnostic criteria

If you are having difficulty in assessing an adult for ASD, here are my suggested changes to the DSM-5 criteria for ASD. I have divided criterion “A” into two parts. The quoted passages below are directly from the DSM-5. I have much respect for the authors of the DSM-5. Their scholarship and clinical experience are obvious, and the DSM-5 remains the single best description of ASD. My justification for adding ToM as a criterion is that ToM demystifies diagnosing ASD in adults.

Persistent deficits in theory of mind that go back to age four to six years and continue to the present. Note that in normal development ToM skills first appear from four to six years of age.
“Persistent deficits in social communication….”
“Persistent deficits in social interaction….”
“Restricted, repetitive patterns of behavior, interests, and activities….”
Some evidence that the symptoms go back to early developmental history.
“Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.”

Differential diagnosis of autism spectrum disorder

Unresolved complex trauma sometimes appears as ASD. (Note that children with ASD often become targets for childhood maltreatment, but that is another part of the ASD narrative.)
ToM deficits can be present in other disorders, especially schizophrenia.
Attention-deficit/hyperactivity disorder (ADHD) appears similar to ASD, but closer analysis of patients displaying only ADHD soon reveals a functioning ToM and, therefore, no ASD.
The DSM-5 lists the following for consideration of differential diagnosis: Rett syndrome, selective mutism, language and communication disorders, intellectual disability, stereotypic movement disorder, attention-deficit/hyperactivity disorder, and schizophrenia.

Associated Signs and Symptoms

The following list can make clinicians aware of the possibility of ASD in an adult. These items are only suggestive, the proverbial “where there is smoke, there may be fire.” A conclusive diagnosis of ASD for an adult must rely on the DSM-5 criteria.

Rigid, naïve expectations of others, especially authority figures, sales people, professionals, tradespeople, and family members, even children.
Frequent aversion to everyday visual, tactile, auditory, olfactory, and gustatory stimuli.
Intense dislike of novel stimuli: Even a change of the packaging in a breakfast cereal.
Preoccupational interests: Those that are either highly unusual in themselves or unusual in the resources devoted to the interests.
Employment difficulties: Successful employment is more about getting along with others than the core knowledge, skills, and abilities of a job. The modern workplace is about teams – the lone craftsperson is largely a thing of the past.
Not waiting to be invited into activities in new settings, e.g. school recess or new workplace.
Obsessive-compulsive issues: Valuing routine and sameness.
Savant abilities.
Substituting numerical values for human values. Often “funny about money.”
Troubled intimate relationships.
Transactional style in all relationships.
One sibling singled out for maltreatment by parents.
Children singled out by adults or peers for maltreatment in K-12.
Conflict with authority (Please see #1 on this list).

Please note that I did not include eye contact on this list. Some patients without ASD never give me sustained eye contact, and some patients with ASD stare at my eyes for entire therapy sessions. The lack of eye contact is relevant in infants and children, but not adults.

The Utility or Inutility of Diagnosis

ASD especially in men is common for unhappily married couples.
Some adults find the diagnosis of ASD comforting as ways of explaining their social difficulties and illuminating their growth edges.

Evolutionary Psychology and Autism

Hypothesis: People with ASD have been necessary for the survival of their communities because (1) different world views and (2) conflicts with authority provide communities with alternatives to groupthink.

Internet diagnosis

Lay people often believe that the internet gives them the ability to diagnose ASD.
But, lay people are often more interested in weaponizing the diagnosis,
Or they neglect the DSM-5 language: “(C)linically significant impairment in social, occupational, or other important areas of current functioning.”
Accurate or not, diagnosis must be left to professionals who have obtained informed consent of individuals being evaluated.

Levels of Severity

The deficits in social communication and the deficits resulting from repetitive behaviors vary from
- Requiring support
- Requiring substantial support
- Requiring very substantial support
Usually if ASD is not diagnosed until adulthood, the severity level is most often “requiring support.” The more serious levels of severity would have been noticed before adulthood.
Often adults who live on the spectrum manage to have careers which range from decent to spectacular, but their personal lives are problematic.
Some adults meet some but not all of the ASD criteria. Although they do not live on the spectrum, they are socially marginalized and, hence, lonely.

Selected bibliography

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington DC: Author.
American Psychological Association (2017). Diagnosing and Managing Autism Spectrum Disorder. https://www.apa.org/topics/autism-spectrum-disorder/diagnosing
Badcock, C. (2009). The Imprinted Brain. Philadelphia PA: Jessica Kingsley.
Doherty, M.J. (2009). Theory of Mind. New York NY: Psychology Press.
Finch D. C. (2012). The Journal of Best Practices: A Memoir of Marriage, Asperger Syndrome, and One Man’s Quest to Be a Better Husband. New York NY: Scribner.
Wilkinson, L. A. (Ed.). (2014). Autism Spectrum Disorder in Children and Adolescents. Washington DC: American Psychological Association.

Endnotes

For the past 10 years I had been mulling over the question: What is the quintessential symptom of autism spectrum disorder?
I had repeatedly turned to ToM deficit, but that answer never was satisfactory.
Then I realized that ToM deficit is not the quintessential symptom but rather a necessary but not sufficient condition.
I hope that by making ToM deficit explicit, clinicians will be less cowed by the volume of material about diagnosing ASD in adults.
And, perhaps more importantly helping people on the spectrum acknowledge their growth edges and to find workarounds to reach higher levels of social functioning.

Thank you,

Dr. Michael DeCaria

(The featured photo was taken by the author in Salt Lake City on 2 February 2021, Groundhog Day in the USA and Canada.)

Psychotherapy and Psychology

A 21st Century Take on Grief

Introduction

10th East-2

A few years ago I attended a paradigm altering workshop on grief presented by Ligia Houben. Among her many credentials, Houben is a life transitions consultant and coach in Miami, Florida. Here is a link to her website: https://ligiahouben.com. She has revolutionized Elisabeth Kübler-Ross’s seminal work, On Death and Dying. You know: The five stages of grief. In my opinion, Houben is as significant now as Kübler-Ross was then in understanding grief and loss.

You can find out more about Houben’s model of grief and loss and recovery from her book: Houben, L. M. (2017). Transforming Grief and Loss Workbook. PESI Publishing & Media: Eau Claire WI. I highly recommend the book; it is available on Amazon. Houben has broken down her model into 11 principles. With her permission I am quoting them exactly for you. Her books and her website will illuminate these principles for you.

The 11 Principles of Transformation®

Accept Your Loss
Live Your Grief
Go Deeper into the Spiritual Dimension
Express Your Feelings
Share with Others
Take Care of Yourself
Use Rituals
Live the Present
Modify Your Thoughts
Rebuild Your World
Visualize the Life You Want

Two of Houben’s Significant Advances

The principles are not stages. All are important to be worked on more or less simultaneously.
Accepting is the first principle and part of the journey – not only a destination.

I hope you will look at Ligia Houben’s work to assist in managing loss and transition.

Thank you for following my blog!

Dr. Michael

(The photo is of a wild pyracantha bush in my neighborhood. The time was late February 2020, a winter day with spring sensible in the air. I like the contrast between the thorns and the cheerful red berries.)

Psychotherapy and Psychology

Knowledge, Skills, and Abilities of Successful Psychotherapists

Grandeur Peak

I have borrowed the phrase “knowledge, skills, and abilities” from the human resources field. Here is a discussion of the attributes that set successful therapists apart:

Collaboration: Competent therapists see themselves as working alongside their patients; effective therapists do not see themselves as applying treatment to their patients. Successful therapists view the patients as equal human beings, worthy of full respect and dignity, who have been entrusted to their care. These concepts take in Carl Rogers’ principles of empathy and “unconditional positive regard.”

Genuineness: Successful therapists care only about their individual patients during the sessions and convey that caring to the patients. Outside the sessions, competent therapists think about their patients respectfully and consider it an honor to work with them. Competent therapists never discuss their patients with others in a disparaging manner even if their identity is not betrayed. Sadly, I have encountered a few therapists who have spoken of patients in terms of demeaning nicknames or made fun of supposed foibles. Fortunately, therapists do not have to be models of behavior to be successful, but they do have to care deeply about their patients and about the the therapy process both in and out of the sessions.

Ethical Principles: When asked what the first principle of ethical behavior is, most therapists immediately say, “Do no harm!”; Actually that is second. The first principle is informed consent. Successful therapists assure that patients know the potential consequences desirable or not, of all aspects of therapy before participating. Just as psychotherapy is a powerful force for getting unstuck, it has the potential for miring patients even deeper.

I sometimes encounter patients whose stated reason for therapy is to work through a problem with a difficult situation at their employment, say, an abusive supervisor. During the course of history taking I might discover some significant childhood maltreatment that is not particularly distressing for the patient now. The treatment for resolving that trauma will unleash considerable upset before resolution. Because the patient is not asking for assistance about the trauma and the trauma is not an important factor now, I will let it go. Possession of a tool is not sufficient reason to utilize it.

Personal Success in Accepting Transitions, Loss, and Death: In the prior post I stated the goal of therapy is to get people unstuck. The experiences which get us stuck are denying the reality of transitions, loss, and death. By clinging to the past we cannot move into the future. Because successful therapists have a history of getting unstuck, they are further down the road as able companions to their patients during their adventures. In the end successful therapists have confidence in the process of getting people unstuck and convey that confidence to their patients. Competent therapists are enthusiastic about helping, and they do not shrink from the process or the patients.

Recommended Books: Here are three books which I consider essential reading for any therapist or aspiring therapist.

Emotional Intelligence by Daniel Goleman.
Give and Take by Adam Grant.
In the Company of Women: Indirect Aggression among Women: Why We Hurt Each Other and How to Stop by Pat Heim, Susan A. Murphy, and Susan Golant.

I like these books so much that I have both hard and digital copies. I recommend these three titles and authors exactly as I have written them above. In my opinion authors with similar titles provide incomplete reflections of the brilliance of these books and may be capitalizing without adding value.

Ending Thoughts:

It is worth repeating that ultimately patients heal themselves. Therefore, the mission of a therapist is to facilitate progress.
Successful therapists come to the field already demonstrating requisite knowledge, skills, and abilities. Graduate school, internships, residencies, fellowships, lifelong continuing education, and most importantly patient success enhance the knowledge, skills, and abilities. Being a successful therapist is not a threshold where one rests on one’s laurels.

I invite your comments.

Warm regards,

Dr. Michael

(The featured image is Grandeur Peak as seen from Sugarhouse Park in Salt Lake City.)

Psychotherapy and Psychology

Psychotherapy: An Introduction

Green Door at Tulloch Castle

What is psychotherapy?

Psychotherapy is the process of patient and therapist working together to get the patient unstuck. When I first saw patients 48 years ago, I realized that therapy was bigger than I was. That realization remains valid today. I have witnessed the power of therapy thousands of times. I began providing therapy in my twenties and still lacked many relevant adult experiences as result of my having been cloistered in Catholic priesthood seminary and in graduate school. In spite of my inexperience, the patients achieved their goals and enhanced their lives by therapy. These patients were often older than I and were married with families. Many had lived through wars, on the home front or on the battlefield, and had weathered economic recessions and even the Great Depression. They struggled under clouds of despair, anxiety, memories of domestic terror as children, psychoses including schizophrenia and bipolar disorder, and substance use. And as a result of therapy, they discovered their paths forward; they became unstuck.

So, what is psychotherapy?

Providing psychotherapy is an art that requires a myriad of explicit and intuitive skills. Those skills are acquired through individual study, classroom training, providing therapy under close supervision, and listening to patients. The classroom training is intense during graduate school but must be continued yearly throughout one’s career. Looking back I think I was a “good enough” therapist early in my career, but my proficiency has continued to grow. In spite of all, I have occasionally encountered gaps in my knowledge and struggled to get back on track with certain patients.

What is the role of the patient?

Although I take pride in my work, the patients are the stars of therapy. They bravely flounder in a state of beneficial uncertainty for weeks, months, and even years. Here is the secret: Patients ultimately heal themselves. My job is to set up a healing environment. The courageous work on the part of patients account for my early “successes” in providing therapy as well as my current satisfaction in still practicing.

What are my allegories for patient-therapist cooperation?

I use a metaphor and a story to illustrate the therapy process to my patients. First the metaphor: Needing therapy is like being lost in the middle of a tropical island jungle. Safety requires reaching a beach. The therapist has been parachuted into the island at the patient’s location. Neither the therapist nor the patient knows the way out. Each has knowledge, skills, and abilities that complement the other’s. Working together, they find the beach. In the next post, I will elaborate on the knowledge, skills, and abilities of a competent therapist.

Another story that illustrates therapy is the 1976 episode, titled The Hunters, from the Michael Landon series, Little House of the Prairie. An old blind man played by Burl Ives and the 9-year-old Laura played by Melissa Gilbert find themselves in an isolated mountain range. The old man and the little girl have to find a doctor to save the grievously wounded Charles Ingalls, the victim of an accidental gunshot. The old man had not been off the mountain for 30 years. By teaming up, the old man with his keen sense of smell and hearing rekindling his memory and Laura with her agility and eyesight find their way to help.

When I tell these two allegories to patients, they listen grimly but don’t object. When I try to lighten the mood by giving the patient the choice of roles in the second scenario, I am always assigned the role of Laura.

What is the mission for future posts?

The next post will address the characteristics of effective therapists.
Subsequent posts will highlight posttraumatic stress disorder (PTSD), autism spectrum, happiness, cognitive behavioral therapy (CBT), mindfulness, and beyond.
I expect this blog to have two types of posts, those pertaining to psychotherapy and health and those pertaining to scientific psychology. Spoiler alert: Scientific psychology is a hard science and much more than psychotherapy.

What is my invitation?

I eagerly look forward to your comments, questions, and suggestions for further posts. Of course, I would be honored if you signed on as a follower.

Warm regards,

Dr. Michael

About the featured image: A gate at Tulloch Castle on the Scottish Highlands. (Photograph by the author)