What the Heck is “Euthymia”, and Why Should I Care?

Before getting into details, let’s make note of this: I’m altering the definition of the term as a way of creating a framework that allows us to look at something we don’t hear enough about in psychology and counseling- what is healthy!  We’re great at discussing “issues”, what’s “wrong”, what’s “unhealthy”, “mental illness” and etc, but we’re not so great at talking about the opposite!  Something to work toward, identification of what’s mentally, emotionally, and “spiritually” healthy, is a great way to change our feelings and our lives.

Oversimplifying, “euthymia” is a medical term, a term most often used in psychology, psychiatry, or philosophy to describe happiness or wellness.  Wikipedia separates out euthymia in terms of medicine, and philosophy.  In both, it is used to describe a “non depressed” mood, or “world perception” or “view” (Weltanschauung) as noted by the famous Greek philosopher Democritus.  Wordnik, a preferred website of librarians and info scientists for definitions of terms, defines euthymia as: “n. Philosophical cheerfulness and calm; the avoidance of disturbing passions, as inculcated by Democritus and Epicurus.”

As anyone who knows or has worked with me can imagine, I prefer the more global definition, the one hinted at in philosophy.  As promised, I’d offer that euthymia as a term might be most useful if looked at this way: an emotional response that is reasonable, adaptive, and of “right size” intensity, in response to one’s current circumstances.  In short, a healthy emotional response to one’s current circumstances.  Or (again, oversimplifying), a way of knowing that one has a healthy emotional response to the world.

Let’s start by thinking about what might be some indicators of an unhealthy response to the world, commonly understood by the medical and psychological communities.  Someone experiencing a “low grade” depression for an extended period of time might be diagnosed with “dysthymia”.  These symptoms being present, in absence of “psychosocial stressors” (AKA “problems” in life…), is arguably an indicator of something south of optimum health.  Without anything “bad” happening, to be “depressed” is regarded as unhealthy by most helping professions.  In a like way, being “sad” or “depressed” in a way that prevents us from doing things in our lives (work, play, relationships…) about something that happened say, 10 years ago is arguably not a healthy response to what is happening now.  To exaggerate to make the point, in schizophrenia (literally to be “split from reality”), this is an extreme version, the opposite of “euthymia”.  More specifically, if one is seeing things (having visual hallucinations, a common symptom of schizophrenia), I sometimes like to describe this as a response that’s not euthymic.

One of my goals as a therapist is for all of my clients… people who are depressed, anxious, have low self esteem, addicts, codependents, whoever- to have a reasonable, here and now response to their given circumstance.  If we behave for instance, based on old hurts to a current circumstance we tend to at best not be able to resolve either issue, at worst, make one or more of those issues more difficult.  Another way of saying this is that, if I experience a perceived sleight (someone makes fun of me, forgets a “small” responsibility to me, etc), but respond to that with isolation, threats, emotional blackmail, substance use or etc, this isn’t a “right size” response- it’s not euthymic.  Knowing that we are not having a “euthymic” response in this example, or as a way of problem solving, can help a lot in terms of dealing with our problems as right size, and might enable us to problem solve more effectively.  For someone suffering from anxiety, low self esteem, depression, addiction and more, this can be a great tool to start on the road of dealing with our current circumstance as it is.

Going back to some more painful considerations, I would suggest that in taking the example of the death or similar loss of a loved one or animal or etc, being sad is a euthymic response.  Just as our body has less than comfortable sensations in response to illness or injury- these are indicators of recovery from them.  Why don’t we see our relationship with our feelings in a similar light?  As an example of this, when we fall off a bike and skin our knee, most of us who know a little about science know that much of the reason it hurts is because of the inflammatory process- this is due to the healing and protective agents of our bodies (white blood cells to fight off infection, proteins to rebuild the part, fluids for transport of these materials and etc…) being sent to heal the injured part.  It hurts both as an indicator for us to know not to do that again, but as much, because it is healing.  Endlessly interesting to me, humans don’t see their non physical feelings, their emotions, in the same light.  We regard them as something terrible, something to be avoided.  It seems to me that we have them because they give us other information about our environment that we might not otherwise discern from our other senses, and a way of healing other aspects of our lives- hurts, shames, losses and etc.  It’s not to say that our feelings are all necessarily facts, but indicators of possible realities (more on this idea from my blog here).

If the above paragraph is any indicator, in many circumstances, having “bad” feelings might be the process of dealing with non physical difficulties.  Extreme (in terms of intensity) or maladaptive (not useful) responses to these create in turn more problems, and in some cases, diagnosable difficulties.  Having the idea of euthymia as a guidepost, it might give us a more tangible way of gauging our problem solving, behavior, and more.

7400 Hours, Psychology, Clinical Supervision

About three years ago, my friend and colleague Judy McGehee LMFT (Partners in Recovery) began a supervision program for Marriage and Family Therapist interns (people that have completed their coursework for Masters degrees) and trainees (those who are about to complete Masters degree coursework).  Borne solely out of a desire to be helpful, and pass on the ability to provide effective human service, for fun and for free, Judy took on supervising 8 or so trainees and interns.  We were joined also by a visiting therapist, Ted Aaseland, Psy.D.  A little over two years ago I joined her in this endeavor, as I care deeply about passing on how to do “The Work”.

Over the course of those years, those interns provided services to the Glendora School District and elsewhere to children and adolescents for free.  Some of these turned into outpatient clients, individuals and families, also for free.  There were also public speaking engagements for adults and adolescents, professionals and non-professionals.  After all was said and done, over 7400 hours of free therapy (not including the speaking/community education efforts) were provided, all for free.

Interestingly and tragically, there are several stories that run in parallel with this one.  Before I get there though, it would be instructive to tell you a little about this process, both from the perspective of the licensed folk/interns/trainees, and from the folk we hope we were helpful to.

Will start with the experience of the trainees/interns/licensed folk.  Most universities require several hundred hours of internship/clinical experience for graduation.  The processing of these hours is supervised by a licensed therapist (who can be a supervisor, as regulated by the Board of Behavioral Sciences), and the student must pay for this process.  Most universities, in an uncomfortable wrenching of common sense, either don’t have someone to organize/and or set up/maintain these supervision placements, or they’re simply not updated for various reasons.  The student/trainee however, is still required to do this.  To add insult to injury, the trainee when in supervision, if they can find an agency, is rarely given a real experience of being supervised at their work.  It seems flabbergasting to consider this, yet it’s tragically true.

Similarly, interns (therapists just out of school) have to complete over 3000 hours of work with patients/clients, just to sit for the two licensing exams.  They have six years to complete this process, requiring continuing education to reset their chance to sit for the exams.  That means that they have to see clients, and that those hours also have to be supervised.  Related to both this issue and Judy’s (Ted’s, and mine) efforts, we were completely unable to get other clinicians to volunteer for either of these processes (for trainees or interns)- not even a couple of hours a month, let alone the minimal 2-4 hours a week.  In light of the complaints of most people we know not feeling like they received quality supervision, this is no small issue.

The second body of material that is really important here is the students and families.  There were of course the predictable experiences with clients who struggled with behavioral problems, substance use/addiction, depression, stress, bullying, pregnancy, self esteem, eating disorders, anxiety and the like.  It was also really common to have active suicidality, reports of abuse, the precursors of “thought disorders” (schizophrenia, and the like), violence, abandonment, PTSD, mood disorders (bipolar disorder and related problems) and more.  There was psychoeducation, crisis intervention, abuse reporting, ensuring of safety, documentation, creation and use of materials, referrals to resources, interfacing with administrators/Department of Children and Family Services/other clinicians/teachers/families and more, interviewing, showing up for IEP/planning meetings and more, and oh yeah… individual and family therapy.

The interns (and will give a little credit to us as well) braved all of these issues and more.  All for free.  Seven thousand, four hundred hours of it, and the attendant signing off of supervision hours.

We met weekly for all this time, as individuals and as a group, to meet the requirements for the relevant university, and for the Board of Behavioral Sciences.  We met in between to take care of paperwork.  To problem-solve.  To handle questions.  We met for lunches, at each others’ homes, in restaurants, in parking lots.  We celebrated birthdays, mourned losses, processed issues, checked one anothers’ heads.  There was a lot of happiness, crying, efforts to glean resource support to continue the work, discovery.

There’s certainly more to be said, and obviously, more work to be done.  Though this cycle of supervision is over, we still have a lot of passion and ideas for what might be next.  The whole point of writing this though, is simply to honor the work of Michael Cardenas, Eryka Gayoso, Elva Cortez, Jessica Wilson, Jeffrey Craig, Melissa Lamoureux MS, Ted Aaselund Psy.D, and most of all, Judy McGehee LMFT.  Thanks so much for making all this matter, and letting me participate.

Difficulties, Diagnoses, the DSM.

In a New York Times Op-Ed piece from today, one of the leads on the DSM-IV (the “Diagnostic and Statistical Manual”, the current edition of an industry standard tool for mental health, primer here) task force wrote about the upcoming changes in the DSM-V (likely to be released in early 2013).  Summarizing, Allen was suggesting in part, “…after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription.”, and that the American Psychiatric Association was  arguably no longer in a place to be singularly in charge of the meting out of diagnoses, calling it a “monopoly” (offering that an agency akin to the FDA or National Institute on Mental Health might be examples of ways to provide oversight in the efforts to insure some science around diagnosing emotional and mental problems).

Am with Allen on quite a bit of this.  What comes to me often too, is that we have equally large fish to fry with the DSM and the profession than just the pathologizing and monopolizing he suggests.  We have been over-diagnosing ADHD (attention deficit hyperactivity disorder) and bipolar disorder, among others.  Our differential diagnosis (rationalizing one diagnosis vs another) has also been resulting in much harm to people by way of treating issues unneeded, and/or incorrectly.  We are also arguably guilty as a discipline of using interventions that are more “intrusive” than necessary (for instance, medicating a problem before efforts at traditional talk therapy and/or other interventions have yet to be tried).

It seems to me that in reviewing the DSM, we are more currently in need of insuring the accuracy and value of our diagnoses, in terms of insuring that those so suffering are treated more appropriately.  We do know ways to treat depression, anxiety, addictions, bipolar disorders and etc.  We do have means of helping people through grief/loss, communication problems, abuse, suffering with stress and etc.  As the saying goes though, the “cure” (a dubious word to begin with) is only as good as the diagnosis, and with the numbers of the diagnosed only increasing in the US year after year, either our diagnosing or treatment (or maybe a bit of both) are not faring as well as they might.

A quick aside here- not all of the missed treatment opportunities are about the above issues.  Some of them are due to the influence of Big Pharma (an intense imposition by the pharmaceutical industry), access and funding of mental health treatment, the insurance industry and more.

Specifically related to the DSM though, my hope is that we’d simply be better at a lot of the material we already have.  Adding diagnoses, or simply separating them into finer and finer constellations of symptoms seems both unnecessary and unhelpful, philosophically speaking.  Part of what I’m getting at above is that I think we have some good ideas about how to help many ills- I just wish we spent more time treating them, and less time diagnosing new ones.

What to Do?

From P.16 of the PDF “Statutes and Regulations” from the California Board of Behavioral Sciences (the regulatory agency that oversees MFTs, Social Workers, and etc):

“§4980. NECESSITY OF LICENSE (a) Many California families and many individual Californians are experiencing difficulty and distress, and are in need of wise, competent, caring, compassionate, and effective counseling in order to enable them to improve and maintain healthy family relationships.”

Clients as above, come to us for wise counsel.  Among other things of course.  This idea has far-reaching implications, not just for our clients, but for us.  Wisdom is hard to come by!  Oversimplifying, “wisdom” in this case is often a euphemism for answers.

Claiming (or believing) one has wisdom or answers is of course a Bad Idea, yet it seems we have a responsibility to work toward them.  There’s some great ideas and techniques supporting the principle of not giving “answers” (suggestions, direction, etc) outright to clients (or loved ones, certainly) from the therapist’s chair.  My basic mode of operation is to try to lead someone to those answers, typically only giving direct suggestions when my efforts to lead a client to their own answers have been exhausted.

We do treat several diagnoses and/or issues that have “community standards”, fundamental practices or “conventions” most therapists agree on how to treat.  Schizophrenia, bipolar disorder, and other more severe illnesses for instance almost always direct the client to: not “self-medicate”, takes the best supportive medication regime as directed, and is getting :talk therapy” and/or peer/familial support with their illness.  There are few that argue with the utility of these interventions.  There are other examples for addiction, depression, anxiety, and more.

Two things are of interest to me though.  The first is that during the therapeutic process, I often see clients get a suggestion, and dismiss the suggestion out of hand.  What I think is happening is that rarely do I suggest an idea that in a vacuum will ever be sufficient.  What I mean is, most any suggestions I have will never be singular.  It seems that the depth of our sadness or anxiety or pain or whatever often keeps us from “getting” what is offered, unable to accept the responsibility of taking several suggestions.  Summarizing: rarely is one idea sufficient to change anything in the therapeutic process.

The second thing that prompts me to mull this over is the “active” therapists versus the “passive” therapists.  In my view there is room (and each therapist I think, ought use) both styles, often with the same client.  There are times that we should be directive, and not just in terms of extreme examples like when a client is being abused.  Discouraging self-medicating, engaging a support group, ruling out medical concerns with a physician, ways to stop a behavior etc are all examples where there is little controversy over giving someone “direction” about an issue.

People come to us for answers.  We are paid to have a toolset, methods, principles of operating that in many cases should help diminish depression, stress, relationship conflicts, behavioral concerns and the like.  On the subject of not holding these ideas close to one’s chest: there is a great (and occasionally controversial) martial arts instructor who critiques traditional means of training, idealizing the “teacher” and etc.  He also critiques traditional martial arts training as being “cultish”- keeping secrets, claiming answers from some (out of touch and unknowable) “higher source”.  His “instructors” are all referred to as “coaches” or by their first names, and their focus is very simple: performance improvement.  That last idea is part of what I’m getting at here- the “answers” we give as therapists should improve “performance”, which I would argue is diminished if we are too passive.  It is very significant of course, that what is being improved, is clearly defined.  If we think something might be helpful though- there are certainly compelling reasons we should disclose it.

When it comes to performance, we should be helping people get more in touch with their emotional condition, have those feelings gracefully, diminish (but not eliminate) the intensity of negative emotions.  Our interventions should help decrease or stop unwanted behaviors.  The direction we give should help increase intimacy.  Of course this is not an exhaustive list, it may take a long time for these things to happen, and some cannot happen without the others.

My experience has been that many (arguably most) of my clients have come into my office, suffering enough, and out of enough answers, that they are willing to do most things we come up with together.  Had they been in possession of this material on their own to begin with, there would be no (or little) need for my education and experience with the issues they struggle with.

My effort is to put me out of a job and it does people a disservice I think, to have an insight that I wait for them to come to on their own… which they’ve already arguably been trying to do.  Sometimes I ask my clients if they have spent a great deal of time in their lives, saying something like this to themselves: “I just wish someone would tell me what to do about this.”  There are many things, that most(not necessarily all) people can do, directly, to diminish feelings of low self worth, sadness, struggles in relationships and most of the problems they come to a therapist.  If I didn’t go to school to learn to help people know and do these things, then what exactly did I go for?

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