How to Measure Progress

 

See the related video here: https://youtu.be/R3NExV6nl7Y?si=fokbA8Y0mNDNjktL

The more I do this, the more I realize how subjective mental health progress really is. The definition of your optimal state of health depends very much on your current state and your environment. This post posits a general definition of an optimal mental health state and optimal environment, while recognizing that many people can only hope to achieve the best state in sub-optimal environments, and gives examples of treatment courses.

An optimal state for humans would be characterized by high frontal lobe brain activity. This means a state of high awareness of the past, present, and future (no need to avoid thoughts or memories), coupled with low stress activation (low anxiety about the things within awareness). There would be high ability to relate to and cooperate with other humans, and it would be enjoyable. Critical thinking, creativity, and problem solving skills would be sharp. All emotions would be allowed to run their course, meaning they'd come in manageable doses, proportional and adaptive to the situation. There would be a strong sense of agency; one could consider many options and act deliberately.

The environment to foster such a state could meet all basic human needs: food, water, shelter, positive social interaction, and safety. Resource abundance requires little urgency; no need to compulsively hoard, stuff, extract pleasure, or make impulsive decisions. There is no need for symptomatic behaviors to meet unmet needs because there are no unmet needs. This environment is not free from adversity, but the adversity is either chosen through self-exertion, testing of protective boundaries (not threats) from authorities, or is due to random chance (i.e., accidents), but not from others’ symptomatic behaviors. When stress is experienced, there is always the option to discharge it and recover from it, which fosters emotional strength and resilience.

It is adaptive to have low-intensity emotions and high cognitive skills in this environment. And, with the physical and mental strength developed in this environment, the more adaptable a person would be should conditions become less hospitable. Strong healthy humans can manipulate their environment to create hospitable conditions.

Outpatient therapy allows clients to experience a change in environment through the addition of a safe place to discharge and recover from stress, as well as learn skills to manipulate their environment. The quantity of the dosage is usually 50 minutes per week, with the strength of the dose depending on the skill and health of the therapist (NOT the client’s ability to be a “good patient”). Intensive outpatient gives a larger dose (3-5 hours a day, 3-5 days a week), partial hospitalization/day treatment even more (8 hours a day), with residential treatment providing a 24/7 change in environment to foster new adaptations.

With enough exposure to an effective growing place, it is assumed humans will progress toward that optimal state, and influence their environment to match their state. The process is circular: You get stronger in therapy, making it easier to change your environment, which makes it easier to get stronger, etc.

And what does this strengthening process look like? A good analogy is physical strength. To increase the strength of muscle fibers, you must strain and break them down to a reasonable degree, then rest and nourish them appropriately to allow new fibers to grow. If you break them down too much or too fast, you just get injured and the muscles weaken. If you don’t exert them enough, they don’t grow. And, you need different things at different steps of the process: 

-You should only exert when you have the resources to recover effectively. 

-You should rest when your muscles are exhausted and repairing. 

-You need nourishment after exertion to allow for new growth. 

Doing any of these steps at the wrong time can lead to injury or weakness: exerting when you should be resting, eating too much while exerting, etc. The proper sequence follows a U-shape: You feel good, you feel the pain of exertion, rest from exertion, feel the pain of soreness, then feel better.

Our emotions run the same course. However, strengthening emotions is more complicated than strengthening muscles in that it includes more unconscious/involuntary processes. It takes effort to avoid triggers and emotions, whereas reducing restraint allows emotions to run their natural course toward the optimal state for an environment. See “The Importance of Doing Nothing” for more on this.

The U-Model illustrates the course (Diagram 4.a.). If we exist in a relatively safe and resource-rich environment, our emotional functions will gear towards high frontal lobe activity. This means that, if we cease to distract or cope, the emotions will begin to run their course through a painful field of non rational/dissociated Fight/Flight (catastrophizing, defensiveness, victim mentality, or self-criticism), into a state of dissociated Freeze (hopelessness, suicidality, numbness, shame) into a state of rational/mindful Freeze (submission, exhaustion), up to mindful Fight/Flight (grief, appropriate fear/anger), and ending up in a greater state of awareness and compassion for self and others. These are common ways people move through this sequence:

-They might work through an entire cycle over the course of a single therapy session. They come in feeling relatively stable, they are exposed to something angering or frightening (a thought, a memory, a spider), allow their bodies to tense up, shutdown, then restart in the presence of the stimulus, and come away feeling less afraid of it because they didn’t die or get hurt. This is shown in Diagram 4.b.

Or, they might start the session somewhere else on the sequence--in a depressive or anxious state--and finish the sequence while in session.

-They might take more sessions to allow themselves to feel the anger or anxiety under the surface. Our bodies need to feel safe for emotions to flow, so getting used to the therapist may be necessary to get the process going. I’ve seen this take years for certain trauma profiles.

-They might take a hard dive into Freeze with a large dose of reality (either from themselves or the therapist), and stay down there for several months, but come out with increased awareness and maturity proportional to the time they spent in Freeze.

-They might cycle between painful emotions and painful Freeze states, but don’t feel they are getting anywhere. This pattern demonstrates the triggering of a different survival response somewhere along the river. For example, trying to move through the depressive state may trigger unprocessed trauma related to depressive states (perhaps memories of suicidal ideation we tried to forget?), which may send us back to the top of the sequence. We need to process that trauma before we can finish the sequence of the stimulus/trauma we first tried to process.

There are many different courses, but they all follow the principle that you must break down before you get stronger. Impediments to progress are the things preventing the flow through the different emotional states. Some examples:

-You are trying to move through the non rational emotion stage, but people keep throwing logic at you.

-You are trying to rest in Freeze/Depressive state, but people keep expecting things of you.

-You are afraid to feel angry or hopeless, or some other emotion. You’ve had experiences of being punished, shamed, ignored, or invalidated for having certain feelings. We’ll have to process those traumas before you can heal fully.

-You’re afraid of processing emotions or doing therapy “the wrong way,” a very common trait of folks with OCD. We need to address that fear first.

-You are afraid of being in a threatening environment soon after being vulnerable in therapy. As with physical surgery, you should not get emotional surgery if you can’t be in a safe place after. 

Threatening environments are important to consider in outpatient therapy. Sometimes, the most adaptive thing is NOT to develop greater awareness, vulnerability, honesty, and calmness. In a war zone, it is adaptive to develop PTSD symptoms of hypervigilance, irritability/aggression, and poor sleep. You do not want to be calm and philosophical in this environment if you are to survive. When stranded on a lifeboat in the open ocean, it is better to depress body functions and brain activity to preserve water and calories. You shouldn’t be composing symphonies or doing ab workouts. 

If you have to go home to emotionally abusive people after our session is over today, then we have to be careful that we don’t put you in a place to receive greater hurt (e.g., don’t send you home with eyes puffy from crying). Depending on the situation, we might help you process emotions a little, then strategize how to set boundaries or evade toxic people/situations. Or, we help you compartmentalize (voluntarily dissociate) painful thoughts and emotions until you can leave the environment. This is akin to paddling upstream in our River Model, but the situation calls for it. Progress may not involve reducing dissociative or depressive symptoms, but increasing them.

This brings us to the key point of this post, which is that humans adapt to their situations, just as all creatures do. Symptoms are adaptations–they exist to help someone reduce the pain of their situation, at least short term. If symptoms persist, it’s because the environment cannot accommodate change. Examples: 

-If a meth addict cannot find someone to help them process their trauma, contain them safely while their body goes through excruciating withdrawal, then a have safe place to recover and have new validating experiences, they must continue medicating with meth, or likely be overcome with suicidal feelings.

-If a person with OCD is getting nowhere in talk therapy, it may be because the therapist keeps trying to appease the anxiety with formulas and answers, rather than letting the person sit with uncertainty. This person cannot adapt to the reality of uncertainty while the drug of choice is still being administered (reassurance). This is an issue I’m working on as a therapist.

-If someone is chronically depressed, it may be because they feel ashamed of being depressed, and the people around who try to fix it or yank them out of Freeze are inadvertently reinforcing that shame message. It’s a double bind, and guess what the brain’s adaptive response to double binds is? More Freeze. The depression will likely end when the environment allows it to run its course.

So how do we measure progress? It really depends on what you need. You may be ready for a temporary increase of anxiety to draw you out of dissociation. You may need to dissociate to better adapt to your hostile environment. You may need a bout of depression to help you digest recent stressors. Hopefully your therapist can help you conceptualize your course.