Book Review: The Reality Slap

I started this book almost 2 years ago.  In a one month period I tried to read 4 books about ACT therapy, a book on DBT, a book on CBT, and another on psychodynamic psychotherapy.

Yeah - I was nuts. (fitting for a shrink)

I finished all the other books, but never completed Russ Harris' "The Reality Slap."

This week I picked it back up - and I'm very glad I did.

I'll admit - I don't like Russ Harris' writing style.  I don't think we'd work well in a clinic together.  I can do "mindfullness exercises," but not the way he writes them.  I'm not as "touchy, feely" as he is.  I don't think I could use most of his exact words with my patients.

He doesn't fit my personality, my style, or the way I like to relate to people.  AND - I think he's a great author and this book has real value.

He begins with a great point: "All self help books could be lumped into two categories: those that claim you can have everything you ever wanted in life if you only put your mind to it, and those that claim you can't have everything you want but can still lead a rich and rewarding life." (this book is the latter)

Harris points out that being happy with what we have doesn't mean giving up on goals, needs, wants, etc... It means we don't depend on them for our well being and vitality.

Harris is realistic.  He knows that for most of us, challenging our negative thoughts, repeating positive affirmations, and even self-hypnosis don't work long term.  "Our minds continue to be harsh, judgmental, and self critical."

He points out the fact that our brains don't stop.  We churn out thoughts all day long.  When we're driving, walking, eating, talking, listening, watching, reading - our brain just keeps going.  Thoughts about what we're doing, or not doing, or the girl who just walked by, or the movie we saw, or the political turmoil on the world, or how we should have responded differently to our boss last week when he gave us that assignment.
THE MIND JUST KEEPS RUNNING.

Our minds tell us we are smart, funny, silly, stupid, ugly, strong, inept, over-qualified, under-appreciated, etc...  It judges us.  Sometimes correctly, sometimes incorrectly.

Harris doesn't tell us to ignore our thoughts, or to fight against them, embrace them, hate them, or change them.

He asks us simply to acknowledge them.  Know they are there.  See them for what they are - thoughts.  The may be painful, joyful, true or false - but first we just recognize them, and accept the fact that they exist.
He doesn't ask us to enjoy painful thoughts. He knows they suck.  They hurt us because we care.

The only things that hurt us are the things we care about.  Our pain shows us what we value.  Pain is not the enemy.  It sucks, it's not fun, but it is not the enemy.  Apathy is the enemy.  When you don't care anymore, when you are unwilling to feel pain, you are also unwilling to feel joy.  That is the message Harris brings.

He also brings stories, research, exercises, and step by step instructions about how we can accept the pain in our lives, and with that pain, move forward living the life we value.

The book title is genius - The Reality Slap.  What do we do when we realize that our life is not what we want? When we get slapped in the face by a death, a cancer diagnosis, a job loss, addiction, etc...  What do we do when we can't meet our expectations.  Do we "try harder" or "lower our expectations?"  Or is there another option....

The Politics of Diagnosis – A Glimpse

Why diagnose?

In most of medicine – people go to doctors when something is wrong.  Something about them is not “normal” and they want to know what it is, what caused it, and how to fix it.

SO – as “diagnosticians,” doctors over the centuries have observed patients.  We find a group of symptoms that usually seem to go together.  We call that a disease.  We try to find a cause, we try to find a cure, and the purpose behind all of it is to make sick people better, and keep healthy people from getting sick.

We don’t always know what causes disease.  We don’t always have a way to fix it.  But we try.  Sometimes we can diagnose it, fix the problem, and it’s gone forever.  Sometimes we can’t fix the problem, but we can treat the symptoms to make life better.  Sometimes we don’t know the cause of the disease, but we have a lot of educated guesses about stuff that might be causing it – so we try to prevent that. 

And sometimes we really have no idea - so we try everything in the book because we hate the thought of being powerless and being able to do nothing – so we try everything.

Mental illness diagnosis is the same.  Sometimes we know exactly what caused a disease.  We know how to treat it, and it’s fixed.  Often we don’t know the cause, but we know the symptoms, and we know what helps.  

So why does diagnosis matter?  Usually the answer is “Diagnosis dictates Treatment.”  All treatment research is based on diagnosis, so if you don’t know what a person has – there is no research as to how you should treat it.

Unfortunately – “type of treatment” is not always the answer but rather “ability to treat.”  

Example: After Vietnam and Korea, the VA ignored vets with PTSD.  Why???  The diagnosis didn’t exist yet.  Some Physicians saw the symptoms, some wanted to treat them, but they couldn’t.  These soldiers were in the VA system, and as a VA Psychiatrist, you could only treat veterans for a listed number of problems…PTSD as a diagnosis did not exist..so they had to be released to “deal with it.”  The doctor could not get paid, and the patient could not be treated because it was not a diagnosable condition.

Sometimes diagnosis matters because diagnosis opens the door to services, to insurance, to disability, to what the patient needs.

Example: Parents of an autistic child can often find great educational assistance and community programs for their child.  But what if the child doesn’t have “Autism” but rather has “Asperger’s Disorder,” “Childhood Disintegrative Disorder” or “Pervasive Developmental Disorder.”  These children have similar symptoms, but they have no access because the funding and programs are for “autism.”

How do we get help for those kids?  Do we pass new funding bills through Congress to fund every diagnosis?  Do we talk with city councils, schools, and donors to get money for each different disorder?  Or do we just call them all "Autistic" and we’re done?

Next year the new edition of the “Diagnostic Manual” for psychiatry comes out.  The plan is to eliminate all these different names and diagnoses -  and call them all “Autism Spectrum Disorders.”

 
WHY?  

It could be that they should have been called that in the first place.  They really are one disease with different levels of severity.  Or it could be that we just have a bunch of kids that need help and since nothing else has worked, we’re just going to change the label so they can all get assistance.

Is this a slippery slope?  Are we “fudging the numbers”, or changing the labels to fit programs, and insurance plans?

That’s a discussion for another day (or the comments section).