No New Year's Resolutions - Change Your Life

Weight Loss For Sale

It's all done with computers.  Automatically, 12:01 AM !2/25/2011, the Target ads disappear from television screens and Facebook sidebars, the Jennie Craig ads go up.  Next morning, the Lifestyle section of the newspaper switches from appetizer and eggnog recipes to yogurt and exercise programs.  After months of selling excess, now it is time to sell restraint.

How did it work for you last year?  It worked really well for the media.  How did it work for you?

You can't buy change.  And sure as one set of ads replaces another at 12:01 AM, you cannot lose weight by buying a weight loss program.  You yourself, not just your body but even your brain has to change.

Meanwhile, Excess Weight is Killing Us In The US 

How many times have you heard that the US has the best health care in the world?  I won't dwell on that nonsense.  But clearly we do not have the best health.  Out of 221 nations, the US ranks #50 in life span.  That puts us at the 77%, a low C at St. John's Parochial School where I went, maybe a B in public school, grading on the curve.  So to speak.  Meanwhile, compare Jordan at #29, South Korea at #41 and Bosnia/Herzegovina at #45.

Those numbers come from the CIA's World Factbook, where they say Life expectancy at birth is also a measure of overall quality of life in a country and summarizes the mortality at all ages. It can also be thought of as indicating the potential return on investment in human capital.  In other words, a low C, B if grading on the curve, is the quality of life you get healthwise if you were born in the US, the country with the best health care in the world.  Who came up with that claim, anyway?

In a different but related index, the World Health Organization charts BMI, Body/Mass Index, a measure of weight in relation to height.  The US ranks #54 out of the 60 nations for which it has data, for percentage of people with normal weight, neither too heavy nor too thin.  That puts us at the 10th percentile, an F-, whether grading on the curve or no curve.  Only 36% of US citizens have a healthy weight. 

And the cost?  Cardiovascular disorders (high cholesterol, high blood pressure, heart attacks, stroke), metabolic disorders (diabetes) cancer (breast, cervical, uterine, prostate, colon, kidney...), arthritis, sleep apnea... That is the short list of health complications and loss of life associated with excess weight.  I will let you come up with your own list for what you have less of on account of what you have more of...

Excess Weight Is Slaughtering Those With Mental Illness

Meanwhile, back in Prozac Monologues Land, people with severe mental illness beat out the rest of the population in the race to break the scale.  Clinical studies have reported rates of obesity in patients with schizophrenia or bipolar disorder of up to 60%.  That compares to 34% in the US population, a number that already staggers the imagination as it is.

The reasons for the difference are many:

  • The most common medications for these disorders, lithium and antipsychotics, especially the new ones are notorious for weight gain.  It is surmised that the weight gain comes from disrupting both metabolism and the neurotransmitters that regulate appetite.
  • But medication-naive patients also have a higher risk for overweight and obesity.  The negative symptoms of schizophrenia and the depression-part of bipolar (lack of interest, inability to feel pleasure) lead to more sedentary lifestyles and more weight gain. 
  • From the Damned-If-You-Do-And-Damned-If-You-Don't Department, the medications for schizophrenia and bipolar mostly reduce the positive symptoms (delusions in the case of schizophrenia, high energy in bipolar - the symptoms that scare your families and your care providers who write the prescriptions).  They tend to increase the negative symptoms (thereby relieving the anxieties of your families and your care providers who write the prescriptions), providing that synergistic effect that nails you to the sofa.
  • There may be pre-existing genetic connections between what is considered two different conditions, overweight and mental illness.  The DSM defines mental illnesses on the basis of certain symptoms.  It does not describe what is actually going on inside the body to produce the symptoms.  Metabolism, energy levels and regulation of appetite are all controlled by parts of the brain, often with genetic predispositions.  While these are included in the symptom lists for mental illness, they are not the defining symptoms targeted by treatment.

Add it all up, what do you get?

People with severe mental illness die 15-25 years before the US national average.  Rwanda beats us.  We have the life span of people born in Sudan.

What do we die of?  No, suicide is not a significant factor in this equation.  We die of cardiovascular disorders, metabolic disorders and cancer.  Just like everybody else who weighs what we weigh.

What Are Our Doctors Doing To Save Our Lives?

Our doctors are doing their best to prevent symptoms of our mental disorders, the scary symptoms, hallucinations, delusions, too much energy combined with poor judgment that get us into trouble with the law.

They are not doing anything about what is going to kill us.

Well, okay, they are psychiatrists; they treat psychiatric disorders.  They are not general practitioners nor weight-loss specialists.

So here are two more reasons embedded in the US health care system that contribute to our lethal obesity.
  • Notwithstanding that excess weight is a symptom of our disease and also a side effect of treatment, our psychiatrists consider our weight issues to be none of their business.  Never mind how significant this unaddressed health issue is when it comes to whether we are even willing to take the meds they prescribe.
  • People who have mental illness are less likely to have health insurance.  We are less likely ever to see any doctor other than the one at the community mental health center who is treating our mental illness.  Not to mention access to weight loss programs.  Not to mention money for fresh foods or exercise programs.
The upshot: what are our doctors doing to save our lives?  Precious little.

Okay, having said that, some doctors are doing more.  My doctor listened when I told her my family medical history, that everybody in my family dies of heart disease, that my younger brothers had heart attacks at age 55 and age 29.  When I said I would not take Seroquel unless I was psychotic, she paid attention.  She tried to find meds that are weight neutral that I could tolerate.

But from the things I have written lately about my current psychiatrist, my readers who have real life experience with psychiatrists know that she represents a minority in the profession.

We Have To Lose Weight Anyway

What most patients get from most doctors is the pro forma reminder that we won't gain weight if we don't eat more than we expend in energy.  So all we have to do is eat less and exercise more.

There.  Their responsibility has been discharged.

Here, as in almost every area of our recovery, we are on our own.  Recovery is up to us.

We have to lose weight anyway.  We have to.  It's our hearts, our blood vessels, our pancreases, our knees and hips, our brains, our lives, 15-25 years worth of our lives that are at stake.

We will be swimming upstream, up against the forces of whatever is going on in our genes, our dopamine channels, our pineal glands, our medications, our lack of health care, our poverty.  So?  Salmon swim upstream all the time.

Salmon are programmed to swim upstream.  We have to program ourselves.

A New Year's resolution will not change the program.  Did it last year?

So here comes a series on reprogramming our brains.  It is a series, because we have to take it step at a time.

Word of encouragement: If you made it to the bottom of this post, you are probably already past the first step.

Who knows, maybe this series will carry us past the New Year's/Jennie Craig/NutraSystem et al season and up to the Super Bowl/Bud/Doritos season!

Note added, 01/02/13 -- The following are links to the rest of this series:

The Stages of Change and Weight Loss January 3, 2012 -- How do you change a habit?
My Food Autobiography and the Stages of Change March 8, 2012 -- Pre-contemplation and contemplation.
Changing Food Habits -- Contemplation and Preparation March 15, 2012 -- Reviews The End of Overeating by David Kessler and introduces the brain science of the sugar/salt/fat trifecta.
Dopamine -- Can't Live Without It March 23, 2012 -- The brain science behind habit formation and an experiment to try.
Relapse/Maintenance -- Stages of Change May 24, 2012 -- Review and finishing up the series.

clipart and photo of school paper from Microsoft
photo "Angry Father" by Akapl616.  Permission is granted to copy under the terms of the GNU Free Documentation License
photo of salmon in Ketchikan Creek by Wknight94 and used under the terms of the GNU Free Documentation License

Hey, Jesus - Happy Hanukkah!

I must be one of ten people with mental illness in the United States of America who does NOT have holiday trauma issues.  My personal desperate darkness starts each year in late July and breaks some time in late October, with mild depression fading out through November.

Thanksgiving to New Year's is pretty much my best time of year.

Nevertheless, this year I have been sad, not depressed really, just sad, as I read on Facebook the hostility that has come to be the litmus test of Christian fervor.  Evidently inspired by Fox News, Merry Christmas is no longer an expression of joy and good cheer, but a battle cry against the First Amendment and the great American experiment of freedom and tolerance of difference.

Irony abounds here.  One of my own ancestors came over on the Mayflower, as a matter of fact.  The Puritans wanted freedom to practice their religion, not anybody else's, just their own, including a prohibition against Christmas, which they outlawed in 1659.  They knew their religious history, that the holiday originated as a pagan festival, full of excess of every sort, with the thinnest wash of Christian appropriation added later to assure pagans they could still celebrate the Winter Solstice after they got baptized.

The Puritans had mellowed by 1712, when Cotton Mather, whose credentials are as Christian as you get, preached tolerance for other Christians who did want to celebrate the baby's birthday.  I do not now dispute whether People do well to Observe such an Uninstituted Festival at all, or no, he said.

He went on to encourage a Romans 14 attitude: Good Men may love one another, and may treat one another with a most Candid Charity, while he that Regardeth a Day, Regardeth it unto the Lord, and he that Regardeth not the Day, also shows his Regard unto the Lord, in his not Regarding of it...

According to Cotton Mather, he believed in "political correctness", because he found it in the Bible, in Paul. 

The Brain And Christmas, Or At Least Something, Anything

Christian, Jew, Zoroastrian, Wiccan, Druid, "spiritual but not religious," and plain old capitalists, as the days get shorter, our pineal glands go into overdrive, pumping out all that melatonin that makes us want to hibernate.  Our brains cry out for relief.  Push back the darkness!  Light a candle!  Light a bonfire!  Wait a minute -- just a log.  Nothing in the brain requires that anybody get burned at the stake.

Regular readers know that, while Prozac Monologues is not for the purposes of evangelism, I make no secret of my Christian faith, and even defend religion and the disciplines of church membership as resources for mental health.

But not any religion.  Not what passes for Christianity but looks suspiciously like, well -- fascism.  There, I have said the word.  When the cross gets wrapped in the flag, no matter whose flag, you know that the frontal cortex is offline, the lizard brain is in charge, and somebody is about to get crucified.

Which is so not what Jesus would want for his birthday present.

I mean, the first guests invited by heaven to his party were the scruffiest low lifes of the neighborhood, who had probably been passing the bottle to keep warm that night, and some foreign fire-worshipers, for crying out loud!

Theology Alert

He came as a baby.  He came vulnerable.  He came helpless.  In the core and mystery of what Christians call Incarnation, God-in-flesh, that very vulnerability is how God tells us how much God loves us, that the great Almighty would set almighty aside in order to pitch his tent among us.

That God desires to be with us, and will pay whatever price that requires, and would indeed require, is the core of the Gospel, all we need to know that we are beloved.  We are worthy.  Knowing that, then we can exercise the courage it takes to treat others as beloved and worthy.

We can even say, to show our rejoicing for the worth that God gives us and our rejoicing for the worth that God gives our neighbors, Happy Holidays!

These days are holy, they are graced by God's presence among us, whatever days you keep.  That is what I believe.  And I hope for you that these days are happy.

Research on Vulnerability

So here is where the deep truth about God-With-Us and mental health research come together: Brene Brown, research professor at the University of Houston Graduate College of Social Work on The Power of Vulnerability.

That baby who slept in the cold and all the babies who tonight sleep in the cold call us to look deep, deep into our hearts, the hearts of our neighbors, the heart of the world, the heart of God.

Happy holidays.

painting of Announcement to Shepherds by Gaddi Taddeo, c. 1327, in public domain
mezzotint portrait of Cotton Mather by Peter Pelham, 1700, in public domain
photo of Luminaria at Lake Washington from Seattle Municipal Archives, used under the Creative Commons license
painting of Madonna and Child with Cherries by Jan Gossaert, c. 1520, in public domain

Changing Attitudes - Building the Therapeutic Relationship

What if your chart had your picture on it?  What if, as your doctor picked up your file from the top of the pile, just before you walk in the room, there on the cover is a picture of you from when you were well?

Maybe several pictures, images of the life your illness or your meds took from you?  Images of the life you manage to live anyway?  What if your doctor could see, not only your diagnosis, but also -- you?

What if your doctor knew what you still can do?

Okay, the chart is digital where I go for care.  My photos could come up as a slide show!

I want my chart to include my degree from Reed College.  It would come up as soon as the doc hit escape from the slide show.  If your doctor still uses paper file folders, your degree or certificate or major award could be stapled to the inside left cover, right across from the case notes of last month's visit.

Maybe my degree from Yale would be more impressive.  It's a Master's, and it's in Latin.  But I want my doctor to know I went to school with Steve Jobs.  Just as he studied Shakespeare, because scientists study Shakespeare where I went to college, I studied science.  At Reed College even poets are required to learn how to evaluate a research design.  First you read the method.  If the method is flawed, the conclusion is still just somebody's fancy.  You needn't bother reading the rest.

So I know how to detect bullshit when the doctor is parroting back at me the bullshit he/she heard from the sales rep.  I want my doctor to remember that.  It will save us both a lot of time. 

You Want That Placebo Effect

Here is what is at stake in my photo fantasy:

One out of every nine people in the US took antidepressants in 2005-2008, one of every four women aged 40-59.  So how are they working for you?  80% of their success, if they are indeed successful, comes from the placebo effect, the healing power released in your body by your own belief that they will work.

Now you are more likely to believe if you have confidence in the doctor that prescribed them.  Given that you are taking antidepressants in hopes of alleviating some sort of suffering, and given that they cause their own sort of suffering, it is clearly in your interest to maximize the placebo effect, so that the benefits indeed outweigh the costs.

Recently I reported a study that discovered a particular wrinkle in this issue.  You get better results from the same med depending on who your doctor is.  In fact, some doctors get better results from placebos than other doctors get from the medication.  How about that!

It's all about the therapeutic alliance, the relationship between the doctor and the patient.  The relationship carries the weight of the healing. 

All I'm Asking is For A Little Respect

So my recent post, The Therapeutic Alliance - Or Not identifies one factor that I believe is critical to the therapeutic alliance, whether the doctor respects the patient.  We have greater trust in doctors who respect us, who think that we, our lives and our bodies are important, and who demonstrate that respect in specific ways.

I generally do not find that respect reflected in the writings of psychopharmacologists, doctors who treat psychological disease with pharmacology.  I hardly ever find it in anyone who writes about compliance, getting us to take our meds.  I do not find it in most writing about suicide.

Fortunately, my current psychiatrist does give me good examples of how to build trust by demonstrating respect.  So I don't have to invent this post all myself.

My doctor apologizes when common social convention calls for an apology.  My doctor listens to me and pays attention to how my illness and how my meds are affecting the life I want to live.  My doctor prescribes and changes her prescriptions based on the information I give her.  My doctor educates me about my condition, what different medications can do, and how well-founded the claims made for these medications actually are.  My doctor writes things down for me when I am having trouble remembering.  My doctor knows that I will make my own decision.  She asks, What do you want to do? 

Common Ground  Between Doctor And Patient

I suspect this next example is controversial.  My doctor establishes common ground.  We don't spend time talking about her personal life.  But she has photos of her children in her office and pictures they have drawn.

In the early history of analytical psychiatry, doctors were god-like figures who cured by force of their personalities.  Whether that ever was a good idea, the conditions under which this god-like distance was supposed to work no longer prevail, i.e., years of couch time to develop and explore the transferences and counter-transferences.

Nowadays, you could make, I have been making a case that The-Doctor-Knows-Best approach sets up the compliance power struggle that doctors are going to lose, they are going to lose, they might as well give it up, because they are going to lose.

But if my doctor and I have something in common, in this case motherhood, then the distance between us is reduced.  I can imagine that we share some values, an understanding.

Once my wife was in a restaurant that you could call acoustically alive, when she heard a toddler having a full metal jacket meltdown.  She turned, and every person in the room turned to look.  She recognized the toddler who was having the full metal jacket meltdown.  She had seen his photo in my doctor's office.  Sure enough, her eyes met my doctor's, who looked for all the world like the mother of a toddler who was having a full metal jacket meltdown in a restaurant that is particularly acoustically alive.

When I get a little crazy in the head, when my hippocampus takes me on one of those time travel trips and I confuse my current doctor with the one who doesn't do relationships, when I am scared and angry because the latest chemistry experiment is making me sick and I don't believe she will hear me, then the story about that toddler brings me back to reality.  When I see the picture of that child in her office, I remember she is not god-like.  We have some experiences in common.  We are on the same side.

The story even has the power to recall me to my own competence.  When my son used to have a full metal jacket meltdown in some public place (not often, but it happened), I discovered that if I turned him upside down and held him by his ankles, he would gain a different perspective on his world and whatever it was that had disturbed him so.  This different perspective seemed to make him thoughtful.  At least it made him quiet.

This is Car Salesmanship 101, by the way.  When you walk onto a successful car lot, within three minutes a salesperson will have established some sort of connection with you, a place where your lives or interests intersect.  Doctors are not salespersons, you say?  Then why are patients called consumers?

Caveat: Behaviors Are Not Enough

But behavior isn't enough.  Malcolm Gladwell's Blink: The Power of Thinking Without Thinking reveals how our adaptive unconscious helps us make judgments in an instant.  Sometimes this capacity is essential for survival.  Sometimes it makes mistakes.  Sometimes it can be brought into consciousness and trained.

Gladwell defines an instant as a unit of time measuring two seconds.  Those of us with extensive trauma histories, who are the most treatment-resistent, don't need two seconds.  We learned to jump, to duck, to cover on the briefest freeze of a smile or glaze in an eye, a nanosecond of body language.

That's called hypervigilance, and our care providers want to treat us out of it.  Hypervigilance does take a lot of energy, and can interfere with recovery.  But treatment can be dangerous, too.  And while it may be helpful to train our adaptive unconscious, it may not be in our best interest to lose this skill, even if it makes it easier for our caregivers to pull one over on us, such as, make us think that they respect us, nut cases that we are.

No, learning the behaviors of respect is a start, and the bottom line for competent care.  But the truth behind the behaviors lies naked before our hypervigilant eyes.  Better than learned respectful behavior is genuinely held respectful attitude.  Don't just behave as though you respect me.  Respect me!

Now really, patients have to cut our care givers some slack.  Remember, they see us at our worst.  They are not in the room when we are managing a meeting, delivering a speech, making a gingerbread house, organizing a party, taking care of the kids.  No, they see us sick, focused on our symptoms, angry about the last med and the doc who prescribed it, anxious about the next, ranting, delusional, scared...

These are not encounters that build respect.  We don't think much of ourselves when we display these behaviors.  Why would they?  Based on their extensive, though exceedingly narrow experience of people with mental illness, their adaptive unconscious is pretty hypervigilant around us, too.  Not always so unconscious.  Mental health workers experience five times the national average rate of violence on the job.  They write articles, develop protocols, and design buildings to protect themselves.  From us.

Hold on, Goodfellow -- save something for another post!

Changing Attitudes - Building Alliances

Experience forms attitudes; experience can change attitudes.

Another psychiatrist I know who demonstrates respect is on the board of the local NAMI chapter.  He partners with board members, including people who have mental illness, for common goals.  He spends normal time with people with mental illness.  Well, at least he occasionally has coffee with me.  We talked once about my symptoms in his office.  But we left the office and had coffee where normal people have coffee.  When I saw him once interacting with someone who was displaying delusions, I was struck by the respect he demonstrated.  I learned from him how to behave respectfully toward people who have delusions.

I began this post with an idea about putting in front of psychiatrists images of their patients that are positive, that reflect the larger reality of our lives, images of recovery and wholeness and worth.  It's all about how to help them learn to respect us.

Doctors and patients really do need to get on the same side.  The best doctors understand that to get there, they, too, need to move.  And first, from the inside.

photo of baptism by Malaura Jarvis
Team Prozac Monologues NAMI Walk photo by Judy
photo of gingerbread house by Margaret Doke
flair by
book jacket by
logo for Occupational Safety and Health Administration in public domain
college graduation photo by Jenny Krch

The Therapeutic Alliance - Or Not

My therapist asked, Does writing your blog help you overcome your trust issues with psychiatry?

Hah!  So she doesn't read my blog.

Not that I think she should.  Of all the many things about which I have strong opinions, whether care providers should google their patients is not one of them.  They can have that discussion among themselves.

Trust My Psychiatrist?

But her question started me thinking.  I trust my own psychiatrist.  How did that happen?  I tucked that question away for a future blog.

Then last September David Mintz wrote about Psychodynamic Psychopharmacology.  Psychodynamic psychopharmacology explicitly acknowledges and addresses the central role of meaning and interpersonal factors in pharmacological treatment.

One particular paragraph brought my therapist's question and my tucked away post back to mind:

The Prescriber and the Placebo Effect

An analysis of the data from a large, NIMH-funded, multicenter, placebo-controlled trial of the treatment of depression found a provocative treater x medication effect. While the most effective prescribers who provided active drug (antidepressant) had the best results, it was also true that the most effective one-third of prescribers had better outcomes with placebos than the least effective one-third of prescribers had with active drug. This suggests that how the doctor prescribes is actually more important than what the doctor prescribes!

Turned to the patient's perspective, if your meds don't work, maybe you don't need different meds.  Maybe you need a different doctor. 

That is not where David Mintz, MD went with this finding.  He cites research indicating that a strong therapeutic alliance is one of the most potent ingredients of treatment.  Well, an alliance has two partners.  But his article focused on just one side of the alliance, on patients, how our personal psychodynamics might interfere with treatment, (with a passing reference to countertransference in relation to overprescribing).  He pretty much ignored, as in, totally ignored the nature of the alliance.

Today I ask the question the way the patient would ask the question:

What helps me trust my doctor?

I didn't trust my first two psychiatrists.  I had very specific reasons.  When I told one of them that a particular behavior on her part had decreased my trust in her and damaged our relationship, she said, I don't do relationships.  I use pharmacology to treat psychological disease.

Well, I knew where I stood.

But I do trust my current psychiatrist.

I walked into her office predisposed not to trust.  Yes, I did.  I had so little expectation of being heard that I had laryngitis, literally.  Some of that distrust came from my own long-term issues, the psychodynamics of a trauma history.  I will own that.

Part of it came from my work on this blog, reading research articles, discovering the shoddy nature of some research design and unethical practices in publication, coming across the language that generated my OMGThat'sWhatTheySaid feature, disrespectful language, and reading case after case after case of unethical sales practices in the pharmaceutical industry, resulting in lawsuits and fines (not to mention neglectful prescribing practices and consequent harm to patients).

Part of it came from my experiences with those other two psychiatrists.

Mintz would put all this under the category negative transference.  Me, I would put some of it under the category of psychiatrists' behavior.

I can identify specific behaviors on the part of my current psychiatrist that helped me overcome this distrust.

Doctors Apologize?

The very first thing -- she apologized.  It was an institutional screw-up, not hers, that had me sitting in the waiting room for thirty minutes before our first appointment, not filling out paper work, not answering questions, just sitting, no explanation, silence.  But on behalf of the institution, she apologized.

Wow.  Like it mattered, the anxieties I went through during that half hour.  Like I had the right to be treated better.  Like I could expect that in this relationship, and there would be a relationship this time, I would be respected.

Ellen Frank wrote in Treating Bipolar Disorder, ...perhaps because many patients with bipolar disorder have had the great personal or familial success that often accompanies the energy and enthusiasms of bipolar disorder, a subset of patients with bipolar I disorder present with an entitled stance that is rarely seen in other outpatient populations [such as self-effacing unipolar] ... your IPSRT patients will sometimes expect that... you are never late for an appointment, that you never change or cancel...  sometimes there is nothing that can be done other than to apologize for this "affront."

That "affront," in quotes, confused me.  The notion that expectations about being on time come from a sense of entitlement confused me.  Oops -- that the doctor would be on time.  Me, when I am late or I cancel, I apologize, because I respect the doctor.  My new psychiatrist canceled once, is late occasionally.  Each time she apologizes.  I don't think she thinks I have a sense of entitlement.  I think she respects me.

Maybe Frank ought rather to be concerned about her self-effacing unipolar patients.  Maybe part of their depression is the habit of internalizing the disrespect of authority figures.

Respect As The Ground For A Therapeutic Relationship

Last October, John McManamy published a Mental Health Patients' Bill of Rights.  They included:

  • The Right to a psychiatrist who listens
  • The Right to a psychiatrist who values us as human beings
  • The Right to a psychiatrist who values our uniqueness as human beings
  • The Right to a psychiatrist who is committed to getting us well, not just stable.

I think "The Right to a psychiatrist who respects us" is the overarching category.  John's list includes actions and attitudes that proceed from respect.

If my doctor respects me, I can expect certain things to follow.  I can expect that the doctor has my interests at heart when handing me a prescription.  I can expect that the doctor will listen to, care about and remember my concerns, my values, my life outside the office, and the effect of treatment on that life.  I can expect that the doctor pays attention to the results of a particular treatment on me, specifically me.

These issues are important, because the treatments are powerful.  Whether or not they help, they sure can harm.  If my doctor respects me, I can believe that she will pay attention to the harm.

Then I can feel safe(r).  Then we can have a therapeutic alliance.

Next week -- more specific behaviors that demonstrate respect and build a therapeutic alliance.

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