Mental health professionals are going viral on the app, captivating an anxious generation.
The author in the Adirondack Mountains of upstate New York in 2007, during his second stay in a wilderness therapy program. Credit…via Kenneth R. Rosen
All I heard was rain, my thumping heart harmonizing with the tempo of the tempest outside. I waited for the night watchman’s light to sweep over my bunk. He disappeared into the hallway, into the next room of clients who he noted to himself were present and asleep and so moved to the next room.
When he entered another room, I hurried behind him, crouching, to the central alcove, from where I made my escape. My plan included a list — backpack, peanut butter, headlight, rain gear, stolen MapQuest printouts, knife — and a destination, Boston. I’d run to an unfamiliar city, across a state to which I’d been taken against my will, to meet a future I could not be certain was any better. The rain seemed less like a portent, more an encouragement, as if each wind gust carried with its rivulets the words, It’s your time. They’ll never find you. Go now.
They were the escorts. Transporters. Redirection specialists. They, usually two men who take unsuspecting teenagers in the middle of the night to therapeutic programs across the country, went by different names. I was certain they were coming for me. They had come for me several months before the night of my escape, in late winter 2007, at the request of my parents who saw no other way to set me straight. My mom and dad hired the men, after consulting with school officials, psychologists and an education consultant, to take me from my bed and to deliver me like a wasted soul to an experiential therapy program in the Adirondack Mountains in upstate New York. They believed they were practicing “tough love,” making the difficult choice to send their child away to forge a better future away from home.
From New York I’d go on to a program in Massachusetts. I did not know it then, but I’d become one of the tens of thousands of “troubled” or “at-risk” teenagers carted off to these unregulated, private industries each year.
The years leading up to my being taken and the eventual break out is now a blur of misanthropy. I was reckless, taking my mom’s car out for joy rides without permission, skipping class, distrusting authority figures like the high school principal and local municipal authorities sent to curb my behavior, to put me back on a path more, how should we say, normal.
In the nearly 12 months I’d spend between the experiential wilderness therapy program (twice), a therapeutic boarding school in Massachusetts and a residential treatment center on a ranch in Utah, I lived up to the designation of a troubled teen. The programs were what the media called part of a tough love movement, which flourished in the early aughts but still exists today.
I’d return that type of love to my parents, ignoring their written letters, our only form of communication, vetted and censored by my “therapists.” I felt betrayed and discarded. They pleaded with me to accept the programs and to do my best to succeed in them. It felt like they wanted me gone. Really, I was being groomed for institutionalization. The juvenile and criminal justice systems the programs ventured to save me from instead prepared me for adult incarceration. By the end of my time away I recognized a bliss associated with handcuffs. Lockup and lockdown meant the familiarity of strip searches, drug tests, isolation cells and men who handled me like I was worthless: hallmarks of the programs that became synonymous with the word homebound.
But losing any self-actualization and inner-direction came later. On the night of my escape, I still believed I held some agency over my future, shrouded in uncertainty though it was. What would I do in Boston? I didn’t care. How would I earn money? Where would I stay? I would figure it out once I was far away from this place.
My parents were no longer trustworthy. They were part of the growing number of my adversaries working to keep me from personal liberties. At the program I was restricted access to food. I was allowed only communication with my parents, not my friends back home. If I chose not to respond to my parents, I would also be cut off from my peers in the programs. Either way, I’d lose.
I was given prescription medication to ease my anxiety and depression, which left me hollow and numb. I was made to answer questions about my life and emotions until, I was told, I got them right, framing things in a way the program and therapists felt more accurately told a story about my deviance that I then internalized. My journals were confiscated, their private contents used against me in “therapy sessions.”
I wasn’t troubled or bad. I was alone, all the angst and hormonal shifts of adolescence compounded and weaponized against me. I was backed into a corner and told to change, made to think I’d become reproachable and unwanted. What they wanted from me — to be happy, well-adjusted, open to therapy and the mind-numbing boredom I associated with schooling — seemed a betrayal of the very thing they wanted me to be: myself.
Meanwhile, I had broken a number of rules at the school — “cheeking” medication, drinking hand sanitizer, fraternizing with girls. I was certain then, by the fourth month at the program, that I was doomed for another “transport.” Then one night they came.
I’d been waiting, staring deep into the white ceiling overhead, my inability to sleep soundly forever cemented. Before I could jump down from the top bunk bed, the escorts announced that they were there for a different boy, my roommate. He stood from his bed, his head hanging. He pulled a pre-packed suitcase from underneath his bed (we all had our own type of go-bag), gave a weak smile, shrugged, told me he’d see me again, however unlikely, and left with the men flanking him out the door, choosing to go, as they called it, the “easy way.” He had already gone the “hard way.”
Picked off. Kidnapped. Taken. Call it what you wish, but trying to sleep each night with the notion that a pair of strangers could come to lift you from your bed, whether your actions were deserving of this treatment or not, haunts me, haunts thousands. Having watched my roommate get taken was surreal. It made real for the first time what had happened to me, brought into context that it was happening to others, and eventually sold me on my own desire to flee. I would not wait to be taken. I had to get out. No one would take me. I would lead myself away.
Now, standing outside the central alcove with my back to the doorways of the program, I stared into the fields of the Berkshire mountains, another expanse of seclusion and remove, the rain washing over me in blinding sheets. I bent into the storm, leaning into the wind that soon turned, pushed at my back, leading me away from this place into the deep, heaving thicket at the far end of the program’s property.
I vaulted a fence and tore my rain pants. Water and a cold breeze swept into the tear. I began to shiver. Boston seemed farther than ever, the return to my previous life an impossibility. My mother once told me “to strive, to seek, to find, and never to yield,” cribbed from the Tennyson poem. But yield I would, turning around and greeting my future and any hope I had for making it my own. I was told I was troubled and believed it and ran because that’s what bad kids did.
I unceremoniously turned myself in to the night watchman because I had lost all strength to continue being bad. I wanted to be good, loved. It was as much a desire to get away that drove me from the program as it was a display of disapprobation and the final displacement of my waning emotional strength. I would fold into the programs, accepting that if I were to change it would be by a force better accepted than rejected, one that had overpowered and broken me into a shell of my former self.
Those programs are now a distant memory, but the contours of those inescapable feelings of rejection and dismissal, of living up to the expectations held by others and not myself, follow me. When I find the energy to keep those memories from chaining me to a different person, a different time, I do my best never to yield.
Kenneth R. Rosen is the author, most recently, of “Troubled: The Failed Promise of America’s Behavioral Treatment Programs.”
Ariela Safira was on a mission. Shaken by the attempted suicide of a friend during her freshman year at Stanford University in 2013, Ms. Safira sought to understand the opaque mental health care system. She soon learned of the shortage of qualified therapists and, even where they are more plentiful, of the hurdles to obtaining care. Although a computer science and math major, she eventually enrolled in a clinical psychology graduate program at Columbia University.
But she kept coming back to a fundamental view: that there is often a mismatch between need and services, an essential supply-and-demand question. “It’s very difficult to start and keep up a therapy business,” Ms. Safira said. “It’s a 10-person job, not a one-person job, from marketing yourself, doing your own financing and managing your own rent. But even before you get to a place where you manage all those things, what’s so challenging is making a name for yourself so that people want to go to you.”
And so, in 2019, she founded Real Therapy, a small business designed to tackle mental health and overall wellness by easing access and offering a range of services to answer clients’ needs.
Driven by personal experience — and further motivated by the pandemic, which has caused an increase in anxiety and depression among the general population, including among young adults — entrepreneurs like Ms. Safira are focusing on addressing aspects of the mental health care system that they view as broken. They seem undeterred by the complicated nature of that system: a byzantine insurance process, a wide range of provider types, and elusive fits between patient and therapist.
“It’s a crowded space,” Alex Katz, the founder of Two Chairs, which opened its doors with a single clinic in San Francisco in 2017, said of the mental health start-up scene. Nonetheless, he said, “because the problems are massive, we need a lot of great companies working in innovative ways to address the different populations, diagnoses and delivery of care.”
Mr. Katz, another Stanford graduate, began working at Palantir, the data analytics and software company, but sought to understand mental health services when his partner “was going through a tough time in her life.” He eventually quit his job and began to tap into his network of friends and family to understand the mental health care system.
He soon learned that one of the system’s biggest challenges was matching a therapist with a patient, something he thought technology could solve. Yet, after interviewing clinicians, he chose to start a physical clinic, rather than a virtual one. In trying to raise funds for his fledgling business, “I joke that I had three strikes against me: I was a first-time, solo founder of a bricks-and-mortar company in health care.” But from its inception, Two Chairs has relied on technology, using a frequently updated proprietary algorithm to match client and therapist after a prospective client’s first intake meeting.
Although both Ms. Safira and Mr. Katz initially focused on in-person care, with virtual therapy as a long-term goal, they had no choice but to change direction once the pandemic hit. Ms. Safira and her small team quickly had to shift from the Manhattan space they carefully designed and renovated, but never opened, to go completely remote. Within eight long days, she produced a remote platform to provide five types of services, largely group-oriented (one-on-one sessions will wait until the in-person location opens). Mr. Katz — whose company had grown to seven locations in the Bay Area, with a new one set to open in Los Angeles next year — also made the decision in March to continue his business by going fully virtual.
Because both had planned, eventually, to offer remote services, they already knew that the efficacy of remote sessions was already proven. David Mohr, the director of the Center for Behavioral Intervention Technologies at Northwestern University’s Feinberg School of Medicine, who has studied the issue, said that researchers had long found that teletherapy could be as effective as in-person therapy.
“There are no substantial differences in outcomes between remote and face-to-face” therapy, he said, adding that a remote option can solve issues of distance and time constraints that often discourage people from seeking therapy. (Dr. Mohr, through his work at Northwestern, is the principal investigator for IntelliCare, a university program that provides pre-therapy tools for anxiety and depression.) Practitioners have been resistant to this change, but the pandemic has forced their hands.
“We are at an inflection point,” he said. “There is a greater acceptance of the use of technology in mental health care, while at the same time there is a tremendous decrease in the stigma” that had been associated with emotional problems.
Like Ms. Safira, it was personal experience that propelled Kyle Robertson to explore a platform for virtual therapy. The son of a psychiatrist and therapist, Mr. Robertson had difficulty finding help in dealing with his own depression and anxiety while a student at Wharton School of the University of Pennsylvania. He said his parents were hands-off but “definitely pushed early on for making sure that there was integration across medication and therapy,” which they all viewed as sometimes lacking in current practice, whether remote or in-person (only psychiatrists can prescribe medication).
After running a beta test of roughly 100 users at the end of 2019, he co-founded Cerebral in 2019. His timing, of course, proved prescient, and he has secured significant venture funding as well an uptick in clients throughout the year.
As with Two Chairs, Cerebral clients can schedule individual therapy, though group sessions are not yet available. The platform asks clients to keep track of their symptoms and report them monthly. Those responses can trigger a notification to the clinician to alert them if there is any worsening of conditions. If someone doesn’t respond, then someone on the team will reach out to check in, Mr. Robertson said.
All three companies seek to provide access quickly — the first interviews can be the same day after a client has signed up, in an effort to pre-empt mental health emergencies. The goal, Mr. Robertson said, is for new clients to speak to someone “within 10 minutes, something we’re able to do with a network of clinicians across geographies.” (Some of the regulations regarding licensing have been relaxed during the pandemic to enable telemedicine across all specialties, not just mental health care.)
And though these providers must comply with the stringent privacy laws that govern medical care, they are able to use data that they gather to analyze outcomes. “It’s been hard to aggregate data and use it in an effective way in the past,” Mr. Robertson said. “Many therapists are in the equivalent of mom-and-pop shops who don’t have the resources, or the time, to analyze the data.”
The three entrepreneurs are all working with insurance companies to have their services covered. Ms. Safira said that clients could use funds in their health savings or flexible spending accounts, and Mr. Robertson is negotiating with insurers. Mr. Katz said that while his company’s services have been out of network, “we will begin working with insurance companies more broadly in 2021.”
Their platforms welcome all ages. Mr. Robertson says that though some older clients seem less comfortable with the remote format, there are many who adapt.
Ultimately, all three companies hope to connect clients with the right type of therapy and to possibly contribute to the understanding of how to make a match.
“There’s not much research on how to make a match, but there’s a lot that speaks about the importance of the alliance” between therapist and patient, Mr. Katz said. “At the end of the day, if you form a great bond, the quality of care is so much higher.”
Credit Whitten Sabbatini for The New York Times NYTCREDIT: Whitten Sabbatini for The New York Times
Three-year-old Jack Foster sat on his mother’s lap as she wrapped a towel carefully around his neck.
“Jack has cerebral palsy and low muscle tone,” said his mother, Emily Foster, of Northbrook, Ill. “The biggest challenge is holding his head up.”
With help from his occupational therapist, Ms. Foster fit a riding helmet on Jack’s head and clicked the chinstrap buckle into place. She then watched as the occupational therapist and two volunteers positioned her young son onto a red pony. Jack seemed delighted as one volunteer stood to his right and softly sang, while another led the pony slowly around the arena.
Jack was at Horsefeathers Therapeutic Riding in Lake Forest, Ill., for hippotherapy, a form of equine-assisted therapy conducted by licensed physical, occupational and speech therapists to improve muscle tone, speech and other functions (“hippos” is the Greek word for horse; the American Hippotherapy Association has a therapist locator at americanhippotherapyassociation.org). Hippotherapy is used to treat a variety of conditions, including brain injuries, cerebral palsy, spine curvature, intellectual disabilities, language disorders and sensory processing disorders.
The natural movements of the horse and the environmental cues enable therapists to work toward treatment goals in a setting that might feel like fun, but that research shows can have real benefits. A recent study in Physical & Occupational Therapy in Pediatrics, for example, found that children with cerebral palsy had increased body control after only 10 sessions of hippotherapy. Gross and fine motor skills also improved.
A horse striding around the barn takes around 100 steps a minute, said Dr. Tim Shurtleff, an instructor with the occupational therapy program at Washington University in St. Louis. Each stride pushes the rider’s pelvis forward, so after 35 minutes, a rider undergoes more than 3,000 repetitions of “trunk challenge,” in which the trunk is pushed forward and back. With each step the horse takes, the rider must subtly work to stay upright.
“That’s the power of this – it’s an intensive movement experience,” Dr. Shurtleff said. “The person on the horse is forced to respond to that movement.”
For riders like Jack Foster, who has been doing hippotherapy for over a year, the pelvic thrust helps to strengthen the low muscle tone in his neck and trunk, while relaxing the muscles in his hips and thighs. In his daily life “he will arch and extend, which makes his hips and his thighs really tight,” Ms. Foster said. “Sitting on the horse stretches it.”
During a typical therapy session, Jack sits on this horse facing both forward and backwards. Sessions can include a ball toss or placing rings onto long rods and cones, designed to improve trunk and neck control as well as his reaching abilities.
Researchers are now testing hippotherapy as an intervention for adults with multiple sclerosis and other neurological disorders. Dr. Deborah Silkwood-Sherer, the program director for the physical therapy department at Central Michigan University, said hippotherapy can also boost motivation in children who have disabilities and have been in therapy for years.
“People don’t realize they are working hard on a horse,” Dr. Silkwood-Sherer said. The visual and sensory input of a barn and stable setting provides additional stimulation. “For kids, they never think they are doing therapy.”
Meredith Bazaar of Ringwood, N.J., a speech and language pathologist, uses hippotherapy to treat clients, including those with apraxia, a brain disorder that makes it difficult to articulate or speak words.
“The movement of the horse is so repetitive and coordinated,” she said, allowing her to manipulate a client’s lips, chin or cheeks with her hands to help them make a desired sound. With every stride the horse takes, the client repeats the target sound, such as “ga,” which might double as a command to have the horse “go.”
At Horsefeathers, the founder and executive officer Nick Coyne has 10 gentle horses and ponies he uses for both hippotherapy and adaptive riding, which enables people with physical and mental disabilities to ride horses. He refers to some of his animals as “bomb horses,” meaning a bomb could go off and the horse would not react.
The horses are all trained to stop promptly if they sense a rider is slipping and to ignore the sudden, delighted shrieks a rider might make, as well as spastic movements, Mr. Coyne said.
Alex Brock, 22 of Lake Bluff, Ill., has microcephaly and cerebral palsy, and is also nonverbal and incontinent and has difficulty processing language. He aged out of the public school system, but once a week he eagerly leaves his wheelchair to work with Mr. Coyne as an adaptive rider.
His mother, Trina Brock, was initially incredulous when she heard about adaptive riding at Alex’s former high school. “My first thought was, how is he going to ride a horse?” she said. But she said her son now eagerly anticipates his weekly visits to the barn, and says the exercise helps strengthen his trunk.
It takes three people to help Alex ride, and Ms. Brock said the first time she saw her son on a horse, “I cried.”
Hippotherapy is not suitable for everyone. Ms. Bazaar said some clients turn out to have horse allergies, and allergy medications can make them too drowsy to participate. People with spinal abnormalities like spina bifida may not be good candidates either, and those with Down syndrome and other conditions should be first examined by a physician to determine if their spines are stable enough to endure the rides, she said.
But for children like Jack Foster, riding a horse can open up new opportunities. “It was the first therapy he had done without me,” his mother said.
Credit Sara Krulwich/The New York Times
At a recent dinner party, one guest said, “My brothers have not been in the same room for 16 years.” Another is estranged from a sister who she feels over-guards their widowed mother. Yet another lives in the same building as a brother with whom she no longer talks.
Welcome to sibling rivalry, the grown-up variety. There is no law that says we have to love the ones we were raised with, or even that we must reconcile before the grand finale. But as millions of baby boomers hit Act Three, the issue is rankling a generation that grew up believing in sharing, openness and the concept of “closure.”
“I’ve always thought that the psychological field does not give enough attention to the huge impact of siblings,” said Dr. Anna Fels, a psychiatrist in private practice in New York. She is not alone in that sentiment. Dr. Roger Gould, also a New York psychiatrist, agrees: “As I think about my current caseload, every one has a strained, difficult relationship with at least one of their siblings.”
If you have any doubts, look at the culture. On stage in New York recently, “The Humans,” “Dot,” “Familiar,” “Hold On to Me Darling,” “Buried Child” and “Head of Passes” all touch on siblings dealing with money, memories and taking care of ailing parents. The television show “Transparent” may purport to be about a 70-year-old man-turned woman, but it is really about the family’s next generation, acting more like children than children. The Netflix series “Bloodline” has just returned for a second season and deals with four siblings, one of whom — spoiler alert — drowned another at last season’s end. In the film “Alice Through the Looking Glass,” sibling rivalry nearly stops time.
Three books on the best-seller list deal with feuding siblings, including “The Nest” (“Jack and Leo were brothers but they weren’t friends”; “Miller’s Valley,” in which two sisters live on the same property but don’t speak to each other; and “The Nightingale,” about two very different sisters during World War II.
“Readers want to recognize themselves in fiction,” says Anna Quindlen, author of “Miller’s Valley,” “and I think most have some aspect of sibling conflict. In terms of those power relationships, there is no such thing as being grown up. At some level I will be an oldest child until the day I die.”
Most assume the fractures have to do with money, as parents die. What to give away, what to save or how to split? But is it really that simple?
“Usually these start out being about dividing up money, but underneath, it’s about things the siblings have avoided for decades,” says Frederick Hertz, a financial mediator based in Oakland, Calif., who is writing a book with the working title, “Can I Divorce My Sister?” “Their childhood is such an integral part of their identity, and it sometimes becomes hard to put that aside enough to engage in practical decisions. I recently met with a brother and sister during which she stormed out saying, ‘He’s lived off our parents for 50 years!’ All that kind of stuff comes up.” That “stuff” may include one sibling feeling another was favored, thinking he or she was not defended against some form of abuse, or simply being a living reminder of disappointment and distress.
When in doubt, we can always blame Mom and Dad. A 70-year-old man told me he was close to his younger brother in childhood. “I sort of took on the father role. There was minimal parental praise, and let’s say I got less bad attention.” But the boy for whom he wrote class papers and took to the orthodontist, turned into the man who one day said, “I used to think you were the best and now you are the worst brother.” They have not spoken in 10 years.
Envy also can rear its ugly head after all these years. “In my sister’s mind, my arrival signaled the end of her seven-year reign on a pedestal,” a 55-year-old woman told me. A few years ago, she flew from New York to Seattle for her sister’s lung cancer operation. “She came out of recovery, saw me, and said, without the slightest sense of gratitude, ‘What are you doing here?’.” The act was not reciprocated when the younger sister developed breast cancer. She recalled, “My sister said, ‘Of course you would get the cancer that is more treatable.’”
Occasionally a bar mitzvah or wedding may bring squabbling siblings together, but then the parties tend to go back to their corners. More likely, reconciliation comes when an end is in sight. Says Dr. Gould: “Whenever a crisis or death occurs — even though old wounds are opened — the rawness of the experience makes old slights irrelevant and the old image of ‘the other’ vanishes.”
Such occasions can prompt an effort toward reconciliation. Or not. Dr. Vivian Diller, a psychologist, said: “Being aware that we are living longer gives some a sense of new beginnings, with new choices. The byproduct can result in leaving behind poor sibling relationships or working on ones that are worth the effort.”
Experts suggest that parents encourage more family togetherness and extend equal love early on. As they grow, siblings should acknowledge one another’s flaws, which can help to lower expectations. Seeking help from therapists or mediators can bring the real issues out into the open.
“I do see more of a willingness to get therapy,” Dr. Fels said. “Professionals can also help people to recognize — and perhaps even accept — that a sibling might have legitimate mental health issues,” she said. All of the above may improve matters in some families. But there is no guarantee.
Michele Willens is a freelance writer and podcaster for NPR’s Robinhoodradio.
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Every January for the past decade, Jessica Irish of Saline, Mich., has made the same New Year’s Resolution: to “cut out late night snacking and lose 30 pounds.” Like millions of Americans, Ms. Irish, 31, usually makes it about two weeks.
But this year is different.
“I’ve already lost 18 pounds,” she said, “and maintained my diet more consistently than ever. Even more amazing — I rarely even think about snacking at night anymore.”
Ms. Irish credits a new wearable device called Pavlok for doing what years of diets, weight-loss programs, expensive gyms and her own willpower could not. Whenever she takes a bite of the foods she wants to avoid, like chocolate or Cheez-Its, she uses the Pavlok to give herself a lightning-quick electric shock.
“Every time I took a bite, I zapped myself,” she said. “I did it five times on the first night, two times on the second night, and by the third day I didn’t have any cravings anymore.”
As the name suggests, the $199 Pavlok, worn on the wrist, uses the classic theory of Pavlovian conditioning to create a negative association with a specific action. Next time you smoke, bite your nails or eat junk food, one tap of the device or a smartphone app will deliver a shock. The zap lasts only a fraction of a second, though the severity of the shock is up to you. It can be set between 50 volts, which feels like a strong vibration, and 450 volts, which feels like getting stung by a bee with a stinger the size of an ice pick. (By comparison, a police Taser typically releases about 50,000 volts.)
Other gadgets and apps dabble in behavioral change by way of aversion therapy, such as the $49 MotivAider that is worn like a pager, or the $99 RE-vibe wristband. Both can be set to vibrate at specific intervals as a reminder of a habit to break or a goal to reach. The $80 Lumo Lift posture coach is a wearable disk that vibrates when you slouch. The $150 Spire clip-on sensor tracks physical activity and state of mind by detecting users’ breathing patterns. If it detects you’re stressed or anxious, it vibrates or sends a notification to your smartphone to take a deep breath.
But the Pavlok takes things a step further, delivering a much stronger message.
To test the device, I wore it for a week, zapping myself every time I ate dessert. My goal was to curb my craving for sweets after dinner. First I zapped myself before and after I ate a square of dark chocolate, and did it again later in the week after eating ice cream, a red velvet cupcake and a chocolate chip cookie.
Set on low, it feels like a strong tickle. Set on high, it hurts. A lot.
It should be noted that the creator of Pavlok, Maneesh Sethi, once hired a woman to sit next to him and slap him on the face every time she saw him using Facebook, so he could increase his productivity. I called Mr. Sethi and told him that if we ever met, I’d try not to punch him in the face for creating such an awful torture device. “Yeah, I get that a lot,” Mr. Sethi said with a chuckle. “People either love it or hate it.”
“It’s not designed to be painful,” he added. “It’s instantaneous, a surprise sensation, a shock that knocks you out of automatic mode.”
But does this kind of self-imposed aversion therapy actually work?
“The most clever thing about this gadget is the name,” said Dr. Peter Whybrow, a Los Angeles author, psychiatrist and neuroscientist. “It’s an expensive spin on the idea of wearing an elastic band that you snap on your wrist to stop a certain behavior.”
Dr. Marc Potenza, a professor of psychiatry at Yale, says researchers have questioned the ethical nature of shock intervention when more comfortable options like cognitive behavioral therapies, pharmaceutical interventions and 12-step programs are available.
The practice of aversion therapy has been around for 80 years. Schick Shadel Hospital, based in Seattle, reports that it has successfully treated more than 65,000 people for alcohol or drug addiction using counter-conditioning methods like emetic drugs, which make people feel nauseated if they drink alcohol, or supervised shock therapy. The hospital’s medical director, Dr. Kalyan Dandala, said that he was interested in using Pavlok to help people continue recovery once they finish the 10-day inpatient treatment, but added that the device should be professionally supervised.
“It’s better suited as a prescribed tool for behavior modification,” Dr. Dandala said. “The company needs to refine it, put more education in the tool, and have more oversight.”
Michelle Freedland, a psychiatric nurse practitioner in Manhattan, has worked with five patients who use the device for nail biting, addictions, compulsive behaviors and more.
“When one of my patients told me he was using it last year to help him get out of bed in the morning, I was skeptical at first,” she said. “I mean, the notion of being shocked — you can have a little reservation. But when you understand how to use it properly and people are more engaged in their own treatment, they tend to follow through with it more.”
Mr. Sethi, the founder, said the company had just begun to collect data on the long-term success of the device, and was planning a clinical trial later this spring. The Pavlok has been available since November, and he said about 10,000 people had used it.
Despite the potential for pain and the lack of science backing a long-term effect, user feedback on Facebook groups and message boards has been enthusiastic about the device, especially as a last resort for problems like overeating and binge drinking.
Bud Hennekes, 24, a blogger in St. Louis, said he had used Pavlok to kick a nearly two-pack-a-day cigarette habit. “When I tried to quit before, I still had the craving to smoke,” he said. “When I used Pavlok, the cravings completely went away. I don’t know if it’s science or a placebo effect or what, and I don’t really care because it worked.”
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Sixty-five million Americans suffer from chronic lower back pain, and many feel they have tried it all: physical therapy, painkillers, shots. Now a new study reports many people may find relief with a form of meditation that harnesses the power of the mind to manage pain.
The technique, called mindfulness-based stress reduction, involves a combination of meditation, body awareness and yoga, and focuses on increasing awareness and acceptance of one’s experiences, whether they involve physical discomfort or emotional pain. People with lower back pain who learned the meditation technique showed greater improvements in function compared to those who had cognitive behavioral therapy, which has been shown to help ease pain, or standard back care.
Participants assigned to meditation or cognitive behavior therapy received eight weekly two-hour sessions of group training in the techniques. After six months, those learning meditation had an easier time doing things like getting up out of a chair, going up the stairs and putting on their socks, and were less irritable and less likely to stay at home or in bed because of pain. They were still doing better a year later.
The findings come amid growing concerns about opioid painkillers and a surge of overdose deaths involving the drugs. At the beginning of the trial, 11 percent of the participants said they had used an opioid within the last week to treat their pain, and they were allowed to continue with their usual care throughout the trial.
“This new study is exciting, because here’s a technique that doesn’t involve taking any pharmaceutical agents, and doesn’t involve the side effects of pharmaceutical agents,” said Dr. Madhav Goyal of Johns Hopkins University School of Medicine, who co-wrote an editorial accompanying the paper.
Dr. Goyal said he sees many patients with chronic lower back pain who become frustrated when they run out of treatments. “It may not be for everybody,” he said, noting that some people with back pain find yoga painful. “But for people who want to do something where they’re using their own mind to help themselves, it can feel very empowering.”
One of the strengths of the study, published in JAMA on Tuesday, was its sheer size. It included 342 participants ranging in age from 20 to 70. They were randomly assigned in equal numbers to either mindfulness-based stress reduction, cognitive behavioral therapy, or to continue doing what they were already doing.
Sixty-one percent of participants who received meditation training experienced meaningful improvement in functioning six months after the program started, slightly more than the 58 percent who improved with cognitive behavioral treatment but far exceeding the 44 percent who improved with their usual care.
Those who got cognitive behavioral therapy had greater improvement when it came to a measure called “pain bothersomeness,” with 45 percent gaining meaningful improvement compared with 44 percent in the meditation group. But both these treatments were more effective than the usual treatment, which led to improvement in only 27 percent of people.
The benefits were limited, but that’s not really surprising, said the study’s lead author, Daniel Cherkin of Group Health Research Institute in Seattle. “There are no panaceas here. No treatment for nonspecific back pain has been found to make a whole lot of difference for many people.” While some treatments may help some people, he said, they don’t work well for others, which is why it’s important to be able to offer lots of options.
Mindfulness-based stress reduction was developed in the 1970s by Jon Kabat-Zinn, a scientist in Massachusetts who adapted Buddhist meditation practices for an American audience. The goal is for meditators to increase their awareness of their experience and of “how it’s affecting them and how they’re responding to it,” said Dr. Cherkin, adding that the idea is for participants “to change their mind-set and, in a way, almost befriend the pain, and not feel it’s oppressing them.”
The new study is the second showing that meditation may help people manage chronic lower back pain. Earlier this month, researchers at the University of Pittsburgh School of Medicine reported in JAMA Internal Medicine that mindfulness meditation helped older adults manage their pain for up to six months, though the improvements in function did not persist.
Access to mindfulness-based stress reduction can be problematic, however. Training by certified instructors is not available everywhere, and may not be covered by health insurance.
But the need is tremendous. Back pain is a leading cause of disability worldwide and the second most common cause of disability for American adults.
One in four adults in the United States has had a bout of back pain within the past month, according to national health figures, and back pain that has no clear underlying cause can be tough to treat, often improving only to flare up again weeks to months later.
Dr. Cherkin said mindfulness-based stress reduction may be particularly helpful for people because even if their use lapses, they develop a skill they can draw on later when they need it.
“That suggests that training the mind has potential to change people on a more lasting basis than doing a manipulation of the spine or massage of the back,” techniques that may be “effective in the short term but lose effects over time,” Dr. Cherkin said. “You can practice it by waiting at the bus stop and just breathing.”
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Credit Paul Rogers
It did not take long for me to recognize the therapeutic potential of Max, the hypoallergenic 5-month-old Havanese puppy I adopted in March 2014. He neither barked nor growled and seemed to like everyone, especially the many children that come up and down our block.
When I asked if a crying child passing by would like to pet a puppy, the tears nearly always stopped as fluffy little Max approached, ready to be caressed.
So I signed us up for therapy dog training with the Good Dog Foundation, which met conveniently in my neighborhood. If we passed the six-week course, we would be certified to visit patients in hospitals and nursing homes, children in schools, and people in other venues that recognize the therapeutic potential of well-behaved animals.
Training involves a joint effort of dog and owner, usually in groups of four to eight pairs. The dog can be any size, any breed, but must be housebroken; nonaggressive; not fearful of strangers, loud or strange noises, wheelchairs or elevators, and able to learn basic commands like sit, lie down and leave it. Good temperament is critical; a dog that barks incessantly, nips or jumps on people uninvited would hardly be therapeutic.
During our first visit to patients at my local hospital, a woman who said she’d had a “terrible morning” invited Max onto her bed, showered him with affection and, crying with pleasure, thanked me profusely for bringing him around to cheer her up.
Moments later, on the pediatrics ward, a preverbal toddler hospitalized with croup spotted Max and came charging down the hall squealing with delight. The two met eye-to-eye; Max even appeared to smile, and she giggled as she patted his head.
I don’t know about Max, but I was hooked. I agreed to bring him for monthly patient visits, with a promise to do more if my schedule permitted, and I was able to do the required pre-visit bath.
A therapy dog need not be small and fluffy. A neighbor with a “mush” of a 90-pound American pit bull named Pootie has had similar experiences at the Veterans Affairs New York Harbor Healthcare System’s Brooklyn campus. During the first visit, one patient told him repeatedly, “You made my day.”
But while a hospital’s voluntary pet therapy program is designed to aid patients, in my experience the chronically-stressed hospital staff benefits as much if not more from pet visits. “Can I pick him up?” is the typical request from hospital personnel I encounter, and some don’t even wait for me to say yes.
Therapy pets differ from service animals like those that guide the blind, detect impending health crises for people with epilepsy or diabetes, or stimulate learning for children with autism or cerebral palsy.
Pet therapy most often involves privately owned animals – usually dogs, but also cats, rabbits, even kangaroos, birds, fish and reptiles – that their owners take to facilities to enhance the well-being of temporary or permanent residents. Thus, in addition to relieving the monotony of a hospital stay or entertaining residents in a nursing home, Max might visit a school where young children wary of reading aloud will happily read to a dog that does not care about mistakes.
At my local hospital, therapy dogs often attend group sessions for psychiatry patients. Cynthia Chandler, a counseling professor at the University of North Texas and author of “Animal Assisted Therapy in Counseling,” reports that visits by her dog Bailey increased patient participation in group therapy and improved hygiene and self-care among those with severe mental illness.
At Veterans Affairs hospitals, not only therapy dogs but also parrots have reduced anxiety and other symptoms among patients being treated for post-traumatic stress disorder.
Valerie Abel, a psychologist who coordinates the pet therapy program at the Brooklyn Veterans Affairs hospital, said, “The presence of therapy dogs makes such a difference. Many ask when they’ll next be back. A big dog can put its head on patients’ beds and you can actually see them relax.”
Studies have shown that after just 20 minutes with a therapy dog, patients’ levels of stress hormones drop and levels of pain-reducing endorphins rise. Endorphins are the brain’s natural narcotic, the substance responsible for the runner’s high that helps injured athletes ignore pain.
In elderly patients with dementia, depression declines after they interact with a therapy animal. And researchers at the University of Southern Maine showed that therapy dog visits can calm agitation in patients with severe dementia.
In a controlled study of therapy dog visits among patients with heart disease, researchers at the University of California, Los Angeles, found a significant reduction in anxiety levels and blood pressure in the heart and lungs in those who spent 12 minutes with a visiting animal, but no such effect occurred among comparable patients not visited by a dog.
Therapy dogs are often described as better than any medicine. They know instinctively when someone needs loving attention. Last winter, when I was felled by the flu (despite my annual shot), 1-year-old Max lay at the foot of my bed for hours on end, making none of his usual demands for attention and play.
In an intriguing pet therapy program, sometimes called pets behind bars, benefits accrue to both the animals and the humans with whom they interact. Shelter dogs considered unadoptable and living on “death row” are assigned to be cared for and trained by selected prison inmates, including convicted killers and rapists, many of whom have serious anger issues.
The inmates work to socialize the dogs, teaching them to trust people, behave appropriately and obey simple commands. In turn, violence and depression among the inmates is lessened; they learn compassionate behavior, gain a sense of purpose, and experience unconditional love from the dogs in their care.
At the completion of training, rehabilitated dogs are offered to people who want to give a shelter animal a permanent home. Through the Safe Harbor Prison Dog Program at Lansing Correctional Facility in Lansing, Kansas, for example, some 1,200 dogs have been adopted as pets.
In a related program, veterans back from service in Iraq and Afghanistan are giving basic obedience training to shelter dogs, a project that helps the vets readjust to being home and offers the dogs a chance to gain a home of their own.
Before signing up for therapy dog training, you’d be wise to find out first what the program involves and its cost and what will be required of you by the facilities you hope to visit. I’ve had to provide annual documentation of Max’s vaccinations and freedom from intestinal parasites, which typically requires a visit to the vet. I too had to show I was immune to multiple infectious diseases and free of H.I.V., and the hospital had to test me for drug abuse.
Still, the rewards Max and I have accrued as hospital volunteers more than compensate for these requirements.