Dr. Richard Friedman in "Why Are We Drugging Our Soldiers" shows the correlation between Ritalin and Adderall prescriptions and increased PTSD. He cites several studies showing that these drugs enhance the memory of fear-provoking events. Scary and makes all kinds of sense. Read it!
I was interviewed by Stan Emert on his cable TV show, "Public Exposure" a few weeks ago. Here is the YouTube link to the show: http://youtu.be/KsFoHFQxx4o Topics include trauma definitions, PTSD, EMDR, Ego State Therapy, and a minute of traumatic grief.
Due to a neck injury, I've been unable to spend more than a few minutes at a keyboard in the last few months. I hope to resume posting on this blog after I learn to write with Dragon, a voice-recognition program.
Here's a 6 minute video of a Gulf War soldier's PTSD diagnosis with brain scans and then treatment with EMDR. He had a scary childhood, fear for his life in combat, and then was retriggered by witnessing a horrible accident.
My copy of the new book arrived today. Here is what Diana Fosha says about it:
"This is a thorough, accessible, and very practical book, filled with resources and sound ideas, filtered through the intelligence and experience of a savvy, compassionate, down-to-earth, and very experienced clinician. It is like a travel guide to the land of trauma and trauma treatment: if you are new to it, it will orient you to all there is to do and see; if you're a frequent traveler, it is a worthwhile reminder of all that is out there, above and beyond the familiar places you always visit. Once could ask for a better guide. I highly recommend it."
I explain trauma, complex trauma, dissociation and how to assess them and prepare for treatment, and all the kinds of treatment that I know about from the main-stream to the obscure. I talk about working with military, sexually-abused, and relationally traumatized people, and how to take care of yourself while doing the work.
Some of my heroes comment on it. Dan Siegel wrote the introduction, despite my lack of research. Diana Fosha, Stephen Porges, Kathy Steele, and Onno van der Hart wrote very nice blurbs on the back. I'm humbled by their support.
This is the first book written completely by me. I'm amazed to be responsible for synthesizing so many people's therapies in one book. The design is great, and the photos, by Doug Plummer (my beloved) are gorgeous.
Check out Damien Cave's article in today's New York Times. Women are less likely to be granted disability on the grounds that they weren't in combat, even though they are seeing plenty of action in Iraq. Unrecognized, they feel shame about having the flashbacks and aggression that characterized PTSD and are even less likely to seek treatment than male soldiers.
Connie Sidles is a famous Seattle birder. Here is this week's KUOW radio interview with her about why she spends so many hours at the Montlake Fill. Connie gives a cogent discussion of dealing with grief, how to create/have meaning in life, how to get present, and why birding creates bliss in its more conscious adherents. Hear her here: http://kuow.org/program.php?id=17451
And if you want to see my husband's book of photographs of the Montlake Fill, go here: http://issuu.com/dougplummer/docs/at_the_fill . You don't have to buy the book to see the pictures. Click on the book then on the pages below. You can listen to Connie on one Explorer and look at the book on the other. Connie wrote the intro to the book.
Day 1: Bessel van der Kolk is lovely. He's humble, he's funny, and he is the premiere researcher on the neurobiology and/or efficacy of trauma treatments in the world. And cute and brilliant, of course.
Here are nearly random gems from 3 hours of notes:
With trauma, there are no stories, only sensory experience: images, affect, and tactile, olfactory, and auditory experience. Bleure (1920): People can't hold the memory of the trauma--can't tell the story. The solution is taking action against the person who hurt you or telling the story over and over. (Prolonged exposure). Bessel says "No. Telling the story is not enough!" Later: "When people are into their trauma, they cannot talk about it. They become dumbfounded." Because Broca's area in the brain shuts down. "When the left brain shuts down, we must shift to right brain processing."
"Our job as trauma therapists is to bring the frontal lobe on line." (He said that GW Bush showed himself to be a "limbic" president with his "Let's kill them all" speech after 9/11. "A dangerous limbic-run man.")
The body relives and reinstates the initial trauma state, even the stress hormones.
Exposure therapy "blasts people's brains with the trauma and drives them crazy. That's supposed to be good for people?" And said the CBT literature is full of the treatment triggering suicide attempts, substance abuse, and worse symptoms.
He talked about his amazing EMDR vs Prozac study. 80% of adult onset trauma completely cleared PTSD & Depression after 8 weeks of tx. Prozac people felt better until they stopped taking the drugs. EMDR folks got better and better for months after tx and stayed that way. Cool study and he had trouble getting published despite 3X the success of CBT. Politics.) http://www.emdr.dk/artikler/07_kolk.pdf
Bessel talked about vagal nerves (see Porges--later) and said that you can change the way you feel by changing the state of your body (thus our affinity for alcohol, drugs, and sugar.) Drugs, tai chi, karate, yoga, meditation and exercise manipulate the vagus nerves. Do yoga, etc. to affect the state of your body.
"Emotional Regulation is the most important issue in psychotherapy."
Cloitre 2007: '"If treatment relationship lead to affect regulation, the patient gets better."
In a study with chronically traumatized clients: 8 weeks of Yoga class beet 8 weeks of CBT with 28 hours of homework.
In PTSD, the thalamus goes offline. The thalamus orients you to where and when you are in a autobiographical context. Much of the brain goes offline when immobilized and there are no available receptors for attachment or problem-solving.
"Thinking has no avenues of access to the emotional brain. (You can't talk yourself into loving Dick Cheney, whatever the incentive.) . . . Traumatized people don't have a sense of being deeply present because the anterior singulate is off-line. . . Keep clients oriented to 'now' in themselves: 'How does your body experience that feeling?' . . .Help clients process what's inside of their here and now consciousness."
Trauma survivors see the trauma or the "bad thing" as outside of themselves, not as their own response to something that happened. "Bring attention to the body, to internal landscape: What's the sensation? Where do you feel it? What happens if you try something? Take a deep breath, right now. Do TFT tapping on the collarbone spot. . . Notice what comes up and remember how it will come to an end. How can we give the miserable, alone, frightened part of you some company? . . . Tell her you know how terribly lonely it was."
"You can't do trauma work without people deeply observing their own level of consciousness and then deeply connecting on the outside with you."
"The emotional brain runs the show." Feelings should be guides rather than a source of terror.
Bessel spoke of the importance of EMDR and Somatic therapies in working with trauma and showed a moving video of a formerly DID client who was "organized" by neurofeedback. "EMDR is the opening for understanding trauma. You can't do trauma treatment without EMDR or something else that knits the sensory experiences together."
Part II: Francine Shapiro, the brilliant maven of EMDR, looking well and energetic.
Much of what Francine said was material you can find at emdria.com or the EMDR Institute website: The Adaptive Information Processing model and the steps of EMDR treatment. Today I heard her say some different things: The importance of targeting the "small t" traumas. Much of the trauma that can severely impact a life does not fit the criteria for PTSD. She gave many examples of people who developmentally stopped at some distressing, non-life threatening event, until an EMDR session, years later, released them. (It happens. I've seen it many times.)
"Neurophysiology does not equal destiny." There is neuroplasticity in adult brains. Shrunken hippocampi grow again, after the trauma is resolved. Don't give up! A study: 8 sessions of EMDR, 20% increase in hippocampal growth.
Beliefs are a manifestation of trauma. CBT/Exposure = extinction. EMDR = reconsolidation. In prolonged exposure, the memory of the rape doesn't change, but get a competing new memory. But the clients relapse when around a trigger, because the old memory is still there. EMDR reconsolidates memory changes, so the initial triggers won't work.
"Processing dysfunctional and positive memories are the focus of EMDR treatment. Process the negative and integrate the positive. Every positive attunment or modeling by the therapist links the positive information in. . . You need to have positive adaptive memory networks for tx to work."
Process: Family of origin issues, memories that are encoded; Defenses, i.d. the earliest childhood event that caused that pathway to develop; cognition, process the memories that created the cognition--the cause is the encoded earlier event; Somatic/Emotive, "When's the 1st time you felt that way?"; Developmental, "What events derailed attachment?"
(I'm getting too tired to give you all the rest, so I'll hit a few highlights:)
ADHD: some of it is PTSD, some real ADHD.
Body dysmorphia: usually from childhood humiliation, sometimes just one comment. Clears with a few sessions. (There's a chapter in Solutions II about this.)
Small t traumas cause more pathologies than PTSD.
Axis II (personality dx's) are a constellation of attributes, each rooted in earlier events.
Borderline Personality Dx: Cool stuff-- too much to write. But Axis II is moveable and cureable if you go after the childhood antecedents. (I know because I have ex-borderline clients and ex-narcissists.)
If you are treating kids, treat the parents attachment issues and the kids get better. Include in this: targeting the non-bonding event with the child, then make a story about an easy pregnancy, each trimester, an easy delivery, the first breath, first hours, coming home -- better than real life, and install it.
In family systems, you can treat the family of origin issues in every one, all the behavior. Teach skills after the trauma is gone, when it can sink in.
Depression. Yes, See the first 5 chapters in Solutions II.
Phantom Limb Pain. Yes. See the PLP chapter in Solutions I--Wilson
Grief: "There is more positive recall of the loved one after EMDR (for traumatic grief) than after CBT. (Sprang, 2001)
EMDR increases resilency and engenders a new sense of self.
I'm reading piles of books in preparation for writing a trauma therapy survey book. My friend and colleague, Barbara Hinsz lent me Glenn Schiraldi's The Post-Traumatic Stress Disorder Sourcebook. (McGraw-Hill, 2000) It's a great self-help book, one of the best I've seen. Schiraldi's a good writer. I never wanted to fix his sentences. He's simple without being simplistic. He gives a great description of dissociation. He talks clearly and cleanly about therapy. (Giving CBT, EMDR, Counting, and TFT good "marks", describes many other self-help and therapeutic techniques, and gives the same warnings I do about prolonged exposure.)
If you have a client who wants more information and some good self-help advice as an adjunct to therapy, suggest this good and wise book. And if you have suffered a trauma, and are still feeling the after-effects, read this book. I just bought one for myself.
The New York Times published this article today. If you haven't starting gearing up to work with soldiers, get some training now. There are online trainings, in-person trainings, and books. You can even start by watching movies: In the Valley of the Elah is supposed to be a great one. Understand that, so far, EMDR has been statistically superior to any other training for PTSD in soldiers.
THE American troops in Iraq daily face the risk of death or injury — to themselves or their fellow soldiers — by homemade bombs and suicide attackers. So it is not surprising that post-traumatic stress disorder is a common problem among returning soldiers. But how many, exactly, are affected?
This question is key to determining how large an investment the Department of Veterans Affairs needs to make in diagnosing and treating the problem. The United States Army's Mental Health Advisory Team, which conducted a survey of more than 1,000 soldiers and marines in September 2006, found that 17 percent suffered from P.T.S.D. Similarly, a Rand study put the number at 14 percent.
But these estimates do not take into account the many soldiers who will eventually suffer from P.T.S.D., because there is a lag between the time someone experiences trauma and the time he or she reports symptoms of post-traumatic stress. This can range from days to many years, and it is typically much longer while people are still in the military.
To get a better estimate of the rate of P.T.S.D. among Iraq war veterans, two graduate students, Michael Atkinson and Adam Guetz, and I constructed a mathematical model in which soldiers incur a random amount of stress during each month of deployment (based on monthly American casualty data), develop P.T.S.D. if their cumulative stress exceeds a certain threshold, and also develop symptoms of the disorder after an additional amount of time. We found that about 35 percent of soldiers and marines who deploy to Iraq will ultimately suffer from P.T.S.D. — about 300,000 people, with 20,000 new sufferers for each year the war lasts.
Consider that only 22 percent of recent veterans who may be at risk for P.T.S.D. (based on their answers to screening questions) were referred for a mental health evaluation. Less than 40 percent of service members who get a diagnosis of P.T.S.D. receive mental health services, and only slightly more than half of recent veterans who receive treatment get adequate care. Those who seek follow-up treatment run into delays of up to 90 days, which suggests there is a serious shortage of mental health professionals available to help them.
Proper P.T.S.D. care can lead to complete remission in 30 percent to 50 percent of cases, studies show. Thorough screening of every soldier upon departure from the military, immediately followed by three to six months of treatment for those who need it, would reduce the stigma that is attached to current mental health referrals. The Rand study estimates that treatment would pay for itself within two years, largely by reducing the loss of productivity. This is the least we can do for our veterans.
Lawrence M. Wein is a professor of management science at the Stanford Graduate School of Business.
The EMDR International Association, (EMDRIA) is urging its members to write a letter supporting EMDR treatment for soldiers and veterans. The EMDR Humanitarian Assistance Program has been offering and doing volunteer-run, inexpensive Basic trainings to the military and the VA. EMDR has been accepted by the Department of Defense as one of two effective/allowed treatments.
What's the problem? There is hostility on some of the lower levels of bureaucracy towards EMDR. It's new. It's not what they've always done. And some think that anyone professing PTSD is a weenie slacker. Also, some of the people who have lucrative contracts teaching cognitive behavioral techniques to military and VA clinicians are threatened financially and ideologically by EMDR. HAP trainings are much cheaper then what they're doing for profit. And, according to them, EMDR is either woo-woo bullshit (despite all research) or just another form of exposure therapy.
I went to an organizational meeting for the Soldiers Project NW(SP)last night. Forty-two people were there. Therapists from all over the Puget Sound region, one from Yakima, and even one from California. About 10 were veterans. Several had worked for the VA. The rest were people who heard about it and wanted to help. Several expressed despair or shame at the current level of services available for soldiers and veterans and excitement at the possibility of righting the situation.
Trisha Pearce and Lisa Weinberg convened the meeting. They've been working since October to connect with the LA-based project, a 501C3, which started the first chapter. They invited Michelle (whose last name I didn't get), a social worker from the Seattle VA to talk about the interface with VA. SP volunteers will work with people who either don't qualify for, or don't want to interact with VA and the military for mental health needs. We'll work with active duty, honorably and dishonorably discharged soldiers and their families and friends. We can refer appropriate people to the VA for services, if they want to be referred.
There are seven simple rules for SPNW volunteers:
You agree to provide one hour a week of mental health support or tx at no charge.
You agree not to accept donations, insurance payment or barter for services provided.
You agree to educate yourself on the effects of trauma, war and the treatment of combat PTSD and how to refer for veteran's benefits. If you work with families, children, or women you will educate yourself on their special needs.
You agree to screen referrals to determine whether they are appropriate your scope of training, and, if not, refer them back to the SPNW referral system.
You agree to conduct this pro bono work with the same high ethical and professioanl standards as in your general practice.
You agree to keep in touch with SPNW about your availability and practice info.
You agree to maintain appropriate malpractice insurance that covers your work with clients (including those seen at no cost through this project) in private practice.
These are the most simple and elegant membership rules I've ever seen. They all make sense, and they don't dictate how to do the therapy. The only other rules I heard were about the neccessity to be licensed or on the licensure track.
There are plans for support and training of we therapists. I requested information on Traumatic Brain Injury, about which I know little. I offered to do a basic traumatology workshop. The conveners gave us piles of paper full of information, including many information-filled websites for clinicians and active duty people, veterans, and their families. I think that EMDR HAP could get involved, since it's a non-profit, and will be contacting the main office soon, to find out.
Nicole Brodeur featured "The Soldiers Project" in her Friday Seattle Times column. This some of what she said:
" Trisha Pearce, who lives in Stanwood, is starting a Northwest chapter of The Soldiers Project, a network of licensed mental-health counselors who offer free psychological treatment to active-duty soldiers, National Guard members, reserves, veterans and their families.
The nonprofit Soldiers Project was founded in 2004 by Los Angeles psychiatrist Judith Broder, who was moved to act after seeing a performance of monologues written by an active-duty Marine and featuring Iraq veterans.
Some 35 percent of Iraq War veterans seek counseling in the year they return. This year, the U.S. Department of Veterans Affairs will spend $3 billion providing mental-health care to about 1 million veterans.
That helps, Pearce said, but the VA's culture of bureaucracy alienates some veterans.
Others don't want to get in any deeper with the military. Or they don't want mental-health issues to be on their records. Or they were dishonorably discharged and aren't eligible for benefits.
Then there's the National Guard: "They're not coming back to a military base," Pearce said. "They're in Baghdad one day, and then they get off the plane and they're home in Bellevue and their wives want them to clean the gutters.
"They are not going to come back and be who they were."
Before she can help them, Pearce must first build a network of psychotherapists willing to volunteer at least one hour a week to soldiers in need.
Once that's done, clients could call or e-mail and, within 24 hours, receive a response from a clinician who will gauge their needs, then search the database of therapists.
On April 28, she will hold an informational session for therapists from 7 to 9 p.m. at University Lutheran Church in Seattle. (RSVP to firstname.lastname@example.org).
The project has given Pearce a new purpose and forced her to abandon the antiwar sentiment she embraced in the 1960s. "We should all be saying, 'We're here for you,' and support veterans by making it simple for them to get psychiatric care," Pearce said. "It should be our responsibility, like paying taxes, to go out of our way and do something."
The Soldiers Project started in Los Angeles and has offshoots in Chicago and New York, and of course, Seattle. Check out the LA website at http://www.thesoldiersproject.org/ for more information, or better yet, if you'd like to start your own chapter in your town.
The new issue of the Journal of the American Medical Association features an article by Dr. Kerry Ressler and several co-authors found that specific variations in the gene appeared to be influenced by child abuse. That interaction strongly increased the chances for adult survivors of abuse to develp signs of PTSD. The worse the abuse, the stronger the risk in people with the gene. (Though that might be true in any population.) From the Seattle Times: "The results of the new study suggest there are critical periods in childhood when the brain is vulnerable to 'outside influences that can shape the developing stress-response system'. . .Dr. Thomas Insel, director of the NIMH, said the study is valuable for the light it sheds on military veterans. He said the results help explain differences in how two people see the same radside bomb blast. One simply experiences it as a bad day and goes back to functioning. The later develops paralyzing stress symptoms." See below for the Seattle Times link: http://seattletimes.nwsource.com/html/health/2004291429_ptsdgene19.html
The New York Times has an article about concussions adding significantly to the possiblity of PTSD in Iraq War soldiers and veterans. The researchers surmise that many neurological symptoms might be more psychologically treated, while some stress symptoms might be more physically explained.
At least the information is coming from a report mandated by congress. Maybe they'll do something. This depressing report has many links to similar content at the bottom of the page.
In our state, Washington, Senator Murray went to see psych wards at the Tacoma and the Seattle VA's after they were threatened with decertification. She's good at kicking butt. So I'm hoping for some local improvement.
Today's Seattle Times had a good front page article about Thomas Adams, a Command Sgt. Maj. from our locally-based Stryker brigrade, who has been making sure that people under his command get good mental health care. He has been diagnosed with PTSD and traumatic brain injury. Given his history (no head injuries) and based on Scaer's book (above) I'm going to guess that the PTSD has caused the brain injury. Here is a link to the article: http://seattletimes.nwsource.com/html/localnews/2003723997_adamsstory27m.html
I'm on the board of the Humanitarian Assistance Program of EMDR. We are a non-profit organization whose goal is to "expand access to effective mental health treatment for traumatized and underserved communities through direct service and training of local caregivers, anywhere in the world."
HAP's current projects include training therapists in Lebanon, the West Bank,India, Indonesia, and the Philippines. Domestically, it has a big project on the Gulf Coast (post-Katrina), and many projects training staff of community mental health centers, rape crisis centers, child treatment agencies, VA's, military counseling staff, and where ever a non-profit group, serving underserved populations asks them to go (given specific criteria, of course). It is often described as "Doctors Without Borders" for mental health. All trainers and facilitators are volunteers. Trainees are encouraged to become facilitators, and then trainers, so as to create a training infrastructure in each area. (This has happened in Israel, and is well on its way in both the West Bank, and India.)
HAP sends volunteer therapists to some disaster scenes. Many HAP volunteers assisted New Yorkers, post-911, and people in the Gulf Coast, post-hurricanes. In my town, Seattle, we've worked with people in the aftermath of a shooting incident, and with some Katrina transplants. HAP in the midst of formalizing our Trauma Recovery Network (TRN) to be able to connect volunteers to people who need them. Volunteers give 5 free stabilization and EMDR sessions to clients, and are not allowed to see the people, for fee, at anytime. If you are a certified EMDR-therapist, you can volunteer for the TRN here. If you'd like to know more about HAP or make a donation, click here. It's a great organization, well-managed, with most of the money going to direct service. For having a tiny staff, it does alot. HAP's goal for next year is to train 1200 people, who would not otherwise have its traumatology or EMDR trainings. I'm proud to be part of it.
PBS's Frontline has a new show about the psychological effects of the Iraq War on soldiers, including the culture of "suck it up" in the service that prohibits many soldiers from getting treatment, go here to read about it or watch it online.
The New York Times Magazine has a cover story about rape and sexual harassement in the military. Go here to read it.
I had posted on my last thoughts on a private list and got a reply from Francine Shapiro, the founder and steward of EMDR. It was a bit daunting for me. She's smarter, more well-informed, and the inventor of what I do in much of my working hours. She has given me permission to post our discussion. Read the last entry to see what it refers to.
"Regarding a description of VR and EMDR, the actual explanation for the use of exposure therapy is that prolonged exposure is supposed to cause an extinction of the response. Not a dissociation. It is based upon animal models and has a long history in behavior therapy.
Whatever other treatments achieve, I'd be careful about describing shared attributes. That is, EMDR does not focus on increased affect, but rather the affect generated by the stored memory. The dual attention is the attention to the manifestations of the elicited memory:image/thoughts/emotions/physical sensations/beliefs---which is an internal focus--and the bilateral stimulation which is external. The here and now sensations are manifestations of the stored event. So if that is what the other therapies are focusing on it is not dual attention.
As we know in EMDR people can process with a primary attention on body OR thoughts Or images. So none is mandatory as it is in other forms of therapy. Nor do we coach a client to a coherent narrative as done in other therapies. It merely evolves as a byproduct of the reprocessing. As do the changes in affect, body sensation, thoughts, images, sense of self, etc."
My reply: I don't mind you jumping in and I think your comments are absolutely relevant. I've worked with several people who had had exposure therapy for PTSD, and the experience created dissociation in all of them, not extinction. Of course, they all could have had underlying dissociative processes, before the exposure therapy. I went to rat-running behavioral undergrad school: U of Iowa. and cognitive-behavioral graduate school, U Washington. I love how, since then, the neuro-research shows us how it all works. The dampening of affect, with exposure, showing up in the midbrain--I can't remember if it was the amygdala or hippocampus in which the electrical response stops. With EMDR, the integrative process shows up in the left cortex, as more activity in the narrative part of the brain. All the trauma therapies that I like, especially EMDR, which is my "therapy of choice" appear to result in a coherent narrative. I think my language wasn't precise. EMDR brings up "the affect generated by the stored memory." I have witnessed about 20 hours of tapes of Diane Fosha working. I think she does a similar thing. I sat in a 5 day class she did last year. The 6 EMDR therapists who were there, could see the Standard Protocol at work, in what she did. It's all we talked about at lunch. She brings up the old state, the related cognition, the related affect, and the related body sensations. It appeared to us, that the switching of attention back and forth between internal states, related to the trauma, and the connection with the therapist worked much like EMDR. It had the same outcome. Or so it seemed to us. I like EMDR, better, because it's easier to teach and easier to keep track of. It's what I do. The Standard Protocol works, and it's not fuzzy. It can be measured. I've taught some not-very-bright therapists the protocol. They were able to do ok, but not stellar, therapy. I don't think they could do AEDP, because it's not as structured. Thanks for your input, it's always welcome! Warmly and with great respect, Robin
Her reply: "It’s hard to know what outcomes really are, or are maintained, without follow up research. I’d just say that I’d be careful about the neuro research. It’s all in it’s infancy. There are various studies that show various things. And you can’t link “left cortex” to “more coherent narrative.” you can say that Broca’s area is off and then activated. That has to do with language. But things are a lot more complicated than that. Exposure therapists claim the same thing (more coherent narrative) for their therapy."
Virtual Reality? It sounds like old fashioned exposure therapy that teaches dissociation, not healed presence. There are non-EMDR treatments that work for trauma and don't promote dissociation. All of them, that I know about, share EMDR's focus on increased affect, body awareness, dual attention, and a more coherent narrative. In most of the others (AEDP, somatic experiencing, STDP) the "dual attention" is either the tracking of here-and-now body sensation and/or the intense connection/containment by the therapist.
Like a Ghost: Using EMDR to revive a traumatized vet's marriage by Nancy Errebo is a wonderful article in the recent Psychotherapy Networker. Click here to read it.
The Psychotherapy Networker is my favorite therapy magazine. It's readable, easy to look at, open to many modalities, and full of useful information. I always find at least one piece of information I can use in each issue. It's written for clinicians, though lay people would be able to follow many of the article. Since it comes every two months, I'm not overwhelmed with issues. (Unlike the weekly New Yorker! Fall behind one issue and you're a goner!) If you subscribe to only one publication, get this one.