Self-help books

There are a lot of self-help books to choose from, dealing with almost anything including mood problems, anger, anxiety, body image, obesity, shyness, relationship or marriage problems, etc.

There are others that might aim to help a person develop creativity, or guide one with respect to some other life pursuit, such as building a sense of purpose, meaning, balance, simplicity, etc.

I think it is worthwhile to familiarize yourself with the self-help literature. I think it can be something like getting a textbook for a course at school...while some textbooks may not be very well-written, I think having a textbook at all can at least allow some extra tangible structure in therapeutic work.

Most self-help books have exercises to work through, often requiring you to write things out with pen and paper. I think it is important to actually do the exercises, as opposed to just leafing through the book, or thinking that you've done all those things in your mind before anyway. Working through exercises strengthens the mind, even if the exercises themselves are not very well-constructed. It is something like working through arithmetic or grammar problems. Even if the exercises are boring or trite, the earnest effort spent working through them will strengthen your ability and insight about the subject matter. Also, most self-help books, even if they are poorly written, can act as structures to develop your own personalized insights about the subject matter--the workbooks can be a frame to do the work, as opposed to being an intrinsic source of insight.

Many self-help books are organized with cognitive-behavioural ideas in mind. Once again, even if you don't care much for cognitive therapy, the exercises remain useful, provided you engage in them earnestly (it is possible to do these exercises in a half-hearted or sarcastic way, etc. -- which would minimize any possible benefit, just as with any other exercise in life).

What does evidence have to say about self-help books? So-called "bibliotherapy" (yes, someone had to designate an awkward piece of vocabulary to describe "reading") has an evidence base--here are a few references:

Gregory et al. published this 2006 meta-analysis showing cognitive bibliotherapy was effective for depression: Professional Psychology: Research and Practice 2004, Vol. 35, No. 3, 275–280. They concluded that bibliotherapy had an effect size of about 0.77, which is substantial, and comparable to effect sizes from medications and psychotherapy.

Here is a reference to a 2003 meta-analysis by Newman et al. showing that bibliotherapy was effective in the treatment of various anxiety disorders:
http://www.ncbi.nlm.nih.gov/pubmed/12579544

Here is a 2004 reference showing that guided self-help is effective in treating bulimia:
http://www.ncbi.nlm.nih.gov/pubmed/15101068

In conclusion, I do strongly recommend working through self-help books. I find that it can be important to look at several different ones, as there can be style or content differences causing you to prefer one over the other.

The main word of caution I have about self-help is that some authors may have a very biased point of view (perhaps influenced by dogmatic or eccentric beliefs regarding politics, religion, health care, etc.), and may therefore lead a vulnerable individual towards an unhelpful set of beliefs or actions.

So my main recommendation is for standard cognitive-therapy style self-help, as a place to get started. There need not be any bias in cognitive therapy, since it is merely a neutral frame for your own therapeutic work.

Why Cats Paint

Why Cats Paint: A Theory of Feline Aesthetics by Heather Busch & Burton Silver.

I find this book a masterpiece of humour, a wonderful parody of art criticism, and also a simple entertainment for those of us who enjoy pets.

Have a look at the customer review comments from Amazon:
http://www.amazon.com/exec/obidos/ASIN/0898156122/qid=1005224759

Interesting mental health journals

Here are a few journals I recommend following. At my university office I enjoy the luxury of full electronic access to these journals, but almost everyone should at least be able to find on-line abstracts (brief summaries) of articles from each journal. Browsing through some of these will give you a general idea of what's going on in research. There might be a few of these journals you will want to follow in more detail; for this I recommend a monthly trip to a local university library.

I may add to or modify this list over time.

I. General Psychiatry Journals:
The American Journal of Psychiatry: http://ajp.psychiatryonline.org/
Archives of General Psychiatry: http://archpsyc.ama-assn.org/
British Journal of Psychiatry: http://bjp.rcpsych.org/
Canadian Journal of Psychiatry: http://publications.cpa-apc.org/browse/sections/0


II. Psychotherapy Journals:
Psychotherapy Theory, Research, Practice, Training: http://www.apa.org/journals/pst/
American Journal of Psychotherapy: http://web.ebscohost.com/ehost/detail?vid=1&hid=104&sid=e3578a6f-d67f-4195-bde8-70686c4c1f0c%40sessionmgr103&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&jid=ATC
Clinical Psychology and Psychotherapy: http://web.ebscohost.com/ehost/detail?vid=1&hid=104&sid=81922580-de66-4070-9f45-506927e0361c%40sessionmgr108&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&jid=BUX
British Journal of Psychotherapy: http://www3.interscience.wiley.com/journal/117987371/home
Behavioural and Cognitive Psychotherapy: http://journals.cambridge.org/action/displayJournal?jid=BCP
Sexual and Relationship Therapy: http://www.informaworld.com/smpp/title~content=t713446685~db=all

IV. Psychology Journals:
Journal of Personality and Social Psychology: http://www.apa.org/journals/psp/
Journal of Educational Psychology: http://www.apa.org/journals/edu/
Journal of Consulting and Clinical Psychology: http://www.apa.org/journals/ccp/homepage.html

V. Journals pertaining to specific areas within mental health:
Addiction: http://www3.interscience.wiley.com/journal/117967480/toc?CRETRY=1&SRETRY=0
Eating Disorders: the Journal of Treatment and Prevention: http://www.informaworld.com/smpp/title~content=t713666342~db=all
International Journal of Eating Disorders: http://www3.interscience.wiley.com/journal/34698/home
Schizophrenia Research: http://www.sciencedirect.com/science/journal/09209964
Depression and Anxiety: http://www3.interscience.wiley.com/journal/38924/home
Journal of Personality Disorders: http://www.atypon-link.com/GPI/loi/pedi?cookieSet=1
Sleep: http://www.journalsleep.org/
Archives of Sexual Behavior: http://www.springerlink.com/content/101587/
The Journal of Sexual Medicine: http://www3.interscience.wiley.com/journal/118495964/home

VI. Journals pertaining to general health and medicine:
American Journal of Clinical Nutrition: http://www.ajcn.org/
American Journal of Epidemiology: http://aje.oxfordjournals.org/
Journal of the American Medical Association: http://jama.ama-assn.org/
Archives of Internal Medicine: http://archinte.ama-assn.org/
New England Journal of Medicine: http://content.nejm.org/
Science: http://www.sciencemag.org/ (particularly the medicine & neuroscience sections)
Nature: http://www.nature.com/nature/index.html (particularly the medical research & neuroscience sections)

Predictably Irrational - a book review with ideas about psychiatric applications

Dan Ariely has written an interesting book, based on his research, called Predictably Irrational (HarperCollins, 2008).

Ariely is an economist but his research is about human behaviour.

There are a lot of studies done over the past few decades in the field of social psychology, which illustrate very similar behavioural phenomena. Ariely's work reminds me specifically of the work of Robert Cialdini, a social psychologist who studied persuasion.

I think this work is important to look at, because it shows that there are powerful factors which influence our decision-making or judgment, which we may not be aware of. The factors are not mysterious phenomena residing in unconscious childhood memories, etc., but are fairly simple--here are some of Ariely's examples:

1) If a person has to choose between two things which are approximately equal (let's call them "item A" and "item B"), there is about a 50% chance of either one being chosen. Suppose a third thing is added, which is similar but modestly inferior to item A; let's call that thing "item A-". This third item could be called a "decoy". If a person has to choose one item out of this group of three, then item A is chosen much more often than item B (in Ariely's experiments, the "item A" gets chosen about 75% of the time).
These experiments show that our decisions are often strongly influenced by irrelevant comparisons.

2) If a cost of something is suggested, it causes us to form an "anchor" in our minds, such that we are more willing to pay that cost or thereabouts, regardless of the true value. This phenomenon is exploited in advertising. But I suspect that as a general principle, we may be influenced to choose something, or to invest a certain amount of energy or commitment into something, based on suggestions, precedents, or personal "anchors", instead of based on the "true value" of the thing.

3) People are much more likely to choose something that is "free" even if it is a worse deal than something else. Free offers substantially bias judgment. Ariel's studies show this nicely, in a quantitative way.

4) Monetary norms and social norms are conflicting motivators. Social norms are healthier and more powerful motivators. Motivations based on money are tenuous, shallow, and easily changeable. Motivations based on social goals are deeper and more stable. The corporate trend to optimize productivity by continuously monitoring worker output is a type of "monetary" strategy. On a social level, it is often offensive and demoralizing. If workers have a sense of social belonging in their workplace, and also a sense that their employer will care for them in a time of need, then the health of the entire system will be much stronger.

Social language can be a persuasive tactic in advertising though, typically through ads (such as with a bank, cable, or insurance company) which make it sound like your relationship with the seller will be something like with a friend or family member. Such advertising could seem persuasive to some, but I think most sellers would not behave like a friend or family member if you got sick and couldn't make your payment on time!

Ariely wisely encourages the development of healthier social goals in education -- to encourage
education as a means to participate in the improvement of society, rather than as a means to get higher scores on a standardized test, or to attain a higher-paying job.

5) Emotional arousal substantially increases the likelihood of making a risky decision. For example, his experiments showed that a random group of college students were about twice as likely to consider engaging in dangerous or illegal sexual activities if they were sexually aroused when asked about it. This phenomenon highlights the need for two types of protection: first, people need to be protected from the potential consequences of making rash decisions in the heat of passion (e.g. being equipped with condoms would protect against the risks of impulsively-chosen sexual activity).

Second--and this is a point that Ariely does not make--people cannot just learn about how to make decisions while in a cool, "rational" state. Perhaps it is important to teach people--through practice-- how to make decisions while in the heat of passion.

I think this is an important idea in a psychotherapeutic process: calm, gentle analysis of thoughts and emotions is valuable (whether this happens in a therapy session or in a CBT journal, etc.) but it may also be necessary to practice rational and healthy decision-making while in an emotionally heated state. This, too, can sometimes happen in therapy sessions, or in CBT journals, etc.

6) Procrastination. Ariely's studies with groups of students showed that a rigid, external imposition of regular deadlines led to the best grades. Requiring students to commit to their own set of deadlines, in advance, led to grades in a middle range. Having no deadlines at all, except for the requirement that all work had to be in by the end of the term, led to the worst grades. Those in the middle group who committed to regularly-spaced deadlines did as well as the first group. This experiment shows that people have a tendency to procrastinate (no surprise here!), and that a commitment to regularly-spaced deadlines is the best way to improve the quality of the work (whether this commitment is chosen by you, or imposed upon you).


I do suspect that there are individual exceptions to this -- I'd be curious to see a study to show this -- in which some people have a better experience with a bit less structure.

He gives a few good applications of this phenomenon: committing in advance to some kind of care plan (whether it be for your health, your car, your teeth, your finances, etc.) will make it less likely that you will procrastinate or forget to do these tasks (e.g. medical check-ups, oil changes, dental cleanings, etc.). With such a system, everyone benefits (e.g. you stay healthier, your car stays in good shape, the auto mechanics get regular work, etc.). The main problem with this is if you are being sold something that you don't really need. The solution is to be be well-informed in advance about the type of care that works best for your needs.

A psychotherapy frame is usually a regularly-spaced commitment of one's time--I certainly do find that people I see are more likely to engage in a beneficial therapeutic process if this kind of structure is in place.

7) Ownership. People have a tendency to value things more when they "own" them already (Ariely gives entertaining examples of studies showing this phenomenon in a monetary sense). This can lead to biased decision-making if the "owned" item is not valuable, necessary, or healthy. This is a similar phenomenon to loss-aversion. We don't like losing something, even if that something is not really good for us. Other social psychology research has shown that this principle applies to ideas as well: if we have espoused an idea, or a viewpoint, or an attitude, about something, we are much more likely to "own" this idea, and to stick to it. We are less likely to change our view, even if the view is unhealthy for us. I find such thinking patterns often involved in chronic depression.

This is definitely a phenomenon that occurs in a psychotherapy environment: therapy is an invitation to change. Even if the change leads to a better quality of life, people are resistant to change, and are more likely to hold on to systems of thought, perception, or behaviour, which perpetuate unhappiness.

8) People are more likely to choose things that seem to be disappearing. Ariely again demonstrates this phemonenon, using economic measures, in a clever experiment. We see this in sales tactics all the time, such as when we are warned that some item is selling out quickly, so we had better act soon! In life, we may tend to spend a harmful amount of time, energy, money, and commitment, keeping multiple options open: as a result, we may never get very far into any pathway we choose.

9) Stereotypes and expectations substantially affect behaviour and choice. In an amusing experiment involving a blinded beer-tasting test, Ariely showed that college subjects presented with two unlabeled containers actually preferred a beer that had been tainted by 10 drops of balsamic vinegar, over the untainted version. But if the students knew in advance that vinegar had been added, then nobody preferred the "vinegar beer". If we believe--or are persuaded to believe--that something is good or desirable, or that something is bad or undesirable (that "something" could be anything from toothpaste, to a new acquaintance, to a job, to our own self or our own skills), then we are significantly more likely to find our beliefs substantiated.

We need to have ways to "stand outside ourselves" at times, to reduce the biases caused by our own beliefs. I think that this, too, is one of the roles of psychotherapy.

10) Things that cost more tend to have a stronger effect. A more expensive placebo tends to be more effective than a less expensive placebo. This is an important, powerful bias to be aware of. This, too, can be a tool exploited by advertisers, in which the high price of their product is displayed prominently as a signifier of higher quality.

I have one major complaint about this book:

Ariely makes a few statements about medical treatments, including "when researchers tested the effect of the six leading antidepressants, they noted that 75% of the effect was duplicated in placebo controls." (p. 178) This claim is based on one single study, from a minor journal, published over 10 years ago, without considering other data from hundreds or thousands of other publications in the research literature. Furthermore, even if this 75% figure was accurate, the remaining 25% of the effect may be very significant for many suffering people. The psychological impact of Ariely's statement may be to cause skepticism and a dismissive attitude towards certain medical treatments, including antidepressant therapy. Ironically, Ariely would then be persuading people against something, based on a tiny, inadequate, and negatively-framed presentation of the evidence.

11) Randomly-chosen college students in Ariely's experiements had a strong tendency to cheat; but if these subjects were reminded of some kind of honour code immediately prior, they had a much smaller tendency to cheat. Based on his findings, he encourages a more prominent role for "honour codes" to reduce dishonesty. He observes that cheating is no trifling matter: fraud accounts for much more stolen money and property than all other forms of crime put together. Also, cheating is much more likely and pronounced if it is perceived to be indirect: people will cheat more if some kind of token is involved, even if the token is worth the same amount as actual money. Our society is evolving to use indirect currencies much more (various forms of credit, for example), which probably will increase systemic dishonesty.

The idea of an "honour code" may seem a bit odd or trite, maybe hard to take seriously. But I think its application could be imaginative and important, and could, at least in a small way, address something that is missing in many workplaces, homes, or individual lives. I suggest this not necessarily as a way to reduce dishonesty, but as a motivational tactic, that can remind us of ways to live healthily. Many workplaces or lives can be so caught up with being busy, competing, getting through the day, that a grounding sense of purpose is rarely contemplated.

An "honour code" in a psychotherapy frame could involve a formal set of statements for oneself, a "mission statement", which could guide choices, motivations, priorities, and attitudes over time.

So it could be an interesting exercise to write down, and answer for yourself:
"What are your morals/values/guiding principles?"
"What is it to be a good person?"
"How can I live honourably in a world which can be harsh and difficult at times, and in a life which can be harsh and difficult at times?"
etc.

Psychoanalysis & Neuroplasticity

This post is based in part on my thoughts regarding Doidge's book on neuroplasticity.

Psychoanalysis is a type of psychotherapy in which patients usually attend sessions almost every day (3-5 days per week, 50 minutes each time). The details of theory and practice vary, but in general psychoanalysts tend to believe that early childhood events and memories are very important to examine and understand, and that these events (e.g. relationships with mother) have direct causal links to adult personality traits and psychological symptoms. Also psychoanalysts tend to believe that the relationship with the therapist is a setting in which prior relationship dynamics recur, in the form of "transference." Most psychoanalysts assume a relatively quiet or passive stance, tending not to have active conversation or "problem solving" dialogs with patients. Also most psychoanalysts would tend to interpret various types of phenomena, such as dreams, behavioural habits, etc. as laden with meaning. A course of psychoanalysis might take years, and in general the model would be that the patient would "work through" various childhood conflicts, including as they might be transferentially manifest in the therapy, and that the patient might come to understand the various themes at play in their lives, as manifest in dreams, habits, and interpersonal behaviour. This process of understanding and "working through" is thought to lead to symptom relief and life change.


Doidge himself is a psychoanalyst. One of the chapters in his book describes psychoanalysis as a "neuroplastic therapy." (chapter 9, Turning our Ghosts into Ancestors). Part of the support for his claim comes from a case study (a type of evidence characteristic of psychoanalytic thinking). And part of his support comes from briefly describing the life and work of Eric Kandel, the great nobel laureate neuroscientist.

Kandel's work brilliantly demonstrated some of the specific anatomic and molecular changes that happen in neurons as memories are formed.

Kandel himself has been an advocate of incorporating recent biological scientific knowledge into the practice of psychiatry and psychoanalysis (see: http://www.hhmi.org/bulletin/kandel/), and had apparently planned to become a psychoanalyst himself.

I consider it not to be particularly relevant to mention Kandel at all, other than to quote someone important who probably considers psychoanalysis a good thing. It is a common sales tactic to mention an important person's name while trying to convince someone of something. Also it is common in medicine and psychiatry--but especially in alternative medicine--for there to be some mention of something that sounds "scientific" to bolster the public opinion of a product, while the science itself, if looked at closely, is only obliquely related. For example, many questionably effective naturopathic remedies, sold at quite a profit, include advertising laden with some kind of biochemical jargon, much of which, at close examination, lacks substance, but which sounds impressive.

I believe that psychoanalysis can be a powerful and transformative experience. However,I also strongly suspect that there are elements of dogma contained within the theory which are irrelevant to its beneficial effects, and which at times could make it an inefficient therapy.

Consider this thought experiment:

Suppose the beneficial effects of psychoanalysis are due to the following factors:
1) meeting with someone for an hour per day, who will listen and try to understand life problems
2) finding an "explanation" for symptoms. In the case of psychoanalysis this explanation tends to come from an examination of early life events.

Suppose that it is the belief in the explanation that causes symptom improvement, therefore that if some alternative "explanation" for symptoms could be developed, then it would lead to the same symptom improvement. Therefore, suppose that the psychoanalytic theory of character and symptom development is actually a fiction, akin to a dogmatic religious belief system, but that adherence to this belief system, and the resultant faith and conviction, would be the causes of symptom relief and character change.

A way to test this would be to conduct a randomized study of two types of intensive, long-term psychotherapy. Both would be 5 sessions per week, 50 minutes per session, lasting 5 years.

Group 1 patients would have psychoanalysis.
Group 2 patients would receive the same intensive, empathic, sessions, with intelligent and thoughtful, well-boundaried therapists. But let us imagine that some other belief system would underlie the therapy for group 2. For example, astrology. Or some form of religious fundamentalism (of any variety). Here, interpretations would be based on the positions of stars & planets, or on passages from religious texts.

A condition for this type of experiment would be that the patients in both groups would have to lack any differences in bias for or against the style of therapy. So, for example, patients in group 1 would have to have a similar level of belief that psychoanalysis is a valid and culturally-accepted system of thought, and have similar respect for the therapist, compared to the beliefs about therapist and therapy style of patients in group 2 (regarding astrology or fundamentalism, etc.).

In both groups, I suspect that subject matter would come up in the sessions, which would require the therapists to respond either empathically or interpretively. There would probably be dreams that would come up, probably interpreted quite differently--or not at all-- in both groups. The process of therapy, dream interpretation, feelings of closeness with therapist, etc. might well be experienced similarly between groups.

My hypothesis is that both the groups would show similar improvement in a 5 year course of therapy, with only a slight advantage for group 1. I believe this is because the core effect of such therapy is not from the theoretical belief system, but from the process, which is caring, consistent, empathic, understanding, and interpretive. Failed therapy experiences may happen in both groups, some of which because the patients do not like the style or belief system which is being introduced, some of which because life problems can be treatment-resistant at times, some of which because the patient did not feel well-matched with the therapist. I think group 1 would do very slightly better than group 2, because despite the dogma involved in psychoanalytic theory, the underlying process is more intellectually open (at its best).

Unfortunately, I think there is a substantial risk for people in both groups to come out of the experience with stronger dogmatic beliefs, irrespective of any therapeutic improvement. In a more mature psychoanalytic frame, I think this risk would be diminished, as the process would hopefully be more intellectually open.

I do believe that we as intelligent creatures should always seek the "truth" as best we can know it, and therefore we need to challenge our dogmas. The best therapies, in my opinion, need to seek such truths without being restricted by dogma. This is consistent with the underlying theme of psychoanalysis, which I think is about liberation (liberation from symptoms, liberation from past harms or traumas, etc.).

I am reminded now of Joseph Campbell, the comparative mythologist, who might argue that the different styles of therapy are something like different mythologies, none of which are literally "true", but perhaps all of which might contain core aspects of wisdom about the human condition. He might also argue that dogmatic, literalistic adherence to any system of belief could obstruct its underlying message. But he would also agree, I think, that one has to have "faith"--a sense of trust, engagement, and belief--in order to have a transformative experience from anything.

In psychoanalysis, I think it is immensely valuable to seek meaning by examining early childhood events, and by searching for meaning and themes in dreams and nuances of behaviour. But I think it can be can be obstructive to believe, literally, for example, that specific non-traumatic events or patterns of engagement with one's mother at the age of 2, are the causes of specific adult symptoms. I consider the greatness of psychoanalytic interpretation to lie in its focus upon a human life as though it is a great novel or work of art, and that the therapy is partly an experience of understanding, analyzing themes, interpreting, looking at context, in order to enrichen the experience of the art.

A weakness in psychoanalytic practice can, in my opinion, be due to its passive approach at times, which can render it less efficient. Another weakness can be due to a dogmatic or literalistic over-absorption with the theory, causing the therapy to digress--sometimes for years--into an examination of early childhood events, when the core elements of therapeutic need lie solidly in the present, or in the more recent past. I think modern psychoanalysis needs to much more actively incorporate ideas from cognitive and behavioural therapies, from social psychology, as well as from behavioural genetics, etc., and to actively question its dogma.

From a "neuroplastic" point of view, I think the immense advantage of psychoanalysis is in the frame, which is intense (5 days per week), long-term (over years), intellectually open (anything that passes through one's mind is encouraged to be spoken), and consistent. If one was taking language or music lessons, we would see MUCH more "neuroplastic change" in the brain (and, much more importantly, we would see much more language or music learning), if the lessons took place 5 times a week for 5 years, rather than just once a week for 6 months. The consistency and discipline of the psychoanalytic frame is powerfully motivational, just as is any other consistent and disciplined educational framework.

Doidge (Neuroplasticity) review - part 3 (Schwartz)

Doidge devotes a chapter to discussing obsessive-compulsive disorder. He claims that a treatment developed by Jeffrey M. Schwartz is "plasticity-based". The implication is that other psychological treatments for OCD are NOT "plasticity-based."

Schwartz has published articles in the literature going back into the 1980's looking at OCD patients using PET imaging.

I do not find any good study in the literature about Schwartz's particular technique, as published in his book, in particular no study comparing his technique with CBT.

Also the theory is presented that OCD is caused by a failure for the caudate nucleus in the brain to "shift gears automatically", and that the therapy described is a means of "shifting gears manually." While there are a variety of brain metabolism changes in OCD, I think it is an overly strong statement to believe that this is literally true. One could use the idea of the "caudate gear box" as a metaphor, but it may be quite inaccurate, or at least poorly supported by clear evidence, to be taken literally.

So it concerns me that the chapter in Doidge's book about the "brain lock" approach is more of a book plug than something founded on solid evidence. Doidge could well have made the case that CBT is a type of "neuroplasticity-based treatment". In fact, there is good data to support such a case--including numerous imaging studies--and including a recent paper which Schwartz himself co-authored, which shows various regional changes in brain metabolism associated with improvement in OCD symptoms from intensive CBT:
http://www.ncbi.nlm.nih.gov/pubmed/18180761

Yet, I think it is important to be open about any new therapeutic idea--it may be that the "brain lock" therapy for OCD could be helpful to many people. It's just that Schwartz's book has been given an endorsement by Doidge without a convincing amount of good evidence, while minimizing the robust evidence favouring CBT.

Doidge (Neuroplasticity) review - part 2 (Taub)

Doidge devotes a chapter to the work of Edward Taub. I think Taub's ideas are simple but brilliant. He developed a treatment called "constraint-induced movement therapy" which appears to be remarkably effective to help with recovery from strokes and other injuries.

The simple idea is to restrain the normal limb, almost continuously, for at least weeks at a time, after a neurological injury. Otherwise, the normal limb will compensate for the affected limb. If the normal limb is constrained, the brain itself will develop new pathways to improve the function of the affected limb.

This treatment has good evidence-based support:

http://www.ncbi.nlm.nih.gov/pubmed/18077218

{this 2008 study is from Lancet Neurology, one of the top journals in neurology}

http://www.ncbi.nlm.nih.gov/pubmed/17077374

{another very important study from 2006 in JAMA}

I'm curious about the applications of this sort of therapeutic idea to psychiatry. Psychiatric symptoms can be like other neurological impairments, and the psychoanalytic phenomenon of "defences" may be analogous to the tendency for a neurologically-injured person to favour the non-affected limb, while the affected limb loses more and more function. A psychological therapy which challenges defences may be something like a Taubian "constraint-induced movement therapy" for the mind.

Importantly, in order for Taub's therapy to work, the constraint has to be applied almost continuously during waking hours, for at least weeks at a time. It is an immersive experience. It is an interesting challenge to find more psychological therapies that can be "immersive" in this way.

Doidge (Neuroplasticity) review - part 1 (Merzenich)

This post begins my review of Doidge's references from his book on neuroplasticity.

The first references I have looked through pertain to the work of Michael Merzenich. He has done very interesting research, dating back 4 decades, a lot of it having to do with studying the auditory cortex, and how it changes in response to stimulation of various sorts during different phases of development. Also he done major work researching and developing cochlear implants for treating hearing loss.

His 2006 article about using a "brain plasticity based training program" to improve memory in older adults (http://www.ncbi.nlm.nih.gov/pubmed/16888038) is interesting and encouraging, yet it warrants a close look at the actual results: the memory improvements from this technique were very modest (though significant), also the control groups were both quite passive (one group just looked at DVD videos, the other had no "intervention" at all). It would have been much more interesting to me to see an active control group in which the individuals would be doing simple memory exercises or other active intellectual stimulation for the same length of time. Because this type of active control was absent, the results may aggrandize the specific form of skill training described in the study; this skill training regimen is now being marketed, and money is surely disappearing from the pockets of many people, including many elderly people who may not have an abundant financial reserve. This makes me especially less enthusiastic about the results. I have no doubt that active mental exercise changes the brain through "plasticity" but I have to wonder if we have to sign up for the deal ("save 20% and get free ground shipping!") with this specific technique to achieve this. Perhaps signing up for a book club, memorizing poetry, and playing chess daily, would accomplish similar results. I would like to see what the evidence has to say about this. His website is interesting to look at, has a few mental exercises to check out, the style of which I think really is quite positive and imaginative. I will be curious to see if his approach--and variations of it-- could be specifically helpful in treating disorders such as autism. But I don't see good clinical data out there yet.

As an amateur musician, I have found that "ear training" is probably the most important, but often least taught or practiced, form of mental development for improving musicianship. Merzenich's exercises clearly focus on "ear training" as a significant component. Here's his website for you to check it out yourself: http://bfc.positscience.com/

Here's a link to a program you can acquire, designed for music students, which develops musical ear-training ability much more thoroughly, in my opinion (I recommend this to all musicians): http://www.earmaster.com/

Neuroplasticity

This is an important book which I highly recommend:
The Brain that Changes Itself, by Norman Doidge (Penguin, 2007).

Doidge is a psychoanalyst who has done a fine job compiling evidence from recent neuroscience research, and from some older but neglected neuroscience research, that the brain has a tremendous capacity--a capacity which is arguably its most basic, core, innate quality-- for change and adaptation.

The idea of the brain as permanently "hard-wired" is refuted, with solid evidence.

Many of these ideas I have always felt to be obvious truths. For example, it seems an obvious necessity that the brain would have to build new connections in order to form any new thought, experience any new feeling, store any new memory, learn any new skill. But the degree to which whole areas of the brain can "re-wire" themselves is extremely interesting, and the evidence Doidge presents is very convincing.

Also, it has always been an obvious truth to me that any kind of sensitive neuroimaging device would of course demonstrate changes following a successful course of therapy (or of any other sort of learning or substantive life change).

The therapeutic applications based on this book are numerous, here are a few I can think of:

1) structured, intensive practice could lead to far greater effects than what has previously been assumed. The brain itself, as well as people in society, informed by culturally-based attitudes, tend to "work around" problems if the situation allows, whereas it can be the case that the problems themselves can be solved directly under the right conditions. For example, if an English-speaking person moves to a small town in a foreign country, that person will quickly learn that new foreign language, if it is necessary in order to survive. But if there are numerous English speakers in that small town, that person may not learn much of the new language at all.
We may need a type of immersive, constrained experience in order to compel our brain to develop a new faculty.

2) structured, intensive activities that have become part of a cultural norm (e.g. internet use, TV watching, etc.) could substantially alter the brain's connectivity and functionality, to optimally adapt to these new media. This could serve us well, culturally--but it may come at a cost of reduced functionality in media away from the TV or internet, particularly with respect to sustained attention, other intellectual and emotional faculties, and various types of social interaction.

3) Addictive processes are fed by the brain's capacity to adapt, to "re-wire" itself to expect a frequently reinforced behavioural pathway. "Un-learning" addictive behaviour once again may require a massive amount of work, akin to learning a new language.

--I have yet to review all of the references cited in this book. I think the primary source data will be important to go through in detail. There are some areas and claims that I think may possibly be overstated, in my opinion. But first I would like to review the evidence directly. I actually find the term "neuroplasticity" somewhat annoying, especially when therapeutic ideas are labeled "neuroplasticity-based treatments", etc. --I would say in response that ALL therapy, of ANY sort, is of course "neuroplasticity-based", so such lingo is unnecessary, and rings of salesmanship to me (indeed, there are several corporate ventures mentioned in the book). What matters most is the new types of therapeutic ideas that have been conceived by some of the researchers cited in the book, and how well they can work for very entrenched problems.


In the meantime, I do recommend Doidge's book highly.

Happiness and Economics

I just finished reading an excellent book called Happiness: Lessons from a New Science, by Richard Layard (Penguin, 2005).

His main points are in synchrony with ideas that I have alluded to in previous posts:

-Economic growth is a numerical measure which does not correlate consistently with well-being or health. Except for people who are living in poverty. $100 to relieve one person's poverty goes much, much, much farther to improve well-being (for both the individual and for the world) than $100 to increase a wealthy person's leisure budget.
-Despite large increases in wealth in many parts of the world, people are not any happier (in fact, they are often less so, particularly in the U.S.)
-Pursuit of wealth has an addictive quality: it produces short-term satisfaction, but the mind habituates to any short-term external satisfaction. The mind is more satisfied with stability, and is more averse to perceived loss than it is satisfied with material gain.
-If economic growth is optimized, it leads to "pollution" of various sorts. Literal, environmental pollution is one type (actually Layard could do well to include more ideas about environmental care in his thesis). Most economists do not measure this "pollution" in their calculations. But there is other "pollution" as well: a culture which values accumulation of financial wealth as the main priority may do so while "polluting" its social fabric. For example, optimal financial output may require longer workweeks and more worker mobility, which then becomes a social norm, leading to everyone spending less time with family & friends & culture, leading to declining morale and a declining sense of community, increased crime, etc. Once again, this type of social "pollution" from maximizing financial performance in society is often not included in economists' calculations.

The wisdom of his book lies in his attempt to combine the field of economics with psychology and the other social sciences, a combination which I think is badly needed. He encourages economists' calculations to be "weighted" by consideration of emotional well-being, not simply by optimization of simple financial measures.

Some of his specific ideas could be challenged (e.g. see the following paper: http://bpp.wharton.upenn.edu/jwolfers/Papers/EasterlinParadox.pdf). He advocates increased taxation as a deterrent to over-work, as a cost to pay for "pollution". I think the idea deserves attention, but it has certainly been challenged as a specific policy (the "cost" of feeling more burdened by the state may be a different psychological factor to include; furthermore, I think one of his stronger points is that motivations should be best drawn from inner sources, rather than from external incentives or disincentives).

However, the spirit of his ideas encourages us to do the following, as individuals, and as a society, for the sake of improving our lives & happiness:
1) avoid the "rat race" -- i.e. be wary of choosing a lifestyle in which you have to do more and more, to get more and more stuff, in the name of supposedly improving your life, when in fact you are sacrificing not only your own personal, family, social, and cultural life, but also participating in establishing a competitive social norm which others will want to follow, at their own expense, and at the expense of society itself. Let hard work be done for its intrinsic satisfaction, and as a satisfying way of life, rather than as a means to "get ahead" or to "get rich".
2) Pay close attention to nourishing aspects of personal culture which improve personal and collective happiness:
-be involved in helping others & be involved in your community
-avoid making choices just to keep up with someone else
-avoid criticizing or judging yourself in comparison to someone else; the modern world is set up to make you feel needlessly bad about yourself, or needlessly competitive to change something about yourself that needs affirmation rather than change
-educate oneself, and participate in the education of others, about emotional self-care
3) Watch less TV. The TV is a specific device which has clearly been shown to reduce happiness, through a similar process by which wealth itself can reduce happiness: it is an external source of pleasure, to which we become habituated, at the expense of relationships, community, physical fitness, and personal culture. Also it desensitizes us to violence, which is a further factor leading to increased aggression. Also it feeds, through advertising, the rat-race mentality of acquiring more and more stuff; much of this advertising is directed at children. He quotes an interesting study which supports his view: http://jcc.sagepub.com/cgi/content/refs/16/3/263). I might add the internet is another example of something similar.

Addendum: actually, as with many things, I think modern technology can have positive influences too. I remember many experiences of joy, humour, and togetherness watching movies or good TV series. Sometimes the TV can enhance education about the world, history, nature, current events, etc. And TV can introduce us to new aspects of personal culture, and therefore be a cultural enhancement. But I do think that TV can become an addictive and isolative habit; I guess the key is moderation, choosing wisely when and what you watch, and considering carefully why you're watching it.

I especially agree with Layard's ideas about encouraging children to learn from an early age about ways to manage and understand emotion, to practice compassion and empathy (yes, compassion and empathy can be "practiced" and "learned"), and to be involved in community-building. It often concerns me that many supposed community-building activities involving children (e.g. sports, academics, or even music lessons) end up being subverted into yet another rat-race or competition. Ideas from cognitive therapy could be introduced in elementary school, and I'm pretty sure that this could help prevent, or lessen the severity of, many cases of mood and anxiety disorder.

I also especially agree with certain other public policy points: for example, I think it is unconscionable that governments encourage gambling as a form of revenue. To encourage, and advertise, an addictive behaviour which takes individuals away from their families, loved ones, and communities, and leaves some in a miserable state of addiction, just because it is an efficient source of revenue, is extremely poor public policy. It is poor economic policy too, since more people spending more time gambling surely does not lead to increased economic success for individuals or communities, except for the people running the casinos.

I think his ideas about limiting commercial advertising directed at children warrants serious attention. Apparently Sweden has banned such advertising; the Scandinavian countries appear to be a good example to follow in terms of public policy which considers well-being above mere economic optimization.

Borderline Personality, addendum:

I continue to feel this whole subject--of borderline personality-- is a dicey one to wade into, but I didn't want to be avoiding it either.

Part of a problem I've observed is that many extremely important and valid concerns or complaints can be dismissively pathologized as part of a "personality disorder trait".

For example, negative experiences of physicians or the hospital system need not be considered part of an individual's "pathology".

In fact, I think it is more uncommon than common for anyone to have a smooth journey through any medical care system--it tends to be laden with frustration, despite hopefully encountering some good people along the way.

Negative experiences of individual caregivers or relationships within a system need not be dismissed as so-called "splitting" (a "borderline" phenomenon)--they may be accurate and insightful accounts of having encountered a negative relationship.

The experiences may be a product of having encountered poor medical care, a poor medical system, or an unhealthy set of social structures which provide inadequate help. Sometimes an individual's complaints about these negative experiences may actually be a sign of courage, a character strength, rather than of a "borderline trait".

I think a larger view of so-called "borderline phenomena" has to do with group dynamics, as opposed to individual dynamics. If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working. The relationship failure may be due to an inadequate structure, a lack of mutual understanding, communicative failure, a long history of relationship problems which biases the present point of view, tiredness or frustration on either side, or an insurmountable cultural gap. This reminds me of some of the conflicts between nations that go on today, in which each nation's "point of view" is understandable and valid, but the relationship fails, sometimes in a very destructive way, sometimes leading to an "arms race." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators. My point here is that sometimes it is not the individual who has a "borderline personality disorder", but the relationship, or the system, which is suffering from "borderline dynamics".

An author on the subject of borderline personality I consider important is David Dawson. Title: Relationship Management of the Borderline Patient, Brunner/Mazel, 1993

I do find him wise and frank. He challenges some of the the professionally self-indulgent dogmas about psychotherapy, psychiatric hospitalization, and psychiatric medication, dogmas which may not apply to every situation, dogmas which may well, in some cases, aggrandize the "healing power" of the system or the therapeutic process, dogmas which deserve a generous dose of humility in order to more soundly be helpful. He describes numerous dramatic "case vignettes", with much needed attention given to the consideration of process and relationship dynamics. Many of his ideas about the vignettes I disagree with, but the book could open a forum for debate and discussion.

But-- I find his style at times too cynical and lacking in gentle warmth, to affirm it strongly. In fact, Dawson's ideas I think at times have been misapplied in the medical system, used as part of a tactic to prematurely discharge some patients from hospital or from other follow-up care. Yet, I think Dawson's views are important to hear, at least as the starting point for a debate.

Reading List

Here is a set of books that can be worthwhile to read, dealing with mental health & self care issues. I think I will try to update this list regularly as I stumble upon new titles.

1) The Feeling Good Handbook by David Burns. An overview of cognitive therapy ideas, with lots of exercises to work through, pertinent to anxiety, depression, relationship conflict management, procrastination, among other things. Sometimes the book may come across as saying (imagining the smiling face of the author on the cover of the book): "if only you did my exercises properly or more thoroughly, you too could have a happy life". I think this is a weakness of the book--it is important to acknowledge that cognitive techniques can help, and they require a lot of work, but they may not help all symptoms, sometimes they may not work at all, the exercises often may not be pertinent, some of the content may seem trite; and the style of the book may be annoying to some. Yet I do think it is quite a comprehensive overview of some cognitive techniques, and it is worth looking at; the author validly challenges you to actually work through all the exercises with pen and paper, cover to cover, before judging the book. While cognitive therapy can help during a bout of severe depression, I think it is most useful when you are actually feeling better already, or only feeling mildly symptomatic. The cognitive therapy can help prevent relapses, help you stay well.

2) Against Depression by Peter Kramer. A very good defense of biological psychiatry. Also some interesting ideas about how quite severe depression, with its associated severe suffering, may have been "normalized" in current and past culture, in the arts, etc. It is an interesting and thought-provoking idea. I personally agree with many of his points.

3) An Unquiet Mind by Kay Jamison. Her other books are also worth looking at. She tells her personal story of dealing with manic depressive illness. From an interesting perspective, in that she is a famous research psychologist who has co-authored one of the major textbooks on the subject of manic depression.

4) various of the books by Irvin Yalom. Enchanting and delightful at times. Some might find him annoying. But an example of what psychotherapy experience can be like. He has a very open and liberal style (perhaps too liberal for some).

5) various of the books by Oliver Sacks. Interesting to learn about the different experiences and phenomena associated with the brain and its disorders. In this way a commentary on the human experience in general.

6) I encourage people to visit an academic library, and browse through some of the major psychiatry and psychology journals. Look through them as you would copies of waiting-room magazines. You'll get a sense of what's going on in research, what some of the new treatments are, and how psychiatrists and psychologists think. Many of the articles are pedantic and questionably relevant, but others are more readable, pertinent, and interesting. The biggest psychiatry journals are The American Journal of Psychiatry and Archives of General Psychiatry. Another good large journal is The British Journal of Psychiatry (more of a European perspective). Journals devoted specifically to the latest medications and other technologies for treating mental illness include The Journal of Clinical Psychiatry (this journal seems quite influenced by industry, but has good updates about medication treatments), The Journal of Clinical Psychopharmacology, and Biological Psychiatry (this journal can be very technical). There are lots of interesting journals devoted specifically to psychotherapy as well, and in the psychology literature there is a wealth of other perspectives to look at (however, many psychology journals contain articles that are full of technical jargon).

7) Read a textbook of social psychology. A wonderful field, very interesting. The textbooks are easy to read. And presents a rich body of evidence about social factors in personal psychological experience that we often neglect to consider in managing emotional problems.

8) Yoga for Depression by Amy Weintraub. This was recommended to me. As I scan through it I see good things. If not this particular book, I do think that at least something in this genre deserves an important place on your bookshelf.

9) The How of Happiness by Sonja Lyubomirsky. The author is a psychologist who has researched happiness, and the factors that contribute to it. An important subject, often neglected by the majority of us who focus on the factors that contribute to negative states or disorders, rather than the factors that contribute to health. However, the book, in my opinion, while having some good practical suggestions in it, is fairly weak and limited in its usefulness in its approach towards managing major mental illnesses. It is most useful for those who well, or who are recovering from their illness already, and want to consider some changes that could help them stay healthy and happy. It is also helpful, I think, for those who are chronically demoralized, moderately unhappy, but not clinically depressed.

10) Influence: the psychology of persuasion by Robert Cialdini. A useful book by a social psychologist, looking at the factors that persuade us to buy something, do something different, or change our mind. I think that being more aware of these factors -- often used in advertising or by salespeople -- can protect us from being persuaded to do things that we don't really want or need, and can therefore help us to make healthier decisions.

11) How to Start a Conversation and Make Friends by Don Gabor. So many of us struggle with shyness, or find it difficult to make new friends, or hold a conversation, etc. Here's a book that gives a lot of practical suggestions on how to approach these things more easily. I realize that many people believe a "how-to" book would not do much for them, or that the ideas in the book are things that are already very familiar or obvious to some, but I think that working through the book can only help, at least as a frame to contemplate and plan ways to make things better. There is a wide variety of books on this subject, and I invite people to check out numerous different titles--some people may need to check out numerous titles to find a book whose style and content suits them best. A search on a bookselling site such as Amazon, looking for "social anxiety" or "shyness" books will yield a nice variety to choose from.

12) Find a newspaper with a large collection of daily cartoons. Read them regularly. If you have a favourite cartoonist or humourist, get an anthology (e.g. I always liked The Far Side). A lot of other stuff in newspapers has a negative impact on mood, in my opinion, since newspapers focus on disaster and conflict in the world, rather than on things that are going well. We have to find a balance between staying well-informed and involved in debate or activism, etc. while not allowing the terrible stresses of the world to damage us. Of course, when depressed, it may be that nothing seems funny at all--and reading cartoons may just be an irritation; if this is the case, I'd advise you to give it a break until you're feeling better.