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.
Showing posts with label Psychotherapy. Show all posts
Showing posts with label Psychotherapy. Show all posts
Tuesday, March 17, 2009
Monday, February 23, 2009
Pathological & Therapeutic Crying
This post is in response to a previous comment:
Antidepressants can directly reduce crying, probably independent of other effects on emotion.
There is a condition called "pathological crying" which can occur after a stroke or other brain damage; in this condition the afflicted person may be weeping uncontrollably, with or without a subjectively sad or negative emotional state. SSRI antidepressants can help greatly with this, here is a reference:
http://www.ncbi.nlm.nih.gov/pubmed/10576464
Here is a reference showing that mirtazapine could be an alternative:
http://www.ncbi.nlm.nih.gov/pubmed/16239769
A similar antidepressant-induced "reduction in crying" may sometimes be one of the sources of relief in depression. But such an effect could be unwelcome if it leads to a subjective restriction of emotional range.
Are tears therapeutic? Most of us would agree that crying is often a relief, or even a necessary emotional outlet. Many psychotherapists would consider a patient's tearfulness in a session to be therapeutic.
In my opinion, tears can sometimes be a relief, and can sometimes be very therapeutic -- but sometimes tearfulness can feed a cycle of exhausting, out-of-control sadness or despair. And sometimes tearfulness can be so reflexive that almost any event or trigger in daily life can bring it on. Occasionally tearfulness may be a type of "defence" which prevents dialog (with self or others) about an underlying experience or emotion.
I would add, as a formal personal opinion, that tearfulness need not be a sign of "loss of emotional control" (though sometimes it could be). A person who is confident, stable, mature, and sensitive may feel quite at ease with tearfulness. Tearfulness, in this case, is a normal, and often healthy, emotional display. For some individuals, tearfulness happens more naturally, for others they may be more comfortable experiencing emotion without tearfulness.
What does some of the evidence have to tell us:
http://www.emotionalprocessing.org.uk/tears/is%20crying%20good%20for%20you.htm
(a website with an introduction to the subject)
http://www.ncbi.nlm.nih.gov/pubmed/18509370
(here's a case study showing that crying can be therapeutic -- even if it is the therapist who cries; this is a position I strongly support, for a variety of reasons, most of all because I believe in the "Rogersian" idea of genuineness and transparency, also I believe that crying need not be considered a form of weakness, but a symbol of sensitivity and compassion, whether the tear is shed by the patient or by the therapist. Too many therapists are, in my opinion, so defended by various tactics of emotional detachment, that they become aloof, and in some cases ironically afraid of emotional intensity--this may in some cases lead to dismissive, or ineffectively cold, postures towards tearful or suffering patients. Of course, if the therapist is not functioning, and is tearful due to emotional fragility or depression, then the tearful therapist needs to take a break and seek therapy himself or herself.)
http://www.ncbi.nlm.nih.gov/pubmed/17587475
(an interesting look--from an anthropological perspective-- at a phenomenon called "wailing", a type of crying & lamentation which is part of a group ritual of mourning in the Yemenite Jewish community; this article includes interesting perspectives about crying and its theoretical role in bereavement. It suggests that the idea of "healthy bereavement" has been heavily influenced by Freudian, and largely "male", ideas, viewing emotions in a kind of "hydraulic" way -- as forces to be directed, or cathartically released, and in particular pronouncing healthy grief as a process involving letting go of the relational bond with the deceased. In the "wailing" phenomenon the author suggests that the group crying, accompanied by lyricism and dialog, may act to build a kind of emotional or relational "cradle" where the bereaved person may maintain a continuing loving bond with the deceased, rather than aim to let the bond go)
...So, maybe if there was a medication that would stop you from crying, depression levels could be taken down?----
Antidepressants can directly reduce crying, probably independent of other effects on emotion.
There is a condition called "pathological crying" which can occur after a stroke or other brain damage; in this condition the afflicted person may be weeping uncontrollably, with or without a subjectively sad or negative emotional state. SSRI antidepressants can help greatly with this, here is a reference:
http://www.ncbi.nlm.nih.gov/pubmed/10576464
Here is a reference showing that mirtazapine could be an alternative:
http://www.ncbi.nlm.nih.gov/pubmed/16239769
A similar antidepressant-induced "reduction in crying" may sometimes be one of the sources of relief in depression. But such an effect could be unwelcome if it leads to a subjective restriction of emotional range.
Are tears therapeutic? Most of us would agree that crying is often a relief, or even a necessary emotional outlet. Many psychotherapists would consider a patient's tearfulness in a session to be therapeutic.
In my opinion, tears can sometimes be a relief, and can sometimes be very therapeutic -- but sometimes tearfulness can feed a cycle of exhausting, out-of-control sadness or despair. And sometimes tearfulness can be so reflexive that almost any event or trigger in daily life can bring it on. Occasionally tearfulness may be a type of "defence" which prevents dialog (with self or others) about an underlying experience or emotion.
I would add, as a formal personal opinion, that tearfulness need not be a sign of "loss of emotional control" (though sometimes it could be). A person who is confident, stable, mature, and sensitive may feel quite at ease with tearfulness. Tearfulness, in this case, is a normal, and often healthy, emotional display. For some individuals, tearfulness happens more naturally, for others they may be more comfortable experiencing emotion without tearfulness.
What does some of the evidence have to tell us:
http://www.emotionalprocessing.org.uk/tears/is%20crying%20good%20for%20you.htm
(a website with an introduction to the subject)
http://www.ncbi.nlm.nih.gov/pubmed/18509370
(here's a case study showing that crying can be therapeutic -- even if it is the therapist who cries; this is a position I strongly support, for a variety of reasons, most of all because I believe in the "Rogersian" idea of genuineness and transparency, also I believe that crying need not be considered a form of weakness, but a symbol of sensitivity and compassion, whether the tear is shed by the patient or by the therapist. Too many therapists are, in my opinion, so defended by various tactics of emotional detachment, that they become aloof, and in some cases ironically afraid of emotional intensity--this may in some cases lead to dismissive, or ineffectively cold, postures towards tearful or suffering patients. Of course, if the therapist is not functioning, and is tearful due to emotional fragility or depression, then the tearful therapist needs to take a break and seek therapy himself or herself.)
http://www.ncbi.nlm.nih.gov/pubmed/17587475
(an interesting look--from an anthropological perspective-- at a phenomenon called "wailing", a type of crying & lamentation which is part of a group ritual of mourning in the Yemenite Jewish community; this article includes interesting perspectives about crying and its theoretical role in bereavement. It suggests that the idea of "healthy bereavement" has been heavily influenced by Freudian, and largely "male", ideas, viewing emotions in a kind of "hydraulic" way -- as forces to be directed, or cathartically released, and in particular pronouncing healthy grief as a process involving letting go of the relational bond with the deceased. In the "wailing" phenomenon the author suggests that the group crying, accompanied by lyricism and dialog, may act to build a kind of emotional or relational "cradle" where the bereaved person may maintain a continuing loving bond with the deceased, rather than aim to let the bond go)
Thursday, February 19, 2009
Beta-Blockers
Here's a link to a very interesting study which shows that the beta-blocker propranolol can interrupt the consolidation of fear in humans:
http://www.nature.com/neuro/journal/vaop/ncurrent/pdf/nn.2271.pdf
This study suggests a novel use for beta-blockers, which could facilitate behavioural therapy for PTSD. The study demonstrates a variety of things:
1) as was well-known before, when people experience something fearful or traumatic, it sensitizes them to react more strongly to the same fearful stimulus in the future
2) when people re-experience a fearful or traumatic memory, this re-experience consolidates, or strengthens, the strong fearful reaction. This is consistent with the evolution of PTSD and other anxiety disorders, in which an expanding variety of daily events can trigger and consolidate the fear (e.g. a survivor of a bad traffic accident may constantly re-experience traumatic symptoms when hearing traffic noise, loud sounds, etc.--and may start to avoid these situations. Every time this happens, the anxiety disorder becomes more entrenched).
3) Fears can be "extinguished" by re-experiencing the feared stimulus repetitively, in a safe setting. But the fear can be "re-kindled" after extinction more easily than in non-traumatized people (this suggests a permanence to "emotional memory" that can be only temporarily over-ridden by psychological techniques)
4) If the consolidation phase of fear or traumatic memory could be interrupted, then a person might not develop ongoing post-traumatic symptoms at all. In this experiment, there is evidence that propranolol can interrupt this consolidation.
5) Propranolol may disrupt the "emotional memory" consolidation but not the "declarative memory"--the former process may occur primarily through the amygdala, whereas declarative memory is consolidated mainly in the hippocampus. So, the use of propranolol would not "erase the memory" of a traumatic event--the facts of the event would still be remembered normally--but it might reduce the painful, reflexive feeling of emotional trauma associated with the event.
The study does NOT show that "propranolol erases memories", as some of the news headlines seem to be proclaiming. It DOES suggest that adjunctive propranolol may greatly enhance the effectiveness of behavioural therapy. It requires that the person use propranolol while engaging in exposure therapy. So, for example, a possible technique for treating PTSD or panic (especially new-onset) might be to use a 40 mg dose of propranolol 1-2 hours before a therapy session. In the therapy session, the memories of the upsetting events could be discussed. The propranolol might interrupt the process of these upsetting memories getting further consolidated, might facilitate a behavioural therapy process which would help the person feel emotionally comfortable with their thoughts and memories. This process may occur because of direct beta-blockade in the amygdala, which may interrupt consolidation of emotional memory directly.
Despite this encouraging study, there are a number of negative studies looking at using propranolol similarly, for example:
http://www.ncbi.nlm.nih.gov/pubmed/18761097
http://www.ncbi.nlm.nih.gov/pubmed/19060728
I think the main thing to take from the first study is that propranolol may help, but probably only as an augmentation to enhance the effectiveness of behavioural therapy (or CBT) for treating post-traumatic stress or other anxiety disorders.
Beta-blockers are drugs used primarily in cardiology. Some beta-blockers, such as atenolol, act only peripherally, that is they do not enter the brain very much. Others, especially propranolol, can more easily enter the brain, and therefore can act in the central nervous system as well as peripherally.
In psychiatry, propranolol has been useful to treat performance anxiety, especially if there is a component of tremor (e.g. shaking hands) accompanying the anxiety. Many musicians use doses of propranolol to reduce tremor during performances. The anti-tremor mechanism is most likely peripheral beta-blockade (i.e. outside the brain), but the accompanying reduction of subjective anxiety may also be due to central beta-blockade (i.e. inside the brain). This is consistent with some studies which show that peripherally-acting beta-blockers reduce tremor as well as propranolol, but people subjectively prefer the propranolol.
(Reference: http://www.mdconsult.com/das/citation/body/121508141-4/jorg=journal&source=&sp=6333536&sid=0/N/6333536/1.html?issn= )
Beta-blockers have been studied in the treatment of panic disorder, decades ago. They don't work. Here's a link to one of the many studies showing this:
http://www.ncbi.nlm.nih.gov/pubmed/2651490
Yet, these old studies don't look at the possibility that the beta-blocker could work as an "augmentation" to psychological therapy. Many effective treatments do not work on their own, they work only in conjunction with something else.
Beta-blockers have also been used to treat irritability or rage problems. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/15764868
{one of the studies in the geriatric psychiatry literature, showing possible benefit for using propranolol to help agitated dementia patients}
http://www.ncbi.nlm.nih.gov/pubmed/2136070
{an example of a study showing some benefit of propranolol treatment for reducing rage outbursts -- however the study is of low quality}
http://www.ncbi.nlm.nih.gov/pubmed/3546964
{another study from the Mayo Clinic in 1985, showing some success using propranolol to treat patients with rage outbursts}
http://www.ncbi.nlm.nih.gov/pubmed/9196923
{a review paper from 1997, looking at various pharmacologic treatments for aggression; some of the research about beta-blockers is reviewed here}
In summary of the above studies, beta-blockers may help a bit for irritability, aggression, rage outbursts, and agitation, due to a variety of causes, but the evidence base is mainly from before 1990, and the studies are not very rigorous.
Beta-blockers also help diminish a very uncomfortable symptom called "akathisia". Akathisia is a state of external, and internal, restlessness, that can be caused by older antipsychotic drugs.
Beta-blockers are also useful in migraine prophylaxis. Migraine is associated with depression, so a beta-blocker could be a good therapeutic choice in someone with migraines as well as anxious, irritable, or agitated depression.
There were a few studies suggesting beta-blockers could cause or worsen depression, but many of these studies are weak. Here is a review:
http://www.ncbi.nlm.nih.gov/pubmed/16466322
In a more recent major JAMA review, beta-blockers were not found to be causative of depression or fatigue:
http://www.ncbi.nlm.nih.gov/pubmed/12117400
In my opinion, beta-blockers should be used cautiously in people who have or develop depressive symptoms, but I don't think they are contraindicated, since they may be beneficial overall if they help other symptoms. Also, if there are depressive effects, these may be dose-dependent, and may disappear just by reducing the dose.
---
Beta-blockers literally "block" beta-adrenergic receptors in the body. These beta receptors are normally stimulated by the catecholamines adrenaline and noradrenaline (also called epinephrine and norepinephrine), which are hormones secreted by the adrenal glands and by a small area of cells deep in the brain called the locus ceruleus. There is always a little bit of these hormones in circulation (in quantities in the order of parts per trillion, concentrations which would be achieved by adding a single drop of hormone to the volume of 1-10 olympic-sized swimming pools).**
Here is a reference showing resting adrenaline and noradrenaline levels in healthy subjects:
http://hyper.ahajournals.org/cgi/content/abstract/30/1/71
These tiny quantities of hormone are nevertheless enough to stimulate beta receptors; such stimulation is required to maintain or increase the output of the heart, also many other actions in the body, including in kidneys and muscle tissue.
http://www.psychosomaticmedicine.org/cgi/content/abstract/52/2/129
{An excellent study looking at peripheral catecholamine levels (norepinephrine and epinephrine) in groups of patients with anxiety, patients with pheochromocytoma (a disease causing huge increases in catecholamine levels), and normal controls; they found that peripheral norepinephrine levels correlate with anxiety, but NOT in the pheochromocytoma patients; this supports a theory that anxiety states cause central, and secondary peripheral, stimulation of catecholamine release--but the catecholamines themselves do not necessarily CAUSE the anxiety, but are a RESULT of it. Incidentally, Psychosomatic Medicine is another excellent journal worth following}
http://www.psychosomaticmedicine.org/cgi/reprint/66/5/757
{a study showing that norepinephrine levels in the brain correlate highly with blood pressure in normal controls; but do not correlate at all with blood pressure in people with PTSD, suggesting that in PTSD there is an abnormality in catecholamine regulation}
http://ajp.psychiatryonline.org/cgi/reprint/158/8/1227.pdf
{a study from The American Journal of Psychiatry showing that people with PTSD have levels of CSF norepinephrine almost twice as high as normal, and that the norepinephrine levels correlate with the severity of PTSD symptoms}
http://www-personal.umich.edu/~nesse/Articles/AdrenFunctPanic-ArchGenPsychiatry-1984.PDF
{a study from Archives of General Psychiatry in 1984, showing higher levels of plasma catecholamines in panic disorder subjects; but less responsiveness to further adrenergic stimulation in the panic subjects--this suggests that anxious subjects have chronically high catecholamines, and consequently are actually LESS sensitive to catecholamine changes}
http://www.csbmb.princeton.edu/ncc/PDFs/Locus%20Coeruleus/Aston-Jones%20&%20Cohen%20(ARN%2005).pdf
(an article about the role of norepinephrine released in the brain's locus ceruleus, and its importance for optimizing performance of tasks)
**For the math, let us assume that the resting concentration of epinephrine is 100 pMol, or 10^-10 moles/litre; a litre of water has about 55.5 moles of water, so the concentration can be expressed as one part in (55.5 / 10^-10) or one part in 555 billion. A drop of water has a volume of about 1/20 mL. So this concentration of epinephrine corresponds to an analagous concentration of one drop in (555 billion/20) mL, which is about 1 drop in 28 million litres. An olympic swimming pool has a volume of about 2.5 million litres (http://en.wikipedia.org/wiki/Olympic_size_swimming_pool). So this concentration corresponds to 1 drop in a volume of over 10 swimming pools.
http://www.nature.com/neuro/journal/vaop/ncurrent/pdf/nn.2271.pdf
This study suggests a novel use for beta-blockers, which could facilitate behavioural therapy for PTSD. The study demonstrates a variety of things:
1) as was well-known before, when people experience something fearful or traumatic, it sensitizes them to react more strongly to the same fearful stimulus in the future
2) when people re-experience a fearful or traumatic memory, this re-experience consolidates, or strengthens, the strong fearful reaction. This is consistent with the evolution of PTSD and other anxiety disorders, in which an expanding variety of daily events can trigger and consolidate the fear (e.g. a survivor of a bad traffic accident may constantly re-experience traumatic symptoms when hearing traffic noise, loud sounds, etc.--and may start to avoid these situations. Every time this happens, the anxiety disorder becomes more entrenched).
3) Fears can be "extinguished" by re-experiencing the feared stimulus repetitively, in a safe setting. But the fear can be "re-kindled" after extinction more easily than in non-traumatized people (this suggests a permanence to "emotional memory" that can be only temporarily over-ridden by psychological techniques)
4) If the consolidation phase of fear or traumatic memory could be interrupted, then a person might not develop ongoing post-traumatic symptoms at all. In this experiment, there is evidence that propranolol can interrupt this consolidation.
5) Propranolol may disrupt the "emotional memory" consolidation but not the "declarative memory"--the former process may occur primarily through the amygdala, whereas declarative memory is consolidated mainly in the hippocampus. So, the use of propranolol would not "erase the memory" of a traumatic event--the facts of the event would still be remembered normally--but it might reduce the painful, reflexive feeling of emotional trauma associated with the event.
The study does NOT show that "propranolol erases memories", as some of the news headlines seem to be proclaiming. It DOES suggest that adjunctive propranolol may greatly enhance the effectiveness of behavioural therapy. It requires that the person use propranolol while engaging in exposure therapy. So, for example, a possible technique for treating PTSD or panic (especially new-onset) might be to use a 40 mg dose of propranolol 1-2 hours before a therapy session. In the therapy session, the memories of the upsetting events could be discussed. The propranolol might interrupt the process of these upsetting memories getting further consolidated, might facilitate a behavioural therapy process which would help the person feel emotionally comfortable with their thoughts and memories. This process may occur because of direct beta-blockade in the amygdala, which may interrupt consolidation of emotional memory directly.
Despite this encouraging study, there are a number of negative studies looking at using propranolol similarly, for example:
http://www.ncbi.nlm.nih.gov/pubmed/18761097
http://www.ncbi.nlm.nih.gov/pubmed/19060728
I think the main thing to take from the first study is that propranolol may help, but probably only as an augmentation to enhance the effectiveness of behavioural therapy (or CBT) for treating post-traumatic stress or other anxiety disorders.
Beta-blockers are drugs used primarily in cardiology. Some beta-blockers, such as atenolol, act only peripherally, that is they do not enter the brain very much. Others, especially propranolol, can more easily enter the brain, and therefore can act in the central nervous system as well as peripherally.
In psychiatry, propranolol has been useful to treat performance anxiety, especially if there is a component of tremor (e.g. shaking hands) accompanying the anxiety. Many musicians use doses of propranolol to reduce tremor during performances. The anti-tremor mechanism is most likely peripheral beta-blockade (i.e. outside the brain), but the accompanying reduction of subjective anxiety may also be due to central beta-blockade (i.e. inside the brain). This is consistent with some studies which show that peripherally-acting beta-blockers reduce tremor as well as propranolol, but people subjectively prefer the propranolol.
(Reference: http://www.mdconsult.com/das/citation/body/121508141-4/jorg=journal&source=&sp=6333536&sid=0/N/6333536/1.html?issn= )
Beta-blockers have been studied in the treatment of panic disorder, decades ago. They don't work. Here's a link to one of the many studies showing this:
http://www.ncbi.nlm.nih.gov/pubmed/2651490
Yet, these old studies don't look at the possibility that the beta-blocker could work as an "augmentation" to psychological therapy. Many effective treatments do not work on their own, they work only in conjunction with something else.
Beta-blockers have also been used to treat irritability or rage problems. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/15764868
{one of the studies in the geriatric psychiatry literature, showing possible benefit for using propranolol to help agitated dementia patients}
http://www.ncbi.nlm.nih.gov/pubmed/2136070
{an example of a study showing some benefit of propranolol treatment for reducing rage outbursts -- however the study is of low quality}
http://www.ncbi.nlm.nih.gov/pubmed/3546964
{another study from the Mayo Clinic in 1985, showing some success using propranolol to treat patients with rage outbursts}
http://www.ncbi.nlm.nih.gov/pubmed/9196923
{a review paper from 1997, looking at various pharmacologic treatments for aggression; some of the research about beta-blockers is reviewed here}
In summary of the above studies, beta-blockers may help a bit for irritability, aggression, rage outbursts, and agitation, due to a variety of causes, but the evidence base is mainly from before 1990, and the studies are not very rigorous.
Beta-blockers also help diminish a very uncomfortable symptom called "akathisia". Akathisia is a state of external, and internal, restlessness, that can be caused by older antipsychotic drugs.
Beta-blockers are also useful in migraine prophylaxis. Migraine is associated with depression, so a beta-blocker could be a good therapeutic choice in someone with migraines as well as anxious, irritable, or agitated depression.
There were a few studies suggesting beta-blockers could cause or worsen depression, but many of these studies are weak. Here is a review:
http://www.ncbi.nlm.nih.gov/pubmed/16466322
In a more recent major JAMA review, beta-blockers were not found to be causative of depression or fatigue:
http://www.ncbi.nlm.nih.gov/pubmed/12117400
In my opinion, beta-blockers should be used cautiously in people who have or develop depressive symptoms, but I don't think they are contraindicated, since they may be beneficial overall if they help other symptoms. Also, if there are depressive effects, these may be dose-dependent, and may disappear just by reducing the dose.
---
Beta-blockers literally "block" beta-adrenergic receptors in the body. These beta receptors are normally stimulated by the catecholamines adrenaline and noradrenaline (also called epinephrine and norepinephrine), which are hormones secreted by the adrenal glands and by a small area of cells deep in the brain called the locus ceruleus. There is always a little bit of these hormones in circulation (in quantities in the order of parts per trillion, concentrations which would be achieved by adding a single drop of hormone to the volume of 1-10 olympic-sized swimming pools).**
Here is a reference showing resting adrenaline and noradrenaline levels in healthy subjects:
http://hyper.ahajournals.org/cgi/content/abstract/30/1/71
These tiny quantities of hormone are nevertheless enough to stimulate beta receptors; such stimulation is required to maintain or increase the output of the heart, also many other actions in the body, including in kidneys and muscle tissue.
http://www.psychosomaticmedicine.org/cgi/content/abstract/52/2/129
{An excellent study looking at peripheral catecholamine levels (norepinephrine and epinephrine) in groups of patients with anxiety, patients with pheochromocytoma (a disease causing huge increases in catecholamine levels), and normal controls; they found that peripheral norepinephrine levels correlate with anxiety, but NOT in the pheochromocytoma patients; this supports a theory that anxiety states cause central, and secondary peripheral, stimulation of catecholamine release--but the catecholamines themselves do not necessarily CAUSE the anxiety, but are a RESULT of it. Incidentally, Psychosomatic Medicine is another excellent journal worth following}
http://www.psychosomaticmedicine.org/cgi/reprint/66/5/757
{a study showing that norepinephrine levels in the brain correlate highly with blood pressure in normal controls; but do not correlate at all with blood pressure in people with PTSD, suggesting that in PTSD there is an abnormality in catecholamine regulation}
http://ajp.psychiatryonline.org/cgi/reprint/158/8/1227.pdf
{a study from The American Journal of Psychiatry showing that people with PTSD have levels of CSF norepinephrine almost twice as high as normal, and that the norepinephrine levels correlate with the severity of PTSD symptoms}
http://www-personal.umich.edu/~nesse/Articles/AdrenFunctPanic-ArchGenPsychiatry-1984.PDF
{a study from Archives of General Psychiatry in 1984, showing higher levels of plasma catecholamines in panic disorder subjects; but less responsiveness to further adrenergic stimulation in the panic subjects--this suggests that anxious subjects have chronically high catecholamines, and consequently are actually LESS sensitive to catecholamine changes}
http://www.csbmb.princeton.edu/ncc/PDFs/Locus%20Coeruleus/Aston-Jones%20&%20Cohen%20(ARN%2005).pdf
(an article about the role of norepinephrine released in the brain's locus ceruleus, and its importance for optimizing performance of tasks)
**For the math, let us assume that the resting concentration of epinephrine is 100 pMol, or 10^-10 moles/litre; a litre of water has about 55.5 moles of water, so the concentration can be expressed as one part in (55.5 / 10^-10) or one part in 555 billion. A drop of water has a volume of about 1/20 mL. So this concentration of epinephrine corresponds to an analagous concentration of one drop in (555 billion/20) mL, which is about 1 drop in 28 million litres. An olympic swimming pool has a volume of about 2.5 million litres (http://en.wikipedia.org/wiki/Olympic_size_swimming_pool). So this concentration corresponds to 1 drop in a volume of over 10 swimming pools.
Tuesday, February 3, 2009
Self-Injury
Self-injurious behaviour is common. Cutting skin is probably the most common specific behaviour, but there are many other varieties of self-injury.
There are different reasons why it might arise, or factors that might be motivating the behaviour.
Quite often self-injury leads to a feeling of relief, of focus, of emotional intensity, in the midst of deep anger or sadness. Sometimes a long-suffering person may feel as though the capacity to feel has been lost--he or she may feel numb or empty--and self-injury gives rise to some type of feeling for a moment. Also, an act of self-injury may cause someone to feel "in control" during that moment, while they may feel "out of control" in other parts of life.
Another common motivation is self-hatred. Physical pain may be desired. The sequence of self-hatred, leading to self-injury, leading to a sense of relief, leading perhaps to guilt or worsened self-hatred afterwards, can become a powerfully reinforced, self-perpetuating behavioural pathway.
Another motivation is a wish to experiment with the idea of suicide, perhaps with the thinking that cutting skin deeply enough could cause death, but then discovering that the act of non-suicidal self-injury creates a feeling of focus, control, excitement, or relief.
Self-injury can be a very private act, but sometimes can be an overtly interpersonal act, a type of non-verbal communication. Such communication can sometimes become part of an interpersonal dynamic. This dynamic can sometimes (but not always) be part of a vicious cycle, making symptoms worse (David Dawson's ideas, as expressed in Relationship Management of the Borderline Patient, can sometimes apply here).
Self-injury can become part of a person's sense of identity or personal culture, particularly if it has arisen during adolescence or young adult life.
Regardless of the various motivations, I believe that self-injury is an addictive behaviour. Just like alcohol or opiates, it may create some form of relief in the moment, with consequences to pay afterwards. The person engaging in it may recognize that it isn't "healthy" but may continue, or may feel unable to stop.
In the treatment of any addictive behaviour, I believe there are a number of therapeutic principles which can help:
1) If there are underlying problems which are driving the behaviour, or triggering it, then these problems may be addressed with whatever help is available. For self-injury, these problems may include depression, loneliness, irritability, boredom, struggling with issues having to do with identity, meaning, personal culture, etc. Sometimes addressing these underlying problems satisfactorily will solve the problem of self-injury.
2) The self-injury itself could be understood as a psychological defence. If a defence is to be lowered or set aside, it has to be with the will, motivation, and consent of the individual. Without the defence, there may be periods of more intense discomfort ("withdrawal symptoms"), at least initially . I do not believe that a person should be urged or told to "stop cutting". I do believe that a gentle, frank discussion about addiction, triggers, abstinence, etc. could be introduced, with the patient's consent. Addiction treatment programs have a stronger sense of the dynamics here -- a person cannot and should not be forced or "contracted" to stop something. Such a dynamic is unlikely to help, certainly not for very long.
The will to change has to come from the person seeking help, particularly if a strong theme for the person is having self-control, autonomy, freedom--and particularly if the person's problems have in part been caused by past trauma, in which self-control, autonomy, and freedom were oppressed.
3) Alternative strategies to deal with emotional distress can be found and practiced. Common triggers could be identified (e.g. feeling frustrated, feeling bored, feeling lonely, craving sensation of some type), and plans could be formed to negotiate through these moments. A cognitive-behavioural model could be useful (e.g. using journaling), and meditative practices could be helpful (e.g. mindfulness exercises).
Sometimes "substitute" activities such as rubbing ointment on the skin, snapping an elastic band on the wrist, marking the skin with an erasable pen, etc. can be part of a transition away from more harmful self-injury behaviours.
4) If there is guilt or secrecy around the behaviours, it can help to have a forum--such as psychotherapy-- to talk openly about the issue, without the fear of the dialog leading to a highly charged or panicked emotional exchange. The power of guilt or the power of secrecy can be perpetuating factors. In addiction treatment models, it is acknowledged that a person may not have the power within themselves to stop -- help may be needed -- acknowledgment of this fact may break the cycle of guilt.
In practice, I find that self-injury can gradually settle down as other problems settle. In many cases it may--ironically-- settle best when it does not become a primary focus of therapeutic dialog. It may resurface from time to time under stress. If the problem is very intense and acute, people may have a hard time making it through the day or the week, and may feel that the existing help is not enough (e.g. the therapy may feel inadequate). But I think that sticking to a very stable, regular, open-ended therapeutic framework is important.
There are different reasons why it might arise, or factors that might be motivating the behaviour.
Quite often self-injury leads to a feeling of relief, of focus, of emotional intensity, in the midst of deep anger or sadness. Sometimes a long-suffering person may feel as though the capacity to feel has been lost--he or she may feel numb or empty--and self-injury gives rise to some type of feeling for a moment. Also, an act of self-injury may cause someone to feel "in control" during that moment, while they may feel "out of control" in other parts of life.
Another common motivation is self-hatred. Physical pain may be desired. The sequence of self-hatred, leading to self-injury, leading to a sense of relief, leading perhaps to guilt or worsened self-hatred afterwards, can become a powerfully reinforced, self-perpetuating behavioural pathway.
Another motivation is a wish to experiment with the idea of suicide, perhaps with the thinking that cutting skin deeply enough could cause death, but then discovering that the act of non-suicidal self-injury creates a feeling of focus, control, excitement, or relief.
Self-injury can be a very private act, but sometimes can be an overtly interpersonal act, a type of non-verbal communication. Such communication can sometimes become part of an interpersonal dynamic. This dynamic can sometimes (but not always) be part of a vicious cycle, making symptoms worse (David Dawson's ideas, as expressed in Relationship Management of the Borderline Patient, can sometimes apply here).
Self-injury can become part of a person's sense of identity or personal culture, particularly if it has arisen during adolescence or young adult life.
Regardless of the various motivations, I believe that self-injury is an addictive behaviour. Just like alcohol or opiates, it may create some form of relief in the moment, with consequences to pay afterwards. The person engaging in it may recognize that it isn't "healthy" but may continue, or may feel unable to stop.
In the treatment of any addictive behaviour, I believe there are a number of therapeutic principles which can help:
1) If there are underlying problems which are driving the behaviour, or triggering it, then these problems may be addressed with whatever help is available. For self-injury, these problems may include depression, loneliness, irritability, boredom, struggling with issues having to do with identity, meaning, personal culture, etc. Sometimes addressing these underlying problems satisfactorily will solve the problem of self-injury.
2) The self-injury itself could be understood as a psychological defence. If a defence is to be lowered or set aside, it has to be with the will, motivation, and consent of the individual. Without the defence, there may be periods of more intense discomfort ("withdrawal symptoms"), at least initially . I do not believe that a person should be urged or told to "stop cutting". I do believe that a gentle, frank discussion about addiction, triggers, abstinence, etc. could be introduced, with the patient's consent. Addiction treatment programs have a stronger sense of the dynamics here -- a person cannot and should not be forced or "contracted" to stop something. Such a dynamic is unlikely to help, certainly not for very long.
The will to change has to come from the person seeking help, particularly if a strong theme for the person is having self-control, autonomy, freedom--and particularly if the person's problems have in part been caused by past trauma, in which self-control, autonomy, and freedom were oppressed.
3) Alternative strategies to deal with emotional distress can be found and practiced. Common triggers could be identified (e.g. feeling frustrated, feeling bored, feeling lonely, craving sensation of some type), and plans could be formed to negotiate through these moments. A cognitive-behavioural model could be useful (e.g. using journaling), and meditative practices could be helpful (e.g. mindfulness exercises).
Sometimes "substitute" activities such as rubbing ointment on the skin, snapping an elastic band on the wrist, marking the skin with an erasable pen, etc. can be part of a transition away from more harmful self-injury behaviours.
4) If there is guilt or secrecy around the behaviours, it can help to have a forum--such as psychotherapy-- to talk openly about the issue, without the fear of the dialog leading to a highly charged or panicked emotional exchange. The power of guilt or the power of secrecy can be perpetuating factors. In addiction treatment models, it is acknowledged that a person may not have the power within themselves to stop -- help may be needed -- acknowledgment of this fact may break the cycle of guilt.
In practice, I find that self-injury can gradually settle down as other problems settle. In many cases it may--ironically-- settle best when it does not become a primary focus of therapeutic dialog. It may resurface from time to time under stress. If the problem is very intense and acute, people may have a hard time making it through the day or the week, and may feel that the existing help is not enough (e.g. the therapy may feel inadequate). But I think that sticking to a very stable, regular, open-ended therapeutic framework is important.
Monday, February 2, 2009
Short Term Intensive Dynamic Psychotherapy
Here's yet another interesting therapy style.
A lot of these different styles influenced "my own" style with patients, which I consider to be a flexible and eclectic (and hopefully not too disorganized) mix, parts of which are more helpful in some situations than in others. I think that, in life generally, one must absorb those elements of wisdom or inspiration that resonate in a genuine way with one's nature. Many teachers or mentors may have wonderful kernels of wisdom to share, but perhaps many other aspects to leave aside or reject. I realize that, for my patients too, they may at times find parts of their therapy experience with me to be helpful, other parts less so, other parts not helpful at all.
Anyway, back to the title: "short term intensive dynamic psychotherapy" (STIDP). This style was developed by Habib Davanloo, a Montreal psychiatrist who wished to address the phenomenon of patients whose problems never seemed to change or get better, despite very lengthy courses of psychotherapy.
I consider Davanloo's ideas to be challenging, interesting, sometimes brilliant, often quite eccentric. His technique calls for the therapist to be much more active than in traditional psychodynamic therapy.
Here's my brief summary of what the technique is all about (this is very much my paraphrase, which reflects perhaps those elements of the technique, as I learned it, that have been salient to me over the years):
First of all, in order for the technique to be appropriate, it would be necessary for the patient to be quite stable with respect to symptoms of severe major mental illnesses. So, for example, it would be inappropriate to apply these ideas in situations where the patient is suffering from psychosis or mania.
The technique is based on understanding the dynamics of a patient's situation according to a sort of balance between anxiety, underlying emotion, and defences. In this balance, defences are either conscious or unconscious actions that a person takes in order to cope with anxiety. Both anxiety and defences suppress or distract awareness from underlying "emotion." Defences could include phenomena such as denial or repression, but also such immediate behavioural or conversational phenomena such as intellectualizing, ambivalence, compliance, defiance, passivity, engaging in small-talk, etc. (Here, defences need not be considered "bad" but merely as behavioural tactics that a person uses--often automatically-- to cope with emotion or anxiety). Anxiety could be manifest--again either consciously or unconsciously-- as muscular tension--visible during the therapy session--or through other pathways, including somatization (physical symptoms such as pain).
The technique aims to help a patient "experience underlying emotion" by helping the patient to become more consciously aware--in the moment--of anxiety and defences. With the patient's consent and will, sometimes these defences can be set aside quickly, leading to a strongly emotional experience. I do find it is true that people are often unaware of their defences, and can be unaware of the ways in which anxiety is being manifest.
Often the underlying emotion has to do with anger--the patient's defences being tactics to avoid experiencing or acknowledging anger--and the patient's anxiety being provoked by the magnitude of the underlying anger. If the "underlying anger" is "exerienced" (in a sort of cathartic way), it may be initially directed at the therapist, but upon subsequent dialog, it may be understood that this anger is "transferential", that it originated with an earlier developmental conflict, typically with a parent.
The therapist in this technique can be very active, leading to the patient perhaps feeling criticized or under very close scrutiny. For this reason, the technique only works if there is very clear informed consent, and a very clear and positive therapeutic alliance.
The technique may involve asking the patient to describe a recent problem or conflict in the week, with an emphasis on trying to understand the underlying emotion. The focus may shift to the "here and now" of the session, particularly if defences seem to be very active as the patient recounts the story. Later, the focus may shift again to an early childhood dynamic, perhaps with the idea that such childhood events form core conflicts which keep recurring transferentially.
Another component of the technique involves videotaping the sessions, in order to understand clearly what is helping, and what is not, with a view to considering that the moment-to-moment behaviour of therapist and patient is very significant.
The technique can be used to frame different sorts of problems, ranging from panic attacks, relationship difficulties, anger control problems, past trauma, at least some types of depression, and personality disorders. These different problems could be understood as leading to different forms or styles of defence and different manifestations of anxiety, both of which inhibiting a full expression or ability to experience emotion.
The theoretical lingo in this technique is, in my opinion--just like with so much other therapeutic theory--filled with a lot of overvalued Freudian-style language which is taken as literal truth. So we have dramatic descriptions of "breakthroughs", "unlocking the unconscious", etc. As with other phenomena of this sort, it is a ripe opportunity for some people to adopt the ideas with a sort of dogmatic, quasi-religious fervour; and the "guru effect" may be a factor as well. Yet, perhaps I shouldn't criticize the lingo too much -- it is a truly significant moment when a longstanding psychological truth is discovered, and a new way of experiencing an emotion is discovered -- and perhaps such an experience deserves an impressive-sounding label.
One thing I like about this technique, in a nutshell, is that it encourages the possibility that the therapist can sometimes bravely initiate a discussion about a patient's defences, leading rapidly to positive change. And this dialog may not need to wait for months or years, it could happen during the very first meeting, perhaps minutes after sitting down for the first time. And such a rapid pace could be an immense relief--though perhaps a surprise-- to the patient. In some therapy situations I find that there can be such timidity and passivity on the part of the therapist that very little happens -- not only can this be ineffective, I think it is downright boring sometimes, for patient and therapist!
In some ways it is like a stylistic mixture of cognitive-behavioural therapy and psychoanalytic therapy, but actually with a therapist who is more active than in either of these styles. In some variants of this style, the therapist might view cognitive-behavioural therapy as a sort of subset of the larger, more encompassing dynamic therapy, and might deliberately recommend CBT techniques as a sort of preparatory step.
The risks of the technique, in my opinion, lie in the dogmatism of its theory. Also, the style could be misapplied in such a way as to be offensive, argumentative, or dismissive. It may encourage some therapists to be excessively active, when the patient may need a quiet listener. I also believe it could be seen to aggrandize the role of therapist in a way I'm not particularly comfortable with.
There is a small but positive evidence base for the technique in the mainstream literature.
There is a significant case-series evidence base accumulated by practioners of the technique. Most case series are weak sources of evidence (because there is no control group, it is not prospective, etc.), but because the case series evidence in STIDP is also often accompanied by videotaped sessions demonstrating changes, I feel that this evidence base deserves stronger consideration.
Reference:
http://www.ncbi.nlm.nih.gov/pubmed/15583112
A lot of these different styles influenced "my own" style with patients, which I consider to be a flexible and eclectic (and hopefully not too disorganized) mix, parts of which are more helpful in some situations than in others. I think that, in life generally, one must absorb those elements of wisdom or inspiration that resonate in a genuine way with one's nature. Many teachers or mentors may have wonderful kernels of wisdom to share, but perhaps many other aspects to leave aside or reject. I realize that, for my patients too, they may at times find parts of their therapy experience with me to be helpful, other parts less so, other parts not helpful at all.
Anyway, back to the title: "short term intensive dynamic psychotherapy" (STIDP). This style was developed by Habib Davanloo, a Montreal psychiatrist who wished to address the phenomenon of patients whose problems never seemed to change or get better, despite very lengthy courses of psychotherapy.
I consider Davanloo's ideas to be challenging, interesting, sometimes brilliant, often quite eccentric. His technique calls for the therapist to be much more active than in traditional psychodynamic therapy.
Here's my brief summary of what the technique is all about (this is very much my paraphrase, which reflects perhaps those elements of the technique, as I learned it, that have been salient to me over the years):
First of all, in order for the technique to be appropriate, it would be necessary for the patient to be quite stable with respect to symptoms of severe major mental illnesses. So, for example, it would be inappropriate to apply these ideas in situations where the patient is suffering from psychosis or mania.
The technique is based on understanding the dynamics of a patient's situation according to a sort of balance between anxiety, underlying emotion, and defences. In this balance, defences are either conscious or unconscious actions that a person takes in order to cope with anxiety. Both anxiety and defences suppress or distract awareness from underlying "emotion." Defences could include phenomena such as denial or repression, but also such immediate behavioural or conversational phenomena such as intellectualizing, ambivalence, compliance, defiance, passivity, engaging in small-talk, etc. (Here, defences need not be considered "bad" but merely as behavioural tactics that a person uses--often automatically-- to cope with emotion or anxiety). Anxiety could be manifest--again either consciously or unconsciously-- as muscular tension--visible during the therapy session--or through other pathways, including somatization (physical symptoms such as pain).
The technique aims to help a patient "experience underlying emotion" by helping the patient to become more consciously aware--in the moment--of anxiety and defences. With the patient's consent and will, sometimes these defences can be set aside quickly, leading to a strongly emotional experience. I do find it is true that people are often unaware of their defences, and can be unaware of the ways in which anxiety is being manifest.
Often the underlying emotion has to do with anger--the patient's defences being tactics to avoid experiencing or acknowledging anger--and the patient's anxiety being provoked by the magnitude of the underlying anger. If the "underlying anger" is "exerienced" (in a sort of cathartic way), it may be initially directed at the therapist, but upon subsequent dialog, it may be understood that this anger is "transferential", that it originated with an earlier developmental conflict, typically with a parent.
The therapist in this technique can be very active, leading to the patient perhaps feeling criticized or under very close scrutiny. For this reason, the technique only works if there is very clear informed consent, and a very clear and positive therapeutic alliance.
The technique may involve asking the patient to describe a recent problem or conflict in the week, with an emphasis on trying to understand the underlying emotion. The focus may shift to the "here and now" of the session, particularly if defences seem to be very active as the patient recounts the story. Later, the focus may shift again to an early childhood dynamic, perhaps with the idea that such childhood events form core conflicts which keep recurring transferentially.
Another component of the technique involves videotaping the sessions, in order to understand clearly what is helping, and what is not, with a view to considering that the moment-to-moment behaviour of therapist and patient is very significant.
The technique can be used to frame different sorts of problems, ranging from panic attacks, relationship difficulties, anger control problems, past trauma, at least some types of depression, and personality disorders. These different problems could be understood as leading to different forms or styles of defence and different manifestations of anxiety, both of which inhibiting a full expression or ability to experience emotion.
The theoretical lingo in this technique is, in my opinion--just like with so much other therapeutic theory--filled with a lot of overvalued Freudian-style language which is taken as literal truth. So we have dramatic descriptions of "breakthroughs", "unlocking the unconscious", etc. As with other phenomena of this sort, it is a ripe opportunity for some people to adopt the ideas with a sort of dogmatic, quasi-religious fervour; and the "guru effect" may be a factor as well. Yet, perhaps I shouldn't criticize the lingo too much -- it is a truly significant moment when a longstanding psychological truth is discovered, and a new way of experiencing an emotion is discovered -- and perhaps such an experience deserves an impressive-sounding label.
One thing I like about this technique, in a nutshell, is that it encourages the possibility that the therapist can sometimes bravely initiate a discussion about a patient's defences, leading rapidly to positive change. And this dialog may not need to wait for months or years, it could happen during the very first meeting, perhaps minutes after sitting down for the first time. And such a rapid pace could be an immense relief--though perhaps a surprise-- to the patient. In some therapy situations I find that there can be such timidity and passivity on the part of the therapist that very little happens -- not only can this be ineffective, I think it is downright boring sometimes, for patient and therapist!
In some ways it is like a stylistic mixture of cognitive-behavioural therapy and psychoanalytic therapy, but actually with a therapist who is more active than in either of these styles. In some variants of this style, the therapist might view cognitive-behavioural therapy as a sort of subset of the larger, more encompassing dynamic therapy, and might deliberately recommend CBT techniques as a sort of preparatory step.
The risks of the technique, in my opinion, lie in the dogmatism of its theory. Also, the style could be misapplied in such a way as to be offensive, argumentative, or dismissive. It may encourage some therapists to be excessively active, when the patient may need a quiet listener. I also believe it could be seen to aggrandize the role of therapist in a way I'm not particularly comfortable with.
There is a small but positive evidence base for the technique in the mainstream literature.
There is a significant case-series evidence base accumulated by practioners of the technique. Most case series are weak sources of evidence (because there is no control group, it is not prospective, etc.), but because the case series evidence in STIDP is also often accompanied by videotaped sessions demonstrating changes, I feel that this evidence base deserves stronger consideration.
Reference:
http://www.ncbi.nlm.nih.gov/pubmed/15583112
Friday, January 30, 2009
Narrative Therapy & the "Guru Effect"
This is another interesting therapy style, pioneered by the Australian social worker Michael White (1948-2008).
Here is my condensed account of narrative therapy: the main idea that I appreciate in this style is the application of a "story metaphor" to a person's life and problems. The patient becomes an author. Problems in the person's life (such as depression or eating disorders) become characters, and each of these characters gets a name. These characters are understood to have voices in the narrative, and to influence the story. The ways in which the different characters exert influence upon the story are examined, by the patient and by others. The role of the character--its purpose in the plot, so to speak--is considered. The question is considered of whether the story requires the character in some way, whether the character needs to be present, or what the story would be like without the character at all. The next step is to creatively "re-author" the story, addressing the problems externally as characters to deal with. The motives could be considered about why the different characters are behaving as they do. Elements which empower or weaken the character are considered. Important messages the characters might have to communicate could be considered or validated. The different "antics" of the characters (problems) could be anticipated, "spoken back to", or thwarted, through a creative act of "re-authoring".
The idea is really quite similar to cognitive-behavioural therapy, but perhaps with a more imaginative infusion of literary theory.
I find much of the written theory about this style incredibly cumbersome and laden with unnecessary jargon. Also I think this style, like many others, tended to see the founder as a sort of guru. There is a phenomenon I call the "guru effect" in which people with complex problems report significant change when they encounter some wise, charismatic figure, often in a public setting (I guess we can see this on certain types of TV shows these days).
I don't mean to be too critical of the "guru effect" because I acknowledge that there are some people who can share their charisma and wisdom very effectively, in a way that can be dramatically helpful. The word "guru" itself, and its origins, ought to be treated with respect, and the existence of this phenomenon can be appreciated as a gift to the world.
However, the "guru effect" can sometimes lead to a lot of dogma and a type of religious fervour that can foster overvalued ideas about what it is that is actually helping. This is especially problematic, in my opinion, if the adherents to a particular style begin to reject or criticize other styles or ideas, in ways that are not founded upon good evidence.
In any case, I think there are some imaginative and helpful ideas in narrative therapy--I'm always on the lookout for variations of cognitive-behavioural therapy or other therapies that are a little bit more imaginative, creative, or even fun (therapy isn't always fun, but humour, enjoyment, creativity, and playfulness can be immensely important elements at times).
Here is my condensed account of narrative therapy: the main idea that I appreciate in this style is the application of a "story metaphor" to a person's life and problems. The patient becomes an author. Problems in the person's life (such as depression or eating disorders) become characters, and each of these characters gets a name. These characters are understood to have voices in the narrative, and to influence the story. The ways in which the different characters exert influence upon the story are examined, by the patient and by others. The role of the character--its purpose in the plot, so to speak--is considered. The question is considered of whether the story requires the character in some way, whether the character needs to be present, or what the story would be like without the character at all. The next step is to creatively "re-author" the story, addressing the problems externally as characters to deal with. The motives could be considered about why the different characters are behaving as they do. Elements which empower or weaken the character are considered. Important messages the characters might have to communicate could be considered or validated. The different "antics" of the characters (problems) could be anticipated, "spoken back to", or thwarted, through a creative act of "re-authoring".
The idea is really quite similar to cognitive-behavioural therapy, but perhaps with a more imaginative infusion of literary theory.
I find much of the written theory about this style incredibly cumbersome and laden with unnecessary jargon. Also I think this style, like many others, tended to see the founder as a sort of guru. There is a phenomenon I call the "guru effect" in which people with complex problems report significant change when they encounter some wise, charismatic figure, often in a public setting (I guess we can see this on certain types of TV shows these days).
I don't mean to be too critical of the "guru effect" because I acknowledge that there are some people who can share their charisma and wisdom very effectively, in a way that can be dramatically helpful. The word "guru" itself, and its origins, ought to be treated with respect, and the existence of this phenomenon can be appreciated as a gift to the world.
However, the "guru effect" can sometimes lead to a lot of dogma and a type of religious fervour that can foster overvalued ideas about what it is that is actually helping. This is especially problematic, in my opinion, if the adherents to a particular style begin to reject or criticize other styles or ideas, in ways that are not founded upon good evidence.
In any case, I think there are some imaginative and helpful ideas in narrative therapy--I'm always on the lookout for variations of cognitive-behavioural therapy or other therapies that are a little bit more imaginative, creative, or even fun (therapy isn't always fun, but humour, enjoyment, creativity, and playfulness can be immensely important elements at times).
Thursday, January 29, 2009
Anxiety Hierarchies
The idea of an "anxiety hierarchy" is simple and powerful.
It is an application of behavioural therapy, and is analogous to a well-designed educational or athletic training program.
In education--for example, learning to read, or learning arithmetic--a well-designed workbook would call for you to start with some exercises that you would find very easy. If the initial exercises are too hard, then it would be necessary to go to the previous workbook, and try something easier. If you can do the easier ones fluently, you can move on to the next page, and try some exercises that are just a little bit harder, and so on...the pace could be self-directed; some people might want to leap ahead quickly, others might want to linger on the easier pages, or practice doing them faster, etc.
In athletic training--for example, training for a marathon--one might have to start with just a few minutes of jogging, alternating with a few minutes of walking, a few times per week--once this feels comfortable, the intensity and duration could be increased.
An anxiety hierarchy is basically a "workout schedule" or "curriculum" for overcoming a phobia or an inhibition.
A prerequisite to engaging in this process is a clear wish to overcome the anxiety. It may well be possible to practice the skills necessary to become a skydiver, but unless you really want to skydive, you probably shouldn't do the training!
If the anxiety is social phobia, for example, the prerequisite for this approach is that you truly want to be able to interact socially with greater ease. If you have a phobia of bridges, you have to truly want to be able to cross bridges easily.
To do an anxiety hierarchy, it is necessary to consider tasks which involve your anxiety in some way, and rank them in difficulty, say from 1 to 100.
For social phobia, a rating of 100 might be warranted for the task of showing up for a group function, consisting of strangers, introducing yourself to everyone, striking up a conversation with the person who interests you most, and asking for that person's phone number. A rating of 50 might be for the task of asking a stranger in a crowded cafeteria for the time. A rating of 10 might be for reading a book in a crowded place, instead of at home. The details of how you do the ratings are up to you and how you feel.
It helps to think of as many tasks as you can along the "hierarchy", covering as many numbers as possible from 1 to 100.
The next step is--just like learning arithmetic or training for the marathon--to start with the easiest task, and practice it daily until you feel comfortable with it.
Then move on to the next harder step, and continue gradually working your way up the hierarchy. It is important to do the work every day, if possible; consistency and regularity are extremely important, just as in other learning tasks.
It is important to really take this seriously, and to put in your hours of work and practice. Just like marathon training or language learning, it won't happen unless you do it regularly, at a moderate level of difficulty, for solid blocks of time (e.g. one hour every day).
The pace of change may be quite similar to an educational or athletic task--after all, it is your brain that is changing, just the same way as your brain changes with learning anything else. Also your body learns to change--when you are more physically fit, the same athletic task can be done more efficiently, with less effort, and with less physiological stress. With anxiety tasks, your body will learn not to react with the same anxiety symptoms (e.g. racing heart, sweating, shortness of breath), as you train yourself.
It is an application of behavioural therapy, and is analogous to a well-designed educational or athletic training program.
In education--for example, learning to read, or learning arithmetic--a well-designed workbook would call for you to start with some exercises that you would find very easy. If the initial exercises are too hard, then it would be necessary to go to the previous workbook, and try something easier. If you can do the easier ones fluently, you can move on to the next page, and try some exercises that are just a little bit harder, and so on...the pace could be self-directed; some people might want to leap ahead quickly, others might want to linger on the easier pages, or practice doing them faster, etc.
In athletic training--for example, training for a marathon--one might have to start with just a few minutes of jogging, alternating with a few minutes of walking, a few times per week--once this feels comfortable, the intensity and duration could be increased.
An anxiety hierarchy is basically a "workout schedule" or "curriculum" for overcoming a phobia or an inhibition.
A prerequisite to engaging in this process is a clear wish to overcome the anxiety. It may well be possible to practice the skills necessary to become a skydiver, but unless you really want to skydive, you probably shouldn't do the training!
If the anxiety is social phobia, for example, the prerequisite for this approach is that you truly want to be able to interact socially with greater ease. If you have a phobia of bridges, you have to truly want to be able to cross bridges easily.
To do an anxiety hierarchy, it is necessary to consider tasks which involve your anxiety in some way, and rank them in difficulty, say from 1 to 100.
For social phobia, a rating of 100 might be warranted for the task of showing up for a group function, consisting of strangers, introducing yourself to everyone, striking up a conversation with the person who interests you most, and asking for that person's phone number. A rating of 50 might be for the task of asking a stranger in a crowded cafeteria for the time. A rating of 10 might be for reading a book in a crowded place, instead of at home. The details of how you do the ratings are up to you and how you feel.
It helps to think of as many tasks as you can along the "hierarchy", covering as many numbers as possible from 1 to 100.
The next step is--just like learning arithmetic or training for the marathon--to start with the easiest task, and practice it daily until you feel comfortable with it.
Then move on to the next harder step, and continue gradually working your way up the hierarchy. It is important to do the work every day, if possible; consistency and regularity are extremely important, just as in other learning tasks.
It is important to really take this seriously, and to put in your hours of work and practice. Just like marathon training or language learning, it won't happen unless you do it regularly, at a moderate level of difficulty, for solid blocks of time (e.g. one hour every day).
The pace of change may be quite similar to an educational or athletic task--after all, it is your brain that is changing, just the same way as your brain changes with learning anything else. Also your body learns to change--when you are more physically fit, the same athletic task can be done more efficiently, with less effort, and with less physiological stress. With anxiety tasks, your body will learn not to react with the same anxiety symptoms (e.g. racing heart, sweating, shortness of breath), as you train yourself.
Sunday, January 25, 2009
Reservoir Metaphor
We have "emotional reservoirs" of different types. Some supply "energy", others supply "calm", "happiness", or "well-being".
If the reservoirs are full, we may maintain our energy, calm, happiness, or well-being, even in times of stress. If there is a drought (such as a bad day or week, or other varieties of stress), we maintain a healthy state, even though there is environmental adversity.
If the reservoirs are dry, we become dependent upon the immediate environmental circumstances: there may be energy or happiness, but only if daily events are going well.
The combination of a "dry reservoir" and a "bad day" could be intense symptoms: an emotional crash, lost temper, sometimes thoughts of suicide.
Various psychiatric and medical conditions lead to a "dry reservoir" condition. Depression itself is depleting. "Personality disorders" could be understood as a "reservoir" problem in some cases. Chronic pain conditions of any sort can be depleting. And chronic environmental adversity, of course (e.g. ongoing abuse, oppression, etc.) can keep a "structurally intact" reservoir constantly dry.
To run wild with this metaphor a bit, I suppose there are different varieties of reservoir problems:
1) the "leaky reservoir" : good experiences are not internalized, noticed, or remembered
2) the "too small reservoir": only recent events (over days or weeks) determine the fullness of the reservoir
3) the "blocked reservoir" : there is an abundant inner supply of positivity, but symptoms persist, and the reservoir seems inaccessible
I suppose therapeutically, this reservoir notion could be worked on in several ways:
1) learning ways to "fill one's reservoir" on an ongoing basis -- so that one becomes less dependent on the immediate situation for well-being
2) "reservoir maintenance" : repairing leaks or blockages--there may be ways to consciously maintain, notice, hold onto, positive experience, instead of allowing it too "leak away" or be inaccessible.
3) discovering a reservoir that was always there, but that lay outside of awareness (here's a kind of psychoanalytic idea--though more about uncovering something positive rather than uncovering a hidden problem).
I intend this reservoir idea as a broad life metaphor, but there are direct analogies to be made between the "reservoir metaphor" and neurophysiology. For example, if neurotransmitter reservoirs within neurons are depleted (literally) by a drug such as reserpine, a depressed state will ensue (examples such as this are strong elements of support for neurotransmitter-based hypotheses--such as the serotonin hypothesis-- about depression). One of the problems about neuropharmacologic theory, though, is that it may focus excessively on quantities (such as "reservoir volume", or more literally, "serotonin function") while failing to attend to structure (structural change in the brain must be achieved through thoughts, actions, and relationships, not merely through changing "reservoir levels").
If the reservoirs are full, we may maintain our energy, calm, happiness, or well-being, even in times of stress. If there is a drought (such as a bad day or week, or other varieties of stress), we maintain a healthy state, even though there is environmental adversity.
If the reservoirs are dry, we become dependent upon the immediate environmental circumstances: there may be energy or happiness, but only if daily events are going well.
The combination of a "dry reservoir" and a "bad day" could be intense symptoms: an emotional crash, lost temper, sometimes thoughts of suicide.
Various psychiatric and medical conditions lead to a "dry reservoir" condition. Depression itself is depleting. "Personality disorders" could be understood as a "reservoir" problem in some cases. Chronic pain conditions of any sort can be depleting. And chronic environmental adversity, of course (e.g. ongoing abuse, oppression, etc.) can keep a "structurally intact" reservoir constantly dry.
To run wild with this metaphor a bit, I suppose there are different varieties of reservoir problems:
1) the "leaky reservoir" : good experiences are not internalized, noticed, or remembered
2) the "too small reservoir": only recent events (over days or weeks) determine the fullness of the reservoir
3) the "blocked reservoir" : there is an abundant inner supply of positivity, but symptoms persist, and the reservoir seems inaccessible
I suppose therapeutically, this reservoir notion could be worked on in several ways:
1) learning ways to "fill one's reservoir" on an ongoing basis -- so that one becomes less dependent on the immediate situation for well-being
2) "reservoir maintenance" : repairing leaks or blockages--there may be ways to consciously maintain, notice, hold onto, positive experience, instead of allowing it too "leak away" or be inaccessible.
3) discovering a reservoir that was always there, but that lay outside of awareness (here's a kind of psychoanalytic idea--though more about uncovering something positive rather than uncovering a hidden problem).
I intend this reservoir idea as a broad life metaphor, but there are direct analogies to be made between the "reservoir metaphor" and neurophysiology. For example, if neurotransmitter reservoirs within neurons are depleted (literally) by a drug such as reserpine, a depressed state will ensue (examples such as this are strong elements of support for neurotransmitter-based hypotheses--such as the serotonin hypothesis-- about depression). One of the problems about neuropharmacologic theory, though, is that it may focus excessively on quantities (such as "reservoir volume", or more literally, "serotonin function") while failing to attend to structure (structural change in the brain must be achieved through thoughts, actions, and relationships, not merely through changing "reservoir levels").
Friday, January 23, 2009
Desert Metaphor
A journey through life, especially if affected by mental illness, can be like a journey through a desert.
You may feel lost or starved. The view may be exactly the same, despite having invested days, weeks, or months, trying to forge ahead.
There may be life-threatening moments of intense thirst, and an uncertainty whether you will make it through the day.
The light of day may be intolerable and oppressive, and you may out of necessity have to work only at night, even though you may fear the darkness.
In psychotherapy, it has often been the common practice to examine the past, as part of a key to escaping the desert. In a desert, there may be some value to examining your past, but on the other hand this information may not be relevant to your immediate needs, and may be a distraction impeding your progress. Furthermore, in a desert, sometimes your "past" cannot truly be known, since the shifting sands cover up your path. The search for "past" can be a frustrating, fruitless diversion, punctuated by misleading mirages.
Cognitive-behavioural therapies, or "here and now" psychodynamic therapies, are more likely to help when lost in a desert. Some kind of desert guide may greatly ease the journey, even if the journey does not become any shorter (here I suggest the role of therapist as "desert guide" or "camel").
An immediate source of water and food helps a great deal too, and so does a good sun hat. The most basic needs have to be met first.
A psychodynamic style of therapy focusing extensively on the past is more likely to be helpful once you are already out of the desert, and are perhaps trying to make sense of the whole experience.
You may feel lost or starved. The view may be exactly the same, despite having invested days, weeks, or months, trying to forge ahead.
There may be life-threatening moments of intense thirst, and an uncertainty whether you will make it through the day.
The light of day may be intolerable and oppressive, and you may out of necessity have to work only at night, even though you may fear the darkness.
In psychotherapy, it has often been the common practice to examine the past, as part of a key to escaping the desert. In a desert, there may be some value to examining your past, but on the other hand this information may not be relevant to your immediate needs, and may be a distraction impeding your progress. Furthermore, in a desert, sometimes your "past" cannot truly be known, since the shifting sands cover up your path. The search for "past" can be a frustrating, fruitless diversion, punctuated by misleading mirages.
Cognitive-behavioural therapies, or "here and now" psychodynamic therapies, are more likely to help when lost in a desert. Some kind of desert guide may greatly ease the journey, even if the journey does not become any shorter (here I suggest the role of therapist as "desert guide" or "camel").
An immediate source of water and food helps a great deal too, and so does a good sun hat. The most basic needs have to be met first.
A psychodynamic style of therapy focusing extensively on the past is more likely to be helpful once you are already out of the desert, and are perhaps trying to make sense of the whole experience.
Thursday, January 22, 2009
Antisocial Personality
Many people use the term "antisocial" in daily language to describe a feeling of not wanting to socialize, or of reclusiveness.
In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.
I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.
For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.
A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.
However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".
The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.
There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.
And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.
Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.
Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.
Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.
Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/16291212
Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.
The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".
In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.
So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.
Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.
There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).
Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).
In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.
The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.
I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.
In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.
I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.
For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.
A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.
However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".
The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.
There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.
And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.
Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.
Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.
Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.
Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/16291212
Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.
The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".
In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.
So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.
Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.
There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).
Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).
In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.
The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.
I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.
Thursday, January 8, 2009
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.
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.
Wednesday, January 7, 2009
Borderline Personality
There are many patients I have seen who have had some mixture of the following symptoms or experiences:
1) sudden, intense shifts of mood, often towards extreme sadness, emptiness, or rage. Often times, these sudden shifts occur in the context of a relationship event (a disappointment with someone, a conflictual conversation, a breakup, etc.)
2) very chaotic interpersonal relationships -- lots of conflict, sometimes a lot of aggression, sometimes frequent break-ups, reconciliations, break-ups, reconciliations, etc. Sometimes this is a product of the person having chosen a partner with a chaotic relationship style, but sometimes this relationship chaos occurs even with a partner who is calm
3) prominent, longstanding thoughts about suicide, even when mood is better
4) frequent self-injurious behaviour (most frequently, cutting skin with a razor), which is often done to relieve extreme emotional tension. Sometimes self-injury or suicide attempts occur as a form of non-verbal interpersonal communication or protest.
5) prominent, longstanding self-hatred
6) symptoms which "seem psychotic", such as hallucinations, paranoia, or thought disorganization of various types, but which do not have the characteristic qualities or patterns found in psychotic illness such as schizophrenia
7) pronounced confusion about identity, often with respect to gender, sexuality, or "sense of self"
8) difficulty with relationship boundaries
9) a chaotic and often very negative set of experiences with doctors, the health care system, etc.
10) hospital stays in which symptoms got worse rather than better
I have seen many for whom these symptoms were their manifestation of depression, or part of a type of bipolar disorder, and for whom these issues improved following standard treatments for mood disorder.
For others, some of these symptoms are part of a post-traumatic syndrome.
I have seen many others for whom these symptoms seemed to be part of a developmental struggle, arising with adolescence or earlier, and resolving with time, support, work, development of purpose, meaning, community, autonomy, etc. Often a fairly short-term experience of therapy has helped.
For others, these symptoms become more lasting phenomena, and may in fact become more and more entrenched with time. It is as though the person has a chaotic relationship with time itself, which feeds the symptoms, rather than relieving them.
Some of the symptoms, such as self-injury, seem to have strong addictive components. Other types of addictive behaviours (such as substance abuse) are common in this population as well.
For many of my patients, there is so much overlap between "depression" and so-called "borderline personality traits" that I don't find that there is much point being concerned with "labeling" at all, since the same things help with both.
Here are some things that I have found to be helpful in all cases (in addition my standard advice about a healthy, happy lifestyle):
1) gentle, supportive, compassionate, friendly, consistent care in a setting with clear but non-rigid boundaries
2) treatment of specific symptoms pharmacologically (e.g. antidepressants may help with mood; anticonvulsants or antipsychotics may help with anxiety, irritability, insomnia, and lability; stimulants may help with inattention, hyperactivity, or distractability)
3) avoidance of harm (e.g. I would tend to avoid prescribing potentially addictive medications, or medications that are particularly dangerous in overdose; also some types of overly confrontational, reactive, over-medicalized, suggestive, dogmatic, or "digging into the past" styles of psychotherapy can probably be overtly harmful for some people, especially if the therapy style is engaged in without the patient's full understanding or consent).
4) gentle attention to the same kind of dynamics happening in the therapy as what happens in other relationships (e.g. intense conflicts, feelings of abandonment, "chaos"), and an attempt to gently work it out rather than let the symptoms threaten the relationship
5) cognitive-therapy techniques of various types can be particularly helpful; specifically Linehan's "Dialectical Behavioural Therapy" which is a type of cognitive therapy enriched by ideas from Buddhist mindfulness. Also Linehan's ideas emphasize the idea of "validation" which I consider extremely important -- symptoms need to be calmly understood, empathized with, rather than discounted or dismissed
6) long-term dynamically-oriented psychotherapy, 1-on-1 or group (or both). There is an expanding strong evidence base that this helps a lot
7) trying neither to over-react (e.g. push for an immediate hospital visit), nor to under-react (e.g. ignore or dismiss), regarding suicidal thoughts or self-injury; but to try to be understanding and helpful in any case
8) I do not tend to recommend hospitalization, especially through an emergency admission, as a cornerstone of therapy, except I do encourage people to use the emergency rooms if they cannot survive safely through the day and they do not feel they have other resources available. I believe it is much more therapeutic for people to choose themselves whether or not to use the emergency room.
9) a good day-program, if available, can be very helpful. These are harder to find nowadays
A few references:
http://www.ncbi.nlm.nih.gov/pubmed/16437534
(a Cochrane review of psychotherapy for borderline personality)
http://www.ncbi.nlm.nih.gov/pubmed/16437535
(a Cochrane review of medication for borderline personality; this shows, as I would expect, a modest and inconsistent evidence base, which I think supports the idea of being open-minded about using pharmacological therapies, but perhaps of having modest expectations of them, and being wary of relying too heavily on medication treatments alone)
http://www.ncbi.nlm.nih.gov/pubmed/17541052
(a randomized study showing broad, large effects from psychotherapy in patients having a borderline personality diagnosis, over a 1-year period)
http://www.ncbi.nlm.nih.gov/pubmed/18347003
(a study with an 8 year follow-up! --we need more such very long-term studies-- It shows that an intensive day program approach was very helpful)
http://www.ncbi.nlm.nih.gov/pubmed/17427099
(another longer-term study showing substantial benefits from psychotherapy)
It is important to note that many with so-called "borderline personality" may have depression or other problems at the same time, and each of these problems may improve with specific types of therapy. Many studies are not considering these "comorbid" conditions, and therefore underestimate the effectiveness of various types of therapy.
Here is a link to a dialectical-behavior therapy self-help site:
http://www.dbtselfhelp.com/index.html
1) sudden, intense shifts of mood, often towards extreme sadness, emptiness, or rage. Often times, these sudden shifts occur in the context of a relationship event (a disappointment with someone, a conflictual conversation, a breakup, etc.)
2) very chaotic interpersonal relationships -- lots of conflict, sometimes a lot of aggression, sometimes frequent break-ups, reconciliations, break-ups, reconciliations, etc. Sometimes this is a product of the person having chosen a partner with a chaotic relationship style, but sometimes this relationship chaos occurs even with a partner who is calm
3) prominent, longstanding thoughts about suicide, even when mood is better
4) frequent self-injurious behaviour (most frequently, cutting skin with a razor), which is often done to relieve extreme emotional tension. Sometimes self-injury or suicide attempts occur as a form of non-verbal interpersonal communication or protest.
5) prominent, longstanding self-hatred
6) symptoms which "seem psychotic", such as hallucinations, paranoia, or thought disorganization of various types, but which do not have the characteristic qualities or patterns found in psychotic illness such as schizophrenia
7) pronounced confusion about identity, often with respect to gender, sexuality, or "sense of self"
8) difficulty with relationship boundaries
9) a chaotic and often very negative set of experiences with doctors, the health care system, etc.
10) hospital stays in which symptoms got worse rather than better
I have seen many for whom these symptoms were their manifestation of depression, or part of a type of bipolar disorder, and for whom these issues improved following standard treatments for mood disorder.
For others, some of these symptoms are part of a post-traumatic syndrome.
I have seen many others for whom these symptoms seemed to be part of a developmental struggle, arising with adolescence or earlier, and resolving with time, support, work, development of purpose, meaning, community, autonomy, etc. Often a fairly short-term experience of therapy has helped.
For others, these symptoms become more lasting phenomena, and may in fact become more and more entrenched with time. It is as though the person has a chaotic relationship with time itself, which feeds the symptoms, rather than relieving them.
Some of the symptoms, such as self-injury, seem to have strong addictive components. Other types of addictive behaviours (such as substance abuse) are common in this population as well.
For many of my patients, there is so much overlap between "depression" and so-called "borderline personality traits" that I don't find that there is much point being concerned with "labeling" at all, since the same things help with both.
Here are some things that I have found to be helpful in all cases (in addition my standard advice about a healthy, happy lifestyle):
1) gentle, supportive, compassionate, friendly, consistent care in a setting with clear but non-rigid boundaries
2) treatment of specific symptoms pharmacologically (e.g. antidepressants may help with mood; anticonvulsants or antipsychotics may help with anxiety, irritability, insomnia, and lability; stimulants may help with inattention, hyperactivity, or distractability)
3) avoidance of harm (e.g. I would tend to avoid prescribing potentially addictive medications, or medications that are particularly dangerous in overdose; also some types of overly confrontational, reactive, over-medicalized, suggestive, dogmatic, or "digging into the past" styles of psychotherapy can probably be overtly harmful for some people, especially if the therapy style is engaged in without the patient's full understanding or consent).
4) gentle attention to the same kind of dynamics happening in the therapy as what happens in other relationships (e.g. intense conflicts, feelings of abandonment, "chaos"), and an attempt to gently work it out rather than let the symptoms threaten the relationship
5) cognitive-therapy techniques of various types can be particularly helpful; specifically Linehan's "Dialectical Behavioural Therapy" which is a type of cognitive therapy enriched by ideas from Buddhist mindfulness. Also Linehan's ideas emphasize the idea of "validation" which I consider extremely important -- symptoms need to be calmly understood, empathized with, rather than discounted or dismissed
6) long-term dynamically-oriented psychotherapy, 1-on-1 or group (or both). There is an expanding strong evidence base that this helps a lot
7) trying neither to over-react (e.g. push for an immediate hospital visit), nor to under-react (e.g. ignore or dismiss), regarding suicidal thoughts or self-injury; but to try to be understanding and helpful in any case
8) I do not tend to recommend hospitalization, especially through an emergency admission, as a cornerstone of therapy, except I do encourage people to use the emergency rooms if they cannot survive safely through the day and they do not feel they have other resources available. I believe it is much more therapeutic for people to choose themselves whether or not to use the emergency room.
9) a good day-program, if available, can be very helpful. These are harder to find nowadays
A few references:
http://www.ncbi.nlm.nih.gov/pubmed/16437534
(a Cochrane review of psychotherapy for borderline personality)
http://www.ncbi.nlm.nih.gov/pubmed/16437535
(a Cochrane review of medication for borderline personality; this shows, as I would expect, a modest and inconsistent evidence base, which I think supports the idea of being open-minded about using pharmacological therapies, but perhaps of having modest expectations of them, and being wary of relying too heavily on medication treatments alone)
http://www.ncbi.nlm.nih.gov/pubmed/17541052
(a randomized study showing broad, large effects from psychotherapy in patients having a borderline personality diagnosis, over a 1-year period)
http://www.ncbi.nlm.nih.gov/pubmed/18347003
(a study with an 8 year follow-up! --we need more such very long-term studies-- It shows that an intensive day program approach was very helpful)
http://www.ncbi.nlm.nih.gov/pubmed/17427099
(another longer-term study showing substantial benefits from psychotherapy)
It is important to note that many with so-called "borderline personality" may have depression or other problems at the same time, and each of these problems may improve with specific types of therapy. Many studies are not considering these "comorbid" conditions, and therefore underestimate the effectiveness of various types of therapy.
Here is a link to a dialectical-behavior therapy self-help site:
http://www.dbtselfhelp.com/index.html
Monday, January 5, 2009
Transcendental Meditation for ADHD
Today I encountered an interesting article in the journal
Current Issues in Education, Volume 10, No. 2, 2008
It is about teaching a meditation technique ("transcendental meditation") to children with ADHD, and measuring changes in their symptoms over time. The study shows a significant beneficial effect in numerous symptom clusters, including anxiety and mood.
Some of the authors appear to have good backgrounds in research and scholarship.
Looking up a different author, and checking out some of the other stuff on the internet about TM made me concerned about the level of religious dogma in this area, bolstered by numerous claims (many of which I think are overvalued) about "scientific evidence", also with many claims about TM being part of something morally advanced, yet I note various registered trademarks among the jargon used, together with an insistence that one has to learn the technique from a specially-trained instructor, and an insistence that one cannot learn the technique in other ways. One would think that a purely altruistic set of motives would lead to such ideas being shared more freely and humbly.
The study is substantially weakened by the fact that there is no "placebo control group", hence the findings likely exaggerate the specific benefit of TM (it may be possible, for example, that any other quiet technique taught to children for 10 minutes twice a day, might have led to symptom improvements).
But it is my hunch that meditative techniques can be helpful to improve contentment, and to reduce negative symptoms, for many people. Also, I do agree with the authors' point in this article, that there are different types of meditation, and that some types suit people better than others. Some of my patients have tried meditating, and found it unhelpful. It may be worthwhile in these cases to give a different style of meditating a try. TM apparently does not aim for "mental control"--and therefore it may be more suited for people whose minds and thoughts are hard to "control". "Control" as a meditative goal may just lead to frustration.
And I do--with some reservation--agree that having a meditation teacher or class may be necessary to learn the technique optimally, just like learning to swim or play the violin may require a teacher or class. Yet, I think it is fair to make use of other resources, including books and the internet. I am always wary of salesmanship or charlatanism in these areas, where people are charging a substantial fee while using various elements of persuasion to get you to sign up for something.
Another big area in meditation for treating psychiatric or medical problems is so-called "mindfulness-based meditation". There is an accumulating evidence base for this, and I encourage people to learn more about it. Interestingly, one of the pioneers in using these techniques in medicine first used it for successfully treating chronic physical pain.
I will be on the lookout for other pieces of objective evidence on this issue, as I find meditation interesting, probably beneficial, and at least harmless, provided the practice doesn't lead someone to be swept into some kind of cult-like subculture. I would agree with the statement that if everyone quietly meditated daily in some way, we would probably have a fair bit less violence and conflict in the world.
Current Issues in Education, Volume 10, No. 2, 2008
It is about teaching a meditation technique ("transcendental meditation") to children with ADHD, and measuring changes in their symptoms over time. The study shows a significant beneficial effect in numerous symptom clusters, including anxiety and mood.
Some of the authors appear to have good backgrounds in research and scholarship.
Looking up a different author, and checking out some of the other stuff on the internet about TM made me concerned about the level of religious dogma in this area, bolstered by numerous claims (many of which I think are overvalued) about "scientific evidence", also with many claims about TM being part of something morally advanced, yet I note various registered trademarks among the jargon used, together with an insistence that one has to learn the technique from a specially-trained instructor, and an insistence that one cannot learn the technique in other ways. One would think that a purely altruistic set of motives would lead to such ideas being shared more freely and humbly.
The study is substantially weakened by the fact that there is no "placebo control group", hence the findings likely exaggerate the specific benefit of TM (it may be possible, for example, that any other quiet technique taught to children for 10 minutes twice a day, might have led to symptom improvements).
But it is my hunch that meditative techniques can be helpful to improve contentment, and to reduce negative symptoms, for many people. Also, I do agree with the authors' point in this article, that there are different types of meditation, and that some types suit people better than others. Some of my patients have tried meditating, and found it unhelpful. It may be worthwhile in these cases to give a different style of meditating a try. TM apparently does not aim for "mental control"--and therefore it may be more suited for people whose minds and thoughts are hard to "control". "Control" as a meditative goal may just lead to frustration.
And I do--with some reservation--agree that having a meditation teacher or class may be necessary to learn the technique optimally, just like learning to swim or play the violin may require a teacher or class. Yet, I think it is fair to make use of other resources, including books and the internet. I am always wary of salesmanship or charlatanism in these areas, where people are charging a substantial fee while using various elements of persuasion to get you to sign up for something.
Another big area in meditation for treating psychiatric or medical problems is so-called "mindfulness-based meditation". There is an accumulating evidence base for this, and I encourage people to learn more about it. Interestingly, one of the pioneers in using these techniques in medicine first used it for successfully treating chronic physical pain.
I will be on the lookout for other pieces of objective evidence on this issue, as I find meditation interesting, probably beneficial, and at least harmless, provided the practice doesn't lead someone to be swept into some kind of cult-like subculture. I would agree with the statement that if everyone quietly meditated daily in some way, we would probably have a fair bit less violence and conflict in the world.
Wednesday, December 17, 2008
Social Learning Therapy
Here's another style of therapy probably under-utilized:
This is based on Bandura's work on social learning theory and self-efficacy.
The best examples along this line involve the treatment of phobias. Many approaches to phobias involve graded exposure (i.e. practicing the feared activities), cognitive therapy (examining and challenging thoughts which are associated with the fears), relaxation training, and medication (sedatives and antidepressants).
A neglected but extremely important component of therapy for phobias includes a social learning, or social modeling approach.
For example, a person afraid to swim would simply watch others swim, as a component of treating the fear. But, of course, this could just lead to the frightened person feeling left out, and heighten the sense of alienation or futility. A more effective social modeling experience would be for the person with the phobia to watch OTHER people with the same phobias learning successfully to swim. This could start off with watching videos, and move on to working directly with other people. It may not be convincing evidence that swimming phobia can be overcome just by watching a bunch of swimmers; but it may well be much more convincing evidence to watch other FEARFUL swimmers successfully learn.
If we see someone we feel is similar to ourselves do a difficult task successfully, we are more likely to be able to try or do that task.
I think this is one of the advantages of group therapy, provided there are abundant examples of individuals in the group who are beginning to cope well with their problem. Social modeling of this sort is a particular strength of 12-step groups, where individuals can see others struggling, sometimes slipping back, but finally succeeding, in a way that they can relate to and see themselves in.
Here are a few links to some sites dealing with Bandura's theories:
http://www.stanford.edu/dept/bingschool/rsrchart/bandura.htm
(this link summarizes some of Bandura's opinions about the influence of media violence, etc. on children's behaviour -- an important subject which could be generalized in many ways)
http://www.des.emory.edu/mfp/bandurabio.html
(a nice biographical sketch of Bandura and his ideas)
An introductory experience to something like a social learning therapy approach could involve looking at videos or documentaries showing individuals struggling with and resolving longstanding mental illnesses. This could be a source of inspiration, motivation, and hope. I would like to find some examples of documentaries of this type; if any readers are aware of good examples, please let me know.
I've just found one site that has a few videos (actually the site seems pretty mediocre to me, but I can't find a lot of other better stuff right now); I think the most pertinent videos to look at from here are in the "programmes" section and would be the case studies on page 3 about phobias (you have to log in to this site as a guest to get into the videos):
http://www.mentalhealth.tv/index.php?mod=page&page=Home
This is based on Bandura's work on social learning theory and self-efficacy.
The best examples along this line involve the treatment of phobias. Many approaches to phobias involve graded exposure (i.e. practicing the feared activities), cognitive therapy (examining and challenging thoughts which are associated with the fears), relaxation training, and medication (sedatives and antidepressants).
A neglected but extremely important component of therapy for phobias includes a social learning, or social modeling approach.
For example, a person afraid to swim would simply watch others swim, as a component of treating the fear. But, of course, this could just lead to the frightened person feeling left out, and heighten the sense of alienation or futility. A more effective social modeling experience would be for the person with the phobia to watch OTHER people with the same phobias learning successfully to swim. This could start off with watching videos, and move on to working directly with other people. It may not be convincing evidence that swimming phobia can be overcome just by watching a bunch of swimmers; but it may well be much more convincing evidence to watch other FEARFUL swimmers successfully learn.
If we see someone we feel is similar to ourselves do a difficult task successfully, we are more likely to be able to try or do that task.
I think this is one of the advantages of group therapy, provided there are abundant examples of individuals in the group who are beginning to cope well with their problem. Social modeling of this sort is a particular strength of 12-step groups, where individuals can see others struggling, sometimes slipping back, but finally succeeding, in a way that they can relate to and see themselves in.
Here are a few links to some sites dealing with Bandura's theories:
http://www.stanford.edu/dept/bingschool/rsrchart/bandura.htm
(this link summarizes some of Bandura's opinions about the influence of media violence, etc. on children's behaviour -- an important subject which could be generalized in many ways)
http://www.des.emory.edu/mfp/bandurabio.html
(a nice biographical sketch of Bandura and his ideas)
An introductory experience to something like a social learning therapy approach could involve looking at videos or documentaries showing individuals struggling with and resolving longstanding mental illnesses. This could be a source of inspiration, motivation, and hope. I would like to find some examples of documentaries of this type; if any readers are aware of good examples, please let me know.
I've just found one site that has a few videos (actually the site seems pretty mediocre to me, but I can't find a lot of other better stuff right now); I think the most pertinent videos to look at from here are in the "programmes" section and would be the case studies on page 3 about phobias (you have to log in to this site as a guest to get into the videos):
http://www.mentalhealth.tv/index.php?mod=page&page=Home
Relaxation Training
Here's another example of a therapy style that is probably under-emphasized.
Relaxation techniques are simple, straightforward, and intuitive. There is evidence that they work; here is a reference to a Cochrane review on relaxation techniques for treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/18843744
As with most any other strategy to deal with psychological symptoms, I do believe that a lot of practice is required.
Many people abandon relaxation techniques because they do not work when they try them. I encourage persistence--it could take months of daily practice for these skills to become more effective, effortless, and automatic.
There are different styles of relaxation training out there, and I encourage people to do a bit of research, and try a few different types. There are self-help books on the subject, as well as audio CDs and videos. Joining a group or taking a course can be a good way to learn and practice as well.
The beauty of relaxation therapy is that there is no risk of harm, it is side-effect free. However, some people with panic or psychotic symptoms can feel uncomfortable with certain types of relaxation experiences. If this happens, I think it is a technical problem to work around, rather than necessarily a reason to abandon the technique altogether.
Relaxation techniques are simple, straightforward, and intuitive. There is evidence that they work; here is a reference to a Cochrane review on relaxation techniques for treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/18843744
As with most any other strategy to deal with psychological symptoms, I do believe that a lot of practice is required.
Many people abandon relaxation techniques because they do not work when they try them. I encourage persistence--it could take months of daily practice for these skills to become more effective, effortless, and automatic.
There are different styles of relaxation training out there, and I encourage people to do a bit of research, and try a few different types. There are self-help books on the subject, as well as audio CDs and videos. Joining a group or taking a course can be a good way to learn and practice as well.
The beauty of relaxation therapy is that there is no risk of harm, it is side-effect free. However, some people with panic or psychotic symptoms can feel uncomfortable with certain types of relaxation experiences. If this happens, I think it is a technical problem to work around, rather than necessarily a reason to abandon the technique altogether.
Friday, November 14, 2008
Love
The ancient Greeks described three different forms of love:
1) Eros -- sensual desire; attraction and appreciation of beauty; passion
--In describing eros we need not assume that it only refers to sexual passion; I think there is a component of the "erotic"-- in a broad metaphorical sense--in all moments of life, all motivations, all experiences of beauty in all its forms--
2) Philia -- virtuous, loyal, attachment between friends or family members; dispassionate but balanced, stable, reciprocal, equal.
3) Agape -- this term was adopted by early Christian theologians, referring to unconditional, giving, selfless love for all. In this type of theological view, agape was felt to be the feeling of the divine towards humankind. Psychiatrically I might say that agape was a projection of a feeling onto the projected character of "God" that fit with an idealized philosophy of life which was prescribed by religious leaders to the rest of the community.
I have to wonder if the "agape" idea was a bit of a defensive construct, since people with conservative religious beliefs or values might not want to be using a "love" term associated with eroticism or sexuality in their description of the divine, or in a prescription for ideal behaviour to espouse.
--since I am neither a scholar in Greek, nor well-versed in theological debate, I recognize that my above introduction may contain inaccuracies--
I do think love is one of the great joys of life, a requirement for happiness, a requirement for life itself to continue. A life without love can be intolerable.
But many of the experiences of love can lead to exquisite suffering. Love can be unrequited. Love can lead to obsession and despair. Love can fade and disappear. Love sometimes can throw off our judgment.
I do think that love is an ingredient of the psychotherapy experience. The struggle with "love problems" is one of the most frequent themes bringing people to psychotherapy.
If love occurs between patient & therapist, this love exists within the boundary of the therapeutic frame. Actions associated with this love--according to the rules of psychotherapy--take place through dialog. Actions outside of dialog (such as gift-giving, etc.) may or may not be allowed within the therapeutic frame, but if they do occur certainly would require careful attention or discussion through dialog. In many cases I feel that to reject a gift would be akin to rejecting a handshake--at times it could be humiliating--and that it may sometimes be part of the development of a healthy relationship to permit gifts in psychotherapy. I realize that many of my colleagues would disagree with me (all kinds of talk about boundaries would arise, I'm sure). I do realize that accepting gifts could give rise to a variety of problems in some cases (e.g. anger at generosity not perceived to be reciprocated, or gift-giving "getting out of hand" with more and more financial expense involved, etc.); in some cases I will gently let people know that their presence is a gift, and that other types of gifts can't be something I can accept. Gift-giving can be a much subtler theme, as many times patients may "try harder" in their therapy as a gift to the therapist, etc. Such gifts should not be rejected, yet of course it is important therapeutically to understand this motive, and to find ways to expand the range of motivations for "trying harder".
I affirm strongly that I have--and aspire to maintain-- a feeling of agape towards my work as a psychiatrist, and towards all of my patients.
I feel it is important to convey this positive feeling directly at times, and that it is often a fear of impropriety, or of boundary-crossing, etc. that prevents many therapists from openly pronouncing positive regard for their patients. As a community of therapists, I think this fear stems in part from recognition of many disturbing examples of boundary-crossing behaviour(e.g. therapists having affairs with patients, often with components of exploitativeness, and often causing complex harmful consequences for the patients). Or some therapists may have been taught to believe that the therapist should not "meet a patient's dependency need" but should rather interpret such a need, or help problem-solve around it, to help the patient meet that need outside of the therapy. Well, in many cases I feel that depriving a patient -- in this case, let's use totally frank language: depriving a patient of love -- is merely a tactic that keeps the therapy less personal, more frustrating, and less helpful. Also it fosters greater detachment in therapists, which I think fuels a broader phenomenon of therapists not really enjoying their work, leading to increased cynicism, less appreciation for the beauty and potential of their patients.
I believe all three types of love exist in every human dynamic, in some mixture. This is normal and healthy, a fact of life. This includes patient-therapist interaction. Yet these other varieties of love dynamics may only colour the dialog or the narrative in a therapy setting, they cannot cause the therapeutic frame to change.
Having said this, I think that in many cases, the patient-therapist relationship is much more distant. It can be like the relationship between "homeowner & electrician" or "shopper and retail clerk". This kind of distance may work just fine, the therapy itself doesn't have to be a specific setting to work out "love problems". The therapy may simply be about obtaining advice to relieve a symptom.
There are some cases -- such as in patients who have a history of dangerous interpersonal behaviour, or in cases of psychosis which may involve the therapist in a delusional system -- where the therapeutic relationship has to be much more distant. It is still not without agape though. A truly loveless relationship cannot be of much help; in situations like this it is often necessary to refer the patient to a different therapist.
In some cases, the therapy itself becomes a setting to "work through" love problems, and the love dynamics present in non-therapeutic life may show up in the therapy itself. In the psychoanalytic community, this would tend to be called "transference". The idea of transference is extremely important, since feelings or dynamics in a person's personal or past life may very well appear in the therapy, towards the therapist, and this phenomenon may epitomize a recurrent relational problem in the patient's life. Yet the term "transference" may also be part of a defensive language on the part of the therapist, to negate "true" feelings which may exist between patient and therapist. So I feel that both "transferential" and "non-transferential" feelings can be present, may be something to acknowledge--and sometimes to affirm--in the therapy, provided the boundaries are clear and consistent.
The world needs to devote more of its energy and resources to solving its "love problems", and to celebrating its many examples of powerful, healing, healthy love.
1) Eros -- sensual desire; attraction and appreciation of beauty; passion
--In describing eros we need not assume that it only refers to sexual passion; I think there is a component of the "erotic"-- in a broad metaphorical sense--in all moments of life, all motivations, all experiences of beauty in all its forms--
2) Philia -- virtuous, loyal, attachment between friends or family members; dispassionate but balanced, stable, reciprocal, equal.
3) Agape -- this term was adopted by early Christian theologians, referring to unconditional, giving, selfless love for all. In this type of theological view, agape was felt to be the feeling of the divine towards humankind. Psychiatrically I might say that agape was a projection of a feeling onto the projected character of "God" that fit with an idealized philosophy of life which was prescribed by religious leaders to the rest of the community.
I have to wonder if the "agape" idea was a bit of a defensive construct, since people with conservative religious beliefs or values might not want to be using a "love" term associated with eroticism or sexuality in their description of the divine, or in a prescription for ideal behaviour to espouse.
--since I am neither a scholar in Greek, nor well-versed in theological debate, I recognize that my above introduction may contain inaccuracies--
I do think love is one of the great joys of life, a requirement for happiness, a requirement for life itself to continue. A life without love can be intolerable.
But many of the experiences of love can lead to exquisite suffering. Love can be unrequited. Love can lead to obsession and despair. Love can fade and disappear. Love sometimes can throw off our judgment.
I do think that love is an ingredient of the psychotherapy experience. The struggle with "love problems" is one of the most frequent themes bringing people to psychotherapy.
If love occurs between patient & therapist, this love exists within the boundary of the therapeutic frame. Actions associated with this love--according to the rules of psychotherapy--take place through dialog. Actions outside of dialog (such as gift-giving, etc.) may or may not be allowed within the therapeutic frame, but if they do occur certainly would require careful attention or discussion through dialog. In many cases I feel that to reject a gift would be akin to rejecting a handshake--at times it could be humiliating--and that it may sometimes be part of the development of a healthy relationship to permit gifts in psychotherapy. I realize that many of my colleagues would disagree with me (all kinds of talk about boundaries would arise, I'm sure). I do realize that accepting gifts could give rise to a variety of problems in some cases (e.g. anger at generosity not perceived to be reciprocated, or gift-giving "getting out of hand" with more and more financial expense involved, etc.); in some cases I will gently let people know that their presence is a gift, and that other types of gifts can't be something I can accept. Gift-giving can be a much subtler theme, as many times patients may "try harder" in their therapy as a gift to the therapist, etc. Such gifts should not be rejected, yet of course it is important therapeutically to understand this motive, and to find ways to expand the range of motivations for "trying harder".
I affirm strongly that I have--and aspire to maintain-- a feeling of agape towards my work as a psychiatrist, and towards all of my patients.
I feel it is important to convey this positive feeling directly at times, and that it is often a fear of impropriety, or of boundary-crossing, etc. that prevents many therapists from openly pronouncing positive regard for their patients. As a community of therapists, I think this fear stems in part from recognition of many disturbing examples of boundary-crossing behaviour(e.g. therapists having affairs with patients, often with components of exploitativeness, and often causing complex harmful consequences for the patients). Or some therapists may have been taught to believe that the therapist should not "meet a patient's dependency need" but should rather interpret such a need, or help problem-solve around it, to help the patient meet that need outside of the therapy. Well, in many cases I feel that depriving a patient -- in this case, let's use totally frank language: depriving a patient of love -- is merely a tactic that keeps the therapy less personal, more frustrating, and less helpful. Also it fosters greater detachment in therapists, which I think fuels a broader phenomenon of therapists not really enjoying their work, leading to increased cynicism, less appreciation for the beauty and potential of their patients.
I believe all three types of love exist in every human dynamic, in some mixture. This is normal and healthy, a fact of life. This includes patient-therapist interaction. Yet these other varieties of love dynamics may only colour the dialog or the narrative in a therapy setting, they cannot cause the therapeutic frame to change.
Having said this, I think that in many cases, the patient-therapist relationship is much more distant. It can be like the relationship between "homeowner & electrician" or "shopper and retail clerk". This kind of distance may work just fine, the therapy itself doesn't have to be a specific setting to work out "love problems". The therapy may simply be about obtaining advice to relieve a symptom.
There are some cases -- such as in patients who have a history of dangerous interpersonal behaviour, or in cases of psychosis which may involve the therapist in a delusional system -- where the therapeutic relationship has to be much more distant. It is still not without agape though. A truly loveless relationship cannot be of much help; in situations like this it is often necessary to refer the patient to a different therapist.
In some cases, the therapy itself becomes a setting to "work through" love problems, and the love dynamics present in non-therapeutic life may show up in the therapy itself. In the psychoanalytic community, this would tend to be called "transference". The idea of transference is extremely important, since feelings or dynamics in a person's personal or past life may very well appear in the therapy, towards the therapist, and this phenomenon may epitomize a recurrent relational problem in the patient's life. Yet the term "transference" may also be part of a defensive language on the part of the therapist, to negate "true" feelings which may exist between patient and therapist. So I feel that both "transferential" and "non-transferential" feelings can be present, may be something to acknowledge--and sometimes to affirm--in the therapy, provided the boundaries are clear and consistent.
The world needs to devote more of its energy and resources to solving its "love problems", and to celebrating its many examples of powerful, healing, healthy love.
Tuesday, November 4, 2008
Laughter
It is therapeutic to laugh. Humour is therapeutic.
Laughter can be practiced deliberately, and it is probably very healthy to do so.
Humour is important in psychotherapy as well. Psychotherapy need not always be serious, grave, or have an air of hard work or formality. But of course, it would be important for any humour initiated by a therapist to be gentle, sensitive, careful, and not excessive.
Here are a few links to references about laughter & humour in health & psychotherapy:
http://www.ncbi.nlm.nih.gov/pubmed/17464660
http://www.ncbi.nlm.nih.gov/pubmed/8307702
Here's a link to the website for the "Association for Applied and Therapeutic Humor"--it contains a lot of links to other interesting and funny sites (the fact that there is an association with this title is itself funny to me):
http://www.aath.org/ezine/index.html
Another relevant link:
http://www.helpguide.org/life/humor_laughter_health.htm
Laughter can be practiced deliberately, and it is probably very healthy to do so.
Humour is important in psychotherapy as well. Psychotherapy need not always be serious, grave, or have an air of hard work or formality. But of course, it would be important for any humour initiated by a therapist to be gentle, sensitive, careful, and not excessive.
Here are a few links to references about laughter & humour in health & psychotherapy:
http://www.ncbi.nlm.nih.gov/pubmed/17464660
http://www.ncbi.nlm.nih.gov/pubmed/8307702
Here's a link to the website for the "Association for Applied and Therapeutic Humor"--it contains a lot of links to other interesting and funny sites (the fact that there is an association with this title is itself funny to me):
http://www.aath.org/ezine/index.html
Another relevant link:
http://www.helpguide.org/life/humor_laughter_health.htm
Pets are Therapeutic
It can be beneficial for mental and physical health to have a pet, for the following reasons:
1) pets offer companionship, and therefore may help people to cope with loneliness. At times I have seen relationships with pets be strong protective factors against suicide.
2) many pets, particularly dogs, may help their owners get outside regularly for exercise
3) dogs in particular may act as social catalysts, making it more likely to meet and converse with new people (this could happen while dog-walking).
4) the requirements of caring for a pet may add some structure and an external focus to daily activities, which can be healthy
For some people, having a pet can be more problematic, particularly if it is not possible, for health or economic reasons, to care for the pet adequately. And some people may have pets for unhealthy reasons (e.g. acquiring a large, vicious dog, encouraging its aggressiveness, or failing to train it adequately for safety).
The evidence on health benefits from pet ownership is actually a bit weak. I think part of this is due to inadequate studies on the subject. Also, in order for a pet to have a healthy emotional effect, there would have to be a good "match" between pet & owner, and adequate support for a healthy relationship to develop. Just as in human-human relationships, some people may choose a type of relationship that is not healthy or sustainable for them.
Here's a link to a review on pet ownership and human health:
http://www.ncbi.nlm.nih.gov/pubmed/16308387
Contact with animals can be therapeutic in other ways. There is a lot of anecdotal evidence about the merits of therapy animals. Dogs and cats are examples, but so are large animals such as horses.
Here are references to papers describing the benefits of "animal assisted therapy" with larger animals:
http://www.ncbi.nlm.nih.gov/pubmed/17444990
http://www.ncbi.nlm.nih.gov/pubmed/18405352
Here are some references about the benefits of therapy dogs:
http://www.ncbi.nlm.nih.gov/pubmed/17714002
http://www.ncbi.nlm.nih.gov/pubmed/15293482
I could not find very much in the research literature about "therapy cats"--but I think having a pet cat can be therapeutic.
1) pets offer companionship, and therefore may help people to cope with loneliness. At times I have seen relationships with pets be strong protective factors against suicide.
2) many pets, particularly dogs, may help their owners get outside regularly for exercise
3) dogs in particular may act as social catalysts, making it more likely to meet and converse with new people (this could happen while dog-walking).
4) the requirements of caring for a pet may add some structure and an external focus to daily activities, which can be healthy
For some people, having a pet can be more problematic, particularly if it is not possible, for health or economic reasons, to care for the pet adequately. And some people may have pets for unhealthy reasons (e.g. acquiring a large, vicious dog, encouraging its aggressiveness, or failing to train it adequately for safety).
The evidence on health benefits from pet ownership is actually a bit weak. I think part of this is due to inadequate studies on the subject. Also, in order for a pet to have a healthy emotional effect, there would have to be a good "match" between pet & owner, and adequate support for a healthy relationship to develop. Just as in human-human relationships, some people may choose a type of relationship that is not healthy or sustainable for them.
Here's a link to a review on pet ownership and human health:
http://www.ncbi.nlm.nih.gov/pubmed/16308387
Contact with animals can be therapeutic in other ways. There is a lot of anecdotal evidence about the merits of therapy animals. Dogs and cats are examples, but so are large animals such as horses.
Here are references to papers describing the benefits of "animal assisted therapy" with larger animals:
http://www.ncbi.nlm.nih.gov/pubmed/17444990
http://www.ncbi.nlm.nih.gov/pubmed/18405352
Here are some references about the benefits of therapy dogs:
http://www.ncbi.nlm.nih.gov/pubmed/17714002
http://www.ncbi.nlm.nih.gov/pubmed/15293482
I could not find very much in the research literature about "therapy cats"--but I think having a pet cat can be therapeutic.
Sunday, November 2, 2008
How to make friends
There are many reasons why a person could have trouble making friends; here are a few:
1) shyness (social anxiety)
2) depression (with resulting lack of energy & motivation)
3) difficulty with social skills (in initiating contact or communication with new people, with continuing on after an introductory contact, or with maintaining healthy ongoing friendships)
4) difficulty finding a community of accepting peers, despite having addressed other factors, such as #1-3 above. So, for example, a person with a particular lifestyle or cultural interest may not be able to find many people with whom to share this in the local community.
5) sometimes there may be qualities about a person's behaviour that cause others not to want a friendship (e.g. recurring temper tantrums or other overt manifestations of hostility).
6) lack of time, energy, or money
Here are some ways to address the problem of making friends:
1) treat shyness. Pharmacologically and psychotherapeutically. Strong effort needs to be spent on practicing cognitive-behavioural techniques. I encourage all who believe they may be shy to start by reading some of the many books on the subject of shyness.
2) treat depression
3) Learn about social skills. This can start with reading. A therapy group of almost any sort can be a good resource. Psychotherapy can be a setting to practice social skills. Other activities can be great places to practice, such as taking a class, joining a group, Toastmaster's, etc. Skills have to be practiced. The skills need to be practiced in all three domains (initiating communication with new people, continuing on to the next step following an introduction, and maintaining ongoing positive communication and activity within existing friendships).
4) Identify individual lifestyle and cultural interests, and deliberately seek out groups that can share in this (for example, regarding music, the arts, orientation/identity issues, hobbies, sports). Be willing to at least slightly expand your horizons of cultural interest & involvement. If you have a healthy solitary interest, try to make it a healthy group interest.
5) Identify factors within oneself that may make it hard for someone to befriend you (e.g. temper problems, refusal to allow closeness, etc.) Be very honest with yourself about this. The gentle feedback or support from a therapist can help. It needs to be emphasized, though, that in a depressed state, many people believe they are unattractive for a variety of reasons, and this type of thinking about self can be a symptom of the depression. If you falsely believe that people don't like you -- for any reason -- then your social actions may lead you to become more isolated and alone.
6) Time, energy, and money may need to be set aside, to allow for the development of a social life. There are many community resources that are free, or that may specifically welcome and try to help those in economic need. Maybe your community does not have enough of these types of resources--if this is the case I hope there is the possibility that you can find a different community that does have enough.
In today's world, we of course have access to "virtual communities" and other types of relationship-building that can be done on the internet. I think the internet is a powerful resource, and can be very helpful for making friends, or practicing social skills. But the medium of the internet can itself be addictive, so this needs to be watched for. Some people may spend so much time on internet relationship sites that their non-internet relationship life may be shrinking rather than growing.
A brief google search on the internet with the name of your city or town plus "social networking" or "meetup" may yield a variety of possible real-life social groups to consider joining, some of them geared towards simple friendship, others may be oriented towards a particular activity, others especially for people who are shy, etc.
Here are some of the explanations people have given me about their difficulty making friends:
1) "I'm not attractive enough"
2) "This city is unfriendly"
3) "I can't be bothered"
4) "It's not worth the risk"
5) "I'm too busy"
6) "I'd rather be alone"
7) "I would be/am a burden on other people"
All of these explanations need to be addressed and challenged.
1) Beliefs about unattractiveness are a powerful social obstacle, because they cause the person who feels unattractive to withdraw, assume in advance that others don't like them, etc. Also a belief about innate unattractiveness can cause a person to be resigned to this false belief, such that actual esthetic enjoyments--including superficial but important things such as choice of attire, "spa treatments", etc.--may be unnecessarily avoided
2) While it may well be true that certain cultures or parts of the world have more or less social opportunities and a more or less socially engaging style, I find most complaints about the "unfriendly city" to be projections of one's own social frustrations onto the fairly neutral ground of the geographic city. I would encourage people to do what they can, with an open heart and mind, right where they are geographically, rather than contemplate a move right away to some supposedly more friendly place.
3 - 5) Friendship-building requires energy, and can be frustrating. There is a component of risk, at the very least of being disappointed. I stand by the advice that friendship-building is a necessary health activity for everyone, as is daily exercise of some sort. So it is necessary for your health to bother with it.
6) We all require solitude. Some of us are most comfortable alone. Many of us desire more closeness or intimacy, but have become resigned, such that we tolerate having very little. It can be a symptom of depression to become more and more isolated. Isolative resignation is a problem that needs to be worked on in the treatment of depression.
7) Belief in being a burden is another depressive assumption, just like feeling unattractive. It is time to let go of this kind of belief. Every relationship does require give and take, though, and it can be part of the process of practicing social/relationship skills to be observant of the general balance in your friendships, so that no one feels that the relationships are one-sided.
1) shyness (social anxiety)
2) depression (with resulting lack of energy & motivation)
3) difficulty with social skills (in initiating contact or communication with new people, with continuing on after an introductory contact, or with maintaining healthy ongoing friendships)
4) difficulty finding a community of accepting peers, despite having addressed other factors, such as #1-3 above. So, for example, a person with a particular lifestyle or cultural interest may not be able to find many people with whom to share this in the local community.
5) sometimes there may be qualities about a person's behaviour that cause others not to want a friendship (e.g. recurring temper tantrums or other overt manifestations of hostility).
6) lack of time, energy, or money
Here are some ways to address the problem of making friends:
1) treat shyness. Pharmacologically and psychotherapeutically. Strong effort needs to be spent on practicing cognitive-behavioural techniques. I encourage all who believe they may be shy to start by reading some of the many books on the subject of shyness.
2) treat depression
3) Learn about social skills. This can start with reading. A therapy group of almost any sort can be a good resource. Psychotherapy can be a setting to practice social skills. Other activities can be great places to practice, such as taking a class, joining a group, Toastmaster's, etc. Skills have to be practiced. The skills need to be practiced in all three domains (initiating communication with new people, continuing on to the next step following an introduction, and maintaining ongoing positive communication and activity within existing friendships).
4) Identify individual lifestyle and cultural interests, and deliberately seek out groups that can share in this (for example, regarding music, the arts, orientation/identity issues, hobbies, sports). Be willing to at least slightly expand your horizons of cultural interest & involvement. If you have a healthy solitary interest, try to make it a healthy group interest.
5) Identify factors within oneself that may make it hard for someone to befriend you (e.g. temper problems, refusal to allow closeness, etc.) Be very honest with yourself about this. The gentle feedback or support from a therapist can help. It needs to be emphasized, though, that in a depressed state, many people believe they are unattractive for a variety of reasons, and this type of thinking about self can be a symptom of the depression. If you falsely believe that people don't like you -- for any reason -- then your social actions may lead you to become more isolated and alone.
6) Time, energy, and money may need to be set aside, to allow for the development of a social life. There are many community resources that are free, or that may specifically welcome and try to help those in economic need. Maybe your community does not have enough of these types of resources--if this is the case I hope there is the possibility that you can find a different community that does have enough.
In today's world, we of course have access to "virtual communities" and other types of relationship-building that can be done on the internet. I think the internet is a powerful resource, and can be very helpful for making friends, or practicing social skills. But the medium of the internet can itself be addictive, so this needs to be watched for. Some people may spend so much time on internet relationship sites that their non-internet relationship life may be shrinking rather than growing.
A brief google search on the internet with the name of your city or town plus "social networking" or "meetup" may yield a variety of possible real-life social groups to consider joining, some of them geared towards simple friendship, others may be oriented towards a particular activity, others especially for people who are shy, etc.
Here are some of the explanations people have given me about their difficulty making friends:
1) "I'm not attractive enough"
2) "This city is unfriendly"
3) "I can't be bothered"
4) "It's not worth the risk"
5) "I'm too busy"
6) "I'd rather be alone"
7) "I would be/am a burden on other people"
All of these explanations need to be addressed and challenged.
1) Beliefs about unattractiveness are a powerful social obstacle, because they cause the person who feels unattractive to withdraw, assume in advance that others don't like them, etc. Also a belief about innate unattractiveness can cause a person to be resigned to this false belief, such that actual esthetic enjoyments--including superficial but important things such as choice of attire, "spa treatments", etc.--may be unnecessarily avoided
2) While it may well be true that certain cultures or parts of the world have more or less social opportunities and a more or less socially engaging style, I find most complaints about the "unfriendly city" to be projections of one's own social frustrations onto the fairly neutral ground of the geographic city. I would encourage people to do what they can, with an open heart and mind, right where they are geographically, rather than contemplate a move right away to some supposedly more friendly place.
3 - 5) Friendship-building requires energy, and can be frustrating. There is a component of risk, at the very least of being disappointed. I stand by the advice that friendship-building is a necessary health activity for everyone, as is daily exercise of some sort. So it is necessary for your health to bother with it.
6) We all require solitude. Some of us are most comfortable alone. Many of us desire more closeness or intimacy, but have become resigned, such that we tolerate having very little. It can be a symptom of depression to become more and more isolated. Isolative resignation is a problem that needs to be worked on in the treatment of depression.
7) Belief in being a burden is another depressive assumption, just like feeling unattractive. It is time to let go of this kind of belief. Every relationship does require give and take, though, and it can be part of the process of practicing social/relationship skills to be observant of the general balance in your friendships, so that no one feels that the relationships are one-sided.
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