Antidepressant + CBT superior to either treatment alone for treating social anxiety

Blanco et al. published this study in the March 2010 issue of Archives of General Psychiatry.  Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/20194829 

Patients with social anxiety were divided into four groups in this randomized prospective 24-week study:  placebo; cognitive behavioural group therapy; phenelzine medication; combined CBT + phenelzine.

CBT was modestly effective, phenelzine only slight more effective, but the combination of CBT + medication was substantially more effective, more or less additively so, particularly in terms of total remission rates.  There was a very low placebo response.

Findings of this type are not surprising.   An interesting aspect to this particular study is that it makes use of phenelzine, an old MAO inhibitor.  This shows that sometimes these old drugs can still be quite useful.

This study does not necessarily demonstrate that CBT is the only form of psychotherapy which would work adjunctively to help social anxiety.  I do think that components of CBT, such as emphasizing exposure to anxiety-provoking situations, and practicing social initiatives in a systematic way, are necessary.  But, other forms of psychotherapy might adjunctively help the CBT to work better!  

Self-help books

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

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

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

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

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

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

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

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

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

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

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

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

Non-human Primate Models of Psychiatric Treatment Effects

Before starting the main body of my post, here's a little introduction:

I've been doing quite a bit of reading lately about the history of psychiatry (in particular, an excellent book by Lisa Appignanesi; I'll write a post about it when I've finished, which could be in a while, since the book is 5 cm thick!). Also I've been reading about cultural psychology (another very interesting field), after finding a free set of university lecture notes published online. I'd like to write another post about this subject as well, when I get around to it.

What does this have to do with "non-human primate models of psychiatric treatment effects?" Well, I'm becoming more strongly aware of the powerful effects of culture upon the manifestations of psychological (and, possibly, physical) health and distress. The book I'm reading deals with cultural change through history; these changes have influenced the presentation, management, and course of many psychiatric phenomena. Even terms like "psychiatric phenomena" or "symptoms," etc. are culturally influenced jargon. The cultural psychology subject also deals, of course, with cultural differences, but in this case mainly with the way different groups of people in the present era around the world experience or perceive emotions, psychological distress, social interactions, or cognitive processes. I suspect that cultural differences may exist between families as well, within the same geographical area.

These factors complicate the study of psychiatric therapies, perhaps in many ways that could be subtle but powerful.

I've been interested in finding more evidence about the effect of physical and psychological treatments for psychiatric symptoms in non-human primates. In this case, cultural or personal history biases could be much more carefully controlled.

There are a lot of studies done in rodents, of behavioural therapies and of medication, including a very questionable rodent "model" of antidepressant effectiveness. I think that possible conclusions are much more limited, about human therapies based on research done in mice, etc.

Monkeys or apes are much closer to humans, in terms of genetic similarity and brain structure. They may exhibit behavioural problems that are much more closely analogous to psychiatric symptoms in humans. So, I have been looking for good research about medication and "psychotherapy" effects in primates. Here's a start:

http://www.ncbi.nlm.nih.gov/pubmed/19383215

This 2009 article describes self-injurious behaviour in rhesus macaques. These animals may bite themselves severely; this is thought to be due to an underlying vulnerability combined with social deprivation in infancy or being isolated in captivity. About one-third of macaques experiencing solitary captivity exhibit self-directed stereotypic behaviour. The behaviour is exacerbated by separation from the social group, by disruption of daily routines, or by exposure to a fear-provoking stimulus (for animals, this could be an unfamiliar person trying to interact with them closely). It is interesting to consider that analogous behaviours in humans are probably related to similar vulnerabilities, deprivations, or triggers.

The experiment described in the article is about treating these self-injuring monkeys. Each group started off with 4 weeks of baseline observation, followed by 4 weeks of placebo, before randomization to fluoxetine, venlafaxine, or placebo for the final 4 weeks.

The individuals in the fluoxetine groups, at higher doses in particular, had substantial reductions in self-injurious behaviour (at least 50-75% less self-injury than the placebo group). The venlafaxine group did not improve as much.

There were no changes in "general behaviour" aside from a reduction in "aggressive displays." In particular, there were no signs of sedation or reduced engagement, etc.

I don't mean to make too much of results of this type, but I do think that this is strong evidence that the effect of an SSRI is not simply of an elaborate active placebo, influenced by cultural expectation. Also, just because a symptom is reduced doesn't necessarily mean a problem is solved...however, reducing a problematic behaviour such as self-injury may be a necessary prerequisite to resolving other types of psychological problems.

This type of study would be strengthened if it was extended for a year or more, and if it was to include data about other "quality of life" indicators, such as social integration, longevity, physical health, etc.

Here's another study, showing that tryptophan administration over a 4-week period substantially decreased self-injurious behaviour (again, by 50-75%) in small monkeys. There was also a decrease in previously high levels of cortisol. The dose of tryptophan was over 100 mg/kg per day, which would be a bit inconvenient to administer to humans:
http://www.ncbi.nlm.nih.gov/pubmed/19383216

Here's another study of self-injury in macaques. In this case, housing the animals outdoors led to significant reductions in self-injury. I think the message here could be that a healthy environment which optimizes freedom of movement, space, and natural sensory cues (e.g. of light, sound, and temperature), leads to diminished stress and and diminished symptoms of psychological distress. We could confidently generalize this statement to humans, I think.
http://www.ncbi.nlm.nih.gov/pubmed/16995645

Here is a relevant review on the subject of self-injury in human vs. non-human primates:
http://www.ncbi.nlm.nih.gov/pubmed/16713051

Here's an amusing (and, unfortunately, not very strong) study showing that hearing music leads to increased affiliative behaviour and decreased aggressive behaviour in chimpanzees. There were different degrees of responsiveness to different types of music:
http://www.ncbi.nlm.nih.gov/pubmed/17203919


I'll try to add to this post later. In the "psychotherapy" realm, some of the first important animal studies in primates were done by Harlow. I'm interested to find some more recent stuff in the research literature. I guess there won't be much on cognitive therapy in monkeys, since there is a bit of a problem encouraging non-human primates to keep written diaries with thought records...similarly, psychoanalytic studies are probably in short supply (!) Yet, in all seriousness, I suspect that the key elements for successful therapy in non-human primates involve positive, gentle, consistent relationships; and gentle, non-punitive behavioural education & modeling.

Becoming a "Self Whisperer"

Well, you may accuse me of having sentimental tastes in film, but I really did enjoy the 1998 movie with Robert Redford, called The Horse Whisperer. It's about a reclusive Montana rancher who has an almost mystical ability to gently connect with and rehabilitate horses (and humans?) who are wild, traumatized, or out-of-control.

Since 2002, a dog trainer named Cesar Millan has called himself "the dog whisperer," and has a TV show, website, and has sold millions of books. His approach is basically one of gentle, calm authority: maintaining clear and consistent boundaries without losing one's cool or becoming excessively punitive. Mind you, I see that there is a little bit of debate about some of his techniques. And it's a bit dicey to apply animal training ideas to humans.

Recently, however, people have been trying to generalize these ideas a little bit, to the subject of parenting. Hence the idea of becoming a "child whisperer." Many parents have unhelpful interactions with their children: perhaps there are behavioural or discipline problems, but often times the parents are losing their cool, the parents are resorting to excessive and ineffective punishments, or the parents are giving a lot of praise but without any discipline. Sometimes the timing of praise or discipline is out of synch with the child's behaviour. Some methods of discipline may be harmful to both child and parent. Sometimes misbehaving children seem to be ruling the house, leaving the parents frustrated and exhausted. An exhausted parent in this situation may end up just spending less and less time parenting, in order to find distractions from the problems, or in order to escape. While respite is necessary, this tactic would of course make the parent-child dynamics even worse.

Here's an article from the New York Times on this:
http://www.nytimes.com/2009/11/22/fashion/22dog.html

I would like to generalize this idea one step further, to consider ways to become a "self whisperer."

This may involve nurturing a sense of calm, gentle understanding and authority over the various forces within your own mind:

-in this sense exercises to relax or meditate need not be considered exercises in tolerating an unhealthy state, but rather exercises to produce a stance of calm, loving, gentle authority, which is ideal in "self-whispering."

-part of the process may involve setting very clear boundaries within your own mind, without becoming excessively punitive, bossy, critical, or authoritarian towards aspects of yourself or others. Various therapy styles can help in this sense, including cognitive-behavioural ideas. Methods of non-harmful self-discipline may need to be learned and practiced.

-it can be important to have "respite", but it will be important "to do activities together" with the more challenging aspects of your mind, to be an effective "self whisperer." There needs to be time for reflective, empathic dialog with self, provided there is a benevolent structure, healthy boundaries, and clear safety rules.

--I'll have to edit this posting a bit, I think it's in a formative stage right now, but I thought I'd put it up here as the start of an idea I found enchanting in the moment--

Spread of psychological phenomena in social networks

Here is a link to the abstract of an interesting article by Fowler & Christakis, published in the British Medical Journal in December 2008:
http://www.ncbi.nlm.nih.gov/pubmed/19056788

I think it is a delightful statistical analysis of social networks, based on a cohort of about 5000 people from the Framingham Heart Study, followed over 20 years. This article should really be read in its entirety, in order to appreciate the sophistication of the techniques.

They showed that happiness "spreads" in a manner analogous to contagion. Having happy same-sex friends or neighbours who live nearby, increases one's likelihood of being, or becoming, happy. Interestingly, spouses and coworkers did not have a pronounced effect.

Also, the findings show that having "unhappy" friends does not cause a similar increase in likelihood of being or becoming "unhappy" -- it is happiness, not unhappiness, in the social network, which appears to "spread."

So the message here is not that people should avoid unhappy friends: in fact the message can be that befriending an unhappy person can be helpful not only to that unhappy individual, but to that unhappy person's social network.

There has been some criticism of the authors' techniques, but overall I find the analysis to be very thorough, imaginative, and fascinating.

Here are some practical applications suggested by these findings:

1) sharing positive emotions can have a substantial positive, lasting emotional impact on people near you, including friends and neighbours.
2) nurturing friendships with happier people who live close to you may help to improve subjective happiness
3) this does not mean that friendships with unhappy people have a negative emotional impact, unless all of your friendships are with unhappy people.
4) in the treatment of depression, consideration of the health of social networks can be very important. Here, the "quantity" of the extended social network is not relevant (so the number of "facebook friends" doesn't matter). Rather, the relevant effects are due to the characteristics of the close social network, of 2-6 people or so, particularly those who have close geographic proximity. As I look at the data, I see that having two "happy friends" has a significantly larger positive effect than having only one, but there was not much further effect from having more than two.
5) I have to wonder whether the value of group therapy for depression is diminished if all members of the group are severely depressed. I could see group therapy being much more effective if some of the members were in a recovered, or recovering, state. This reminds me of some of the research about social learning theory (see my previous post: http://garthkroeker.blogspot.com/2008/12/social-learning-therapy.html)
6) on a public health level, the expense involved in treating individual cases of depression should be considered not only on the basis of considering that individual's improved health, function, and well-being, but also on the basis of considering that individual's positive health impact on his or her social network.
7) There is individual variability in social extroversion, or social need. Some individuals prefer a very active social life, others prefer relative social isolation. Others desire social activity, but are isolated or socially anxious. Those who live in relative social isolation might still have a positive reciprocal experience of this social network effect, provided that relationships with people living nearby (such as next-door neighbours or family) are positive.

I should conclude that, despite the strength of the authors' analysis, involving a very large epidemiological cohort, my inferences and proposed applications mentioned above could only really be proven definitively through randomized prospective studies. Yet, such studies would be virtually impossible to do! I think some of the social psychology literature attempts to address this, but I think manages to do so only in a more limited and cross-sectional manner.

Positive Psychology (continued)

This is a response to a reader's comment on my post about positive psychology:
http://garthkroeker.blogspot.com/2009/10/positive-psychotherapy-ppt-for.html

Here's a brief response to some of your points:

1) I don't think there's anything wrong with focusing on pathology or weaknesses. In fact, I consider this type of focus to be essential. Imagine an engineering project in which structural weaknesses or failures were ignored, with a great big smile or a belief that "everything will be fine." Many a disaster has resulted from this kind of approach. I think of the space shuttle disaster, for example.

The insight from positive psychology though, in my opinion, has to do with re-evaluating the balance between a focus on "positivity" vs. pathology.

In depressive states, the cognitive stance is often overwhelmingly critical, about self, world, and future. Even if these views are accurate, they tend to prevent any solution of the problem they describe. It is like an engineering project where the supervisor is so focused on mistakes and criticism that no one can move on, all the workers are tired and demoralized, and perhaps the immediate, relentless focus on errors prevents a different perspective, and a healthy collaboration, which might actually definitively solve the problem.

2) I believe that pronouncements of the "right or wrong" of an emotional or intellectual position are finally up to the individual. It is not for me, or our culture, to judge. There will be all sorts of points of view about the morality or acceptability of any emotional or social stance: some of these points of view will be very critical or judgmental to a given person, some won't. I suppose there are elements of the culture that would harshly judge or criticize someone who appears too "happy": perhaps such a person would be deemed shallow, delusional, uncritical, vain, etc. I prefer to view ideas such as those in "positive psychology" as possible instruments of change, to be tried if a person wishes to try them. CBT, medications, psychoanalysis, surgery, having "negative friends" or "ditching them", etc. are all choices, change behaviours, or ways of managing life, which I think individuals should be free to consider if available, and if legal, but also free to reject if they feel it is not right for them.

In terms of the "gimmicky" nature of positive psychology, I agree. But I think most of the ideas are very simple, and are reflected in other very basic, widely accepted research in biology & behaviour. In widely disparate fields, such as the study of child-rearing, education, coaching, or animal training, it is clear that recognition and criticism of "faults" or "pathologies" is necessary in order for problems to be resolved. Yet the mechanism by which change most optimally occurs is by instilling an atmosphere of warmth, reward, comfort, and joy, with a minority of feedback having to do with criticism. The natural instinct with problematic situations, however, is often to punish. Punishing a child for misbehaviour may at times be necessary, but most times child punishments are excessive and ineffectual, often are more about the emotional state of the punisher rather than the behavioural state of the child, and ironically may reinforce the problems the child is being punished for. Punishing a biting dog through physical injury will teach the dog to be even more aggressive. I find this type of cycle prominent in depressive states: there may be a lot of internal self-criticism (some of which may be accurate), but it leads to harsh self-punishment which ends up perpetuating the depressive state. I find the best insights of "positive psychology" have to do with stepping out of this type of punitive cycle, not by ignoring the negative, but by deliberately trying to nurture and reward the positive as well.

3) The research about so-called "depressive realism" has always seemed quite suspect to me. In a person with PTSD (a disorder which I consider highly analogous to depression and other mental illnesses), very often there is a high degree of sensitivity to various stimuli, that may, for example, cause that person to be able to have better vigilance regarding the potential dangers associated with the sound of footsteps in the distance, or of the smell of smoke, etc. Often times, though, this heightened vigilance comes at great expense to that person's ability to function in life: a pleasant walk, a work environment, or a hug, may instead become a terrifying journey or a place of constant fear of attack.

Similarly, in depressive states, there may be beliefs that are, on one level, accurate, but on another level are causing a profound impairment in life function (e.g. regarding socializing, learning, work, simple life pleasures, spirituality, etc.).

With regard to science, I do not find any need to say that "positive psychology" etc. is about a biased interpretation of data. Instead, my analogy would be along the lines of how one would solve a complex mathematical equation:
-a small minority of mathematical problems have a straightforward answer. If one was to look only at precedents in data, one might conclude that there is no definable answer for many problems. A cynical and depressive approach would be to abandon the problem.
-but most complex problems today require what is called a "numerical analysis" approach. This necessitates basically guessing at the solution, then applying an algorithm that will "sculpt" the guess closer to the true answer. Sometimes the algorithm doesn't work, and the attempted solutions "diverge." But the convergence to a solution through numerical analytical methods is the most powerful phenomenon in modern science. It has permitted most every single major advance in science and engineering in the past hundred years. It is basically analogous to positive behavioural shaping in psychology. It is not about biased interpretation of data, it is about using a set of "positive" tools to solve a problem (in the mathematical case, to get numerical solutions; in the psychological case, to relieve symptoms, to increase freedom of choice, and to expand the realm of possible life functions available).

4) Some of the experiments are weak, no doubt about that. I don't consider experiments evaluating superficial cross-sectional affect to be relevant to therapy research. Experiments which evaluate the change in symptoms and subjective quality of life measures over long periods of time, are most relevant to me. I consider "positive psychology" to be just one more set of ideas that may help to improve quality of life, and overall life function, as subjectively defined by a patient.

In my discussion of this subject, I am not meaning to suggest that so-called "positive psychology" is my favoured therapeutic system. Some of the ideas may be quite off-putting to individuals who may need to deal with a lot of negative symptoms directly before doing "positivity exercises." But I do think that some of the ideas from positive psychology are important and relevant, and deserve to be adopted as part of an eclectic therapy model.

"Positive Psychotherapy" (PPT) for depression

This post is a continuation of my earlier post on the psychology of happiness. I'm trying to look at each of the references in more detail.

PPT (positive psychotherapy) is a technique described in a paper by Seligman et al. Here's a reference, from American Psychologist in 2006:
http://www.ncbi.nlm.nih.gov/pubmed/17115810

In this paper the technique was tested on two groups. The more important finding concerns the application of PPT with severely depressed adults. PPT was compared with "treatment as usual" (mainly supportive therapy), and "treatment as usual plus antidepressant". The trial lasted 12 weeks, and there was follow-up over 1 year.

The PPT group showed significant improvement in depression scores, and significantly increased happiness, compared to the two control groups.

More controlled studies need to be done on the technique, but in the meantime, the ideas are simple, valuable, potentially enjoyable, and easily incorporated into other therapy styles such as CBT. Here are some of the exercises recommended in PPT, as described in the paper mentioned above:

1) Write a 300-word positive autobiographical introduction, which includes a concrete story illustrating character strengths
2) Identify "signature strengths" based on exercise (1), and discuss situations in which these have helped. Consider ways to use these strengths more in daily life
3) Write a journal describing 3 good things (large or small) that happen each day
4) Describe 3 bad memories, associated anger, and their impact on maintaining depression (this exercise to be done just once or a few times, not every day)
5) Write a letter of forgiveness describing a transgression from the past, with a pledge to forgive (the letter need not be actually sent)
6) Write a letter of gratitude to someone who was never properly thanked
7) Avoiding an attitude of "maximizing" as a goal, rather focusing on meaningfully engaging with what is enough (i.e. avoiding addictive hedonism, in terms of materialism or achievement). The authors use the term "satisficing", which led me to look this word up--here's a good article I found: http://en.wikipedia.org/wiki/Satisficing). I think this idea is really important for those of us who are very perfectionistic or who have very specific, fixed standards for the way they believe life should be, and who therefore feel that real life is always lagging behind these expectations or requirements, or that real life could at any moment crash into a state of failure.
8) Identification of 3 negative life events ("doors closed") which led to 3 positives ("doors opened").
9) Identification of the "signature strengths" of a significant other.
10) Give enthusiastic positive feedback to positive events reported by others, at least once per day
11) Arrange a date to celebrate the strengths of oneself and of a significant other
12) Analyze "signature strengths" among family members
13) Plan and engage with a "savoring" activity, in which something pleasurable is done, with conscious attention given to how pleasurable it is, and with plenty of time reserved to do it
14) "Giving a gift of time" by contributing to another person, or to the community, a substantial amount of time, using one of your signature strengths. This could include volunteering.

Here's a link to a blog devoted to positive psychology techniques:
http://blog.happier.com/
This blog is connected to a site in which they want you to sign up and pay for a membership. I'm always a bit jarred when an altruistic psychotherapeutic system is marketed for financial profit. Would it not be more satisfying to everyone to offer this for free? Also I think the photograph of an ecstatic woman in a flowery meadow is a bit over-the-top as advertising for the site. I find the marketing excessively aggressive, it looks like an infomercial. Some of this stuff could really be off-putting to weary, understandably cynical individuals with chronic depression who have tried many other types of therapy already. And there can be a sort of religious fervor among enthusiastic adherents of a new technique, which can skew reason.

Yet, these ideas are worth looking at. And I certainly agree that in psychiatry, and in therapy, we often focus excessively on the negative side of things, and do not attend enough to nurturing the positive.

The Psychology of Happiness

So-called "positive psychology" is, in my opinion, a very important evolving field. Surprisingly, it is a relatively new field, in terms of formal academic study. Much of the past study of psychology, psychotherapy, and psychiatry has been focused on "pathology" or on treating symptoms of illness, rather than studying or understanding happiness.

Positive psychology need not be criticized as a discipline which defines normality as a continuous happy state. Rather, I think it is a different way of looking at, and nurturing, psychological health.

I'd like to discuss this subject further, but for now, here are a few authors to look at:
-Sonja Lyubomirsky
-Barbara Fredrickson
-Martin Seligman
-Richard Layard

Some insights from this field include the following:

- a "steady diet" of positive emotion increases a sense of meaning and purpose in life, and increases the likelihood of "flourishing" in life. * While this may seem like a truism, it really isn't: it is possible to make changes in lifestyle practices, and to practice skills, to increase positive emotion in daily life. Many people coast through their daily lives, lacking positive emotion, or a sense of meaning.

-Specific suggestions for increasing positive emotion include paying attention to kindness (giving and receiving); consciously increasing awareness in the present moment; simply going outside in good weather; or meditation techniques such as "loving kindness meditation."

-Also, a variety of research has suggested that a ratio of "positivity to negativity"-- in terms of dialog with others, personal emotional experience, and I would add, dialog within your own mind--should exceed 5 to 1. Some of this research comes from looking at dialog in marriages, and interactions in other groups. We all have a tendency to criticize too much--with others and with ourselves--which leads to the positive:negative ratio diminishing, often way below 5 to 1. This suggestion does not advocate suppressing criticism or negative dialog; rather it is about balancing the negative with a large abundance of positive. If you think of any teacher or guide who has ever helped you learn something or grow as a person, I'm pretty sure you'll find that the feedback given to you was mostly positive, with only occasional, concise, gentle, criticisms. I recommend this approach in dealing with negative thoughts within your own mind -- try to balance them, aim for that 5 to 1 ratio.



*see the article "Are you Happy Now?", interview of Barbara Fredrickson by Angela Winter, Utne Sep-Oct 09, p. 62-67.


Here are some more references, which I'll comment more on later:
http://www.ncbi.nlm.nih.gov/pubmed/17716102
http://www.ncbi.nlm.nih.gov/pubmed/17115810
http://www.ncbi.nlm.nih.gov/pubmed/16045394
http://www.ncbi.nlm.nih.gov/pubmed/11894851
http://www.ncbi.nlm.nih.gov/pubmed/19485613
http://www.ncbi.nlm.nih.gov/pubmed/18954193
http://www.ncbi.nlm.nih.gov/pubmed/17356687
http://www.ncbi.nlm.nih.gov/pubmed/11934003
http://www.ncbi.nlm.nih.gov/pubmed/19301241
http://www.ncbi.nlm.nih.gov/pubmed/11315250
http://www.ncbi.nlm.nih.gov/pubmed/19056790
http://www.ncbi.nlm.nih.gov/pubmed/19056788
http://www.ncbi.nlm.nih.gov/pubmed/19227700
http://www.ncbi.nlm.nih.gov/pubmed/18841581
http://www.ncbi.nlm.nih.gov/pubmed/18356530
http://www.ncbi.nlm.nih.gov/pubmed/17479628
http://www.ncbi.nlm.nih.gov/pubmed/17327862

Hallucinations

Hallucinations are perceptions which take place in the absence of a stimulus from the peripheral or sensory nervous system.

They may be classified in a variety of different ways (this is an incomplete list):
1)by sensory modality
a) auditory: these are most common, and may be perceived as voices speaking or mumbling; musical sounds; or other more cacophonous sounds
b) visual: these can occur more commonly in delirious states or medical illnesses affecting the brain. Many people experience normal, but unsettling, visual hallucinations, just when falling asleep or waking up.
c) tactile: these are most common in chemical intoxication syndromes, such as with cocaine.
d) olfactory: more common in medical illness

2) by positionality
-when describing hallucinated voices, if the voices are perceived to originate inside the head, or to not have any perceived origin, then they could be called "pseudohallucinations." If the voices are perceived to originate from a particular place, such as from the ceiling or from across the room, then they could be called "hallucinations" or "true hallucinations." This terminology has been used to distinguish between the hallucinations in schizophrenia and psychotic mood disorders (which are typically "true hallucinations") and those experienced in non-psychotic disorders (pseudohallucinations are more typically--though not invariably--associated with dissociative disorders, borderline personality, or PTSD).

3) by insight
An individual experiencing a "psychotic hallucination" will attribute the phenomenon to stimuli outside of the brain. An individual experiencing a "non-psychotic hallucination" will attribute the phenomenon to his or her own brain activity, and recognize the absence of an external stimulus to account for the experience. In most cases, "insight" fluctuates on a continuum, and many individuals experiencing hallucinations will have some intellectual understanding of their perceptions being hallucinatory, but still feel on a visceral level that the perceptions are "real."

4) by character
Voices in particular can be described in a variety of ways. So-called "first rank symptoms of schizophrenia" include hallucinated voices which comment on a person's behavior, or include several voices which converse with each other.
The quality of the voice can vary, with harsh, angry, critical tones more common in psychotic depression, and neutral emotionality more common in schizophrenic states.


--all of these above descriptions are incomplete, and associations between one type of hallucination and a specific "diagnosis" are imperfect. A great deal of variation exists--

It is probably true that some hallucinations are factitious (i.e. the person is not actually hallucinating, despite claiming to), but of course this would be virtually impossible to prove. Something like functional brain imaging might be an interesting, though impractical, tool, to examine this phenomenon. People with psychotic disorders or borderline personality might at times describe factitious hallucinatory phenomena in order to communicate emotional distress or need to caregivers. Or sometimes the phenomena may convey some type of figurative meaning. The motivation to do this might not always be conscious.

There are a variety of ways to treat hallucinations.

In my opinion, the single most effective treatment is an antipsychotic medication. Hallucinations due to almost any cause are likely to diminish with antipsychotic medication treatment.

There is evolving evidence that CBT and other psychotherapy can help with hallucinations. Here are some references:
http://www.ncbi.nlm.nih.gov/pubmed/19176275
http://www.ncbi.nlm.nih.gov/pubmed/9827323

Some individuals may not be bothered by their hallucinations. In this case, it may sometimes be more the physician's agenda than the patient's to "treat" the symptom. Yet, it is probably true that active hallucinations in psychotic disorders are harbingers of other worsening symptoms, so it may be important to treat the symptom early, even if it is not troublesome.

Other types of behavioral tactics can help, including listening to music, wearing ear plugs, other distractions, etc. In dealing with pseudohallucinations or non-psychotic hallucinations, "mindfulness" exercises may be quite important. A well-boundaried psychodynamically-oriented therapy structure could be very helpful for non-psychotic hallucinations or pseudohallucinations associated with borderline personality dynamics or PTSD. Care would need to be taken, in these cases, not to focus excessively or "deeply" on the hallucinations, particularly without the patient's clear consent, since such a dialog could intensify the symptoms.

Opinions on mistakes psychiatrists make

Here's another interesting link from "the last psychiatrist" blog:

http://thelastpsychiatrist.com/2006/11/post_2.html#more


I agree with many of his points.

But here are a few counterpoints, in order:

1.) I think some psychiatrists talk too little. There's a difference between nervous or inappropriate chatter diluting or interrupting a patient's opportunity to speak, and an engaged dialog focusing on process or content of a problem. There is a trend in psychiatric practice, founded or emphasized by psychoanalysis, that the therapist is to be nearly silent. Sometimes I think these silences are unhelpful, unnecessary, inefficient, even harmful. There are some patients I can think of for whom silence in a social context is extremely uncomfortable, and certainly not an opportunity for them to learn in therapy. Therapy in some settings can be an exercise in meaningful dialog, active social skills practice, or simply a chance to converse or laugh spontaneously.

I probably speak too much, myself--and I need to keep my mouth shut a little more often. I have to keep an eye on this one.

It is probably better for most psychiatrists to err on the side of speaking too little, I would agree. An inappropriately overtalkative therapist is probably worse than an inappropriately undertalkative one. But I think many of us have been taught to be so silent that we cannot be fully present, intuitively, personally, intellectually, to help someone optimally. In these cases, sometimes the tradition of therapeutic silence can suppress healthy spontaneity, positivity, and humour in a way which only delays or obstructs a patient's therapy experience.

2) I agree strongly with this one--especially when history details are ruminated about interminably during the first few sessions.
However, I do think that a framework to be comprehensive is important. And sometimes it is valuable, in my opinion, to entirely review the whole history, after seeing a patient for a year, or for many years. There is so much focus on comprehensive history-taking during the first few sessions, or the first hour, that we forget to revisit or deepen this understanding after knowing a patient much better, later on. Sometimes whole elements of a patient's history can be forgotten, because they were only talked about once, during the first session.

There is a professional standard of doing a "comprehensive psychiatric history" in a single interview of no longer than 55 minutes. There may even be a certain bravado among residents, or an admiration for someone who can "get the most information" in that single hour. I object to this being a dogmatic standard. A psychiatric history, as a personal story, may take years to understand well, and even then the story is never complete. It can be quite arrogant to assume that a single brief interview (which, if optimal exchange of "facts" is to take place, can sound like an interrogation) can lead to a comprehensive understanding of a patient.

I do believe, though, that certain elements of comprehensiveness should be aimed for, and aimed for early. For example, it is very important to ask about someone's medical ailments, about substance use, about various symptoms the person may be too embarrassed to mention unless asked directly, etc. Otherwise an underlying problem could be entirely missed, and the ensuing therapy could be very ineffective or even deleterious.

Also, some individual patients may feel a benefit or relief to go through a very comprehensive historical review in the first few sessions, with the structure of the dialog supplied mainly from the therapist. Other individual patients may feel more comfortable, or find it more beneficial, to supply the structure of their story themselves. So maybe it's important not to make strong imperative statements on this question: as with so many other things in psychiatry, a lot depends on the individual situation.

3. I think it's important not to ignore ANY habitual behavior that could be harmful. Yet perhaps some times are better than others to address or push for things like smoking or soft-drink cessation: a person with a chronically unstable mood disorder may require improved mood stability (some of which may actually come from cigarette smoking, in a short-term sense anyway), before they are able to embark on a quit-smoking plan.

4. not much to add here
5. Well, point taken. I've written a post about psychiatry and politics before, and suggested a kind of detached, "monastic role." But on the other hand, any person or group may have a certain influence--the article here suggests basically that it's none of psychiatry's business to deal with political or social policy. Maybe not. But the fact is, psychiatry does have some influence to effect social change. And, in my opinion, it is obvious that social and political dynamics are driven by forces that are similar to the dynamics which operate in a single family, or in an individual's mind. So, if there is any wisdom in psychiatry, it could certainly be applicable to the political arena. Unfortunately, it appears to me that psychiatrists I have seen getting involved in politics or other group dynamics are just as swept up in dysfunctional conflict, etc. as anyone else.
But if there's something that psychiatry can do to help with war or world hunger, etc. -- why not? In some historic situations an unlikely organized group has come to the great aid of a marginalized or persecuted group in need of relief or justice, even though the organized group didn't necessarily have any specialized knowledge of the matter they were dealing with.

6. I strongly agree. I prefer to offer therapy to most people I see. And I think most people do not have adequate opportunities to experience therapy. Yet I do also observe that many individuals could be treated with a medication prescribed by a gp, and simply experience resolution of their symptoms. Subsequent "therapy" is done by the individual in their daily life, and does not require a "therapist." In these cases, the medication may not be needed anymore, maybe after a year or so. Sometimes therapists may end up offering something that isn't really needed, or may aggrandize the role or importance of "therapy" (we studied all those years to learn to be therapists, after all--therefore a therapist's view on the matter may be quite biased), when occasionally the best therapy of all could simply be self-provided. Yet, of course, many situations are not so simple at all, and that's where a therapy experience can be very, very important. I support the idea of respecting the patient's individual wishes on this matter, after providing the best possible presentation of benefits and risks of different options. Of course, we're all biased in how we understand this benefit/risk profile.
7. some interesting points here...but subject to debate. Addressing these complex subjects in an imperative manner makes me uncomfortable.
8. polypharmacy should certainly not be a norm, though intelligent use of combination therapies, in conjunction with a clear understanding of side-effect risks, can sometimes be helpful. Some of the statements made in this section have actually not been studied well, for example it makes no pharmacological sense to combine two different SSRI antidepressants at the same time. But there has not been a body of research data PROVING that such a combination is in fact ineffectual. Therefore, before we scoff at the practitioner who prescribes two SSRIs at once, I think we should look at the empirical result--since there are no prospective randomized studies, the best we can do is see whether the individual patient is feeling better, or not.
9. I'm not a big fan of "diagnosis", but sometimes, and for some individuals, it can be part of a very helpful therapy experience, to be able to give a set of problems a name. This name, this category, may lead the person to understand more about causes & solutions. Narrative therapy makes a good use, I think, of "naming" (a variant of "diagnosing") as a very useful therapeutic construct.

10. There isn't a number 10 here, but the comments at the end of this article were good.

Perils of Positive Thinking?

Joanne Wood et al. had an article published in Psychological Science in June 2009. It was a study in which subjects with low self-esteem felt worse after doing various "positive thinking" exercises. Subjects with higher self-esteem felt better with self-affirming statements.

Here is a link to the abstract: http://www.ncbi.nlm.nih.gov/pubmed/19493324


So the study seems to suggest that it could be detrimental to engage in "positive thinking" if you are already having depressive thoughts, or negative thoughts about yourself or your situation. The authors theorize that if you if have a negative view of yourself, then it may simply draw more attention in your mind to your own negative self-view, if you force yourself to make a positive statement about yourself. The positive statement may simply seem ridiculous, unrealistic, unattainable, perhaps a reminder of something you don't have or feel that you cannot ever have.

However, the study is weak, and demonstrates something that most of us could see to be obviously true. The study is cross-sectional, and looks at the effect of a single episode of forced "positive thinking." This is like measuring the effect of marathon training after one single workout, and finding that those already in good shape really enjoyed their workout, while those who hadn't run before felt awful afterward.

Any exercise to change one's mind has to be practiced and repeated over a period of months or years. A single bout of exercise will usually accomplish very little. In fact, it will probably lead to soreness or injury, especially if the exercise is too far away from your current fitness level. I suppose if the initial "exercise" is a gentle and encouraging introduction, without overdoing it, then much more could be accomplished, as it could get one started into a new habit, and encourage hope.

"Positive thinking" exercises would, in my opinion, have to feel realistic and honest in order to be helpful. They may feel somewhat contrived, but I think this is also normal, just as phrases in a new language may initially feel contrived as you practice them.

And, following a sort of language-learning or athletic metaphor again, I think that "positive thinking" exercises cannot simply be repeating trite phrases such as "I am a good person!" Rather, they need to be dialogs in your mind, or with other people -- in which you challenge yourself to generate self-affirming statements, perhaps then listen to your mind rail against them, then generate a new affirming response. It becomes an active conversation in your mind rather than bland repetition of statements you don't find meaningful. This is just like how learning a language requires active conversation.

Self-affirmation may initially be yet another tool which at times helps you get through the hour or the day. But I believe that self-affirming language will gradually become incorporated deeply into your identity, as you practice daily, over a period of years. Actually, I think the "language" itself is not entirely the source of identity change; I think such language acts as a catalyst which resonates with a core of positive identity which already exists within you, and allows it to develop and grow with greater ease. This core of positivity may have been suppressed due to years of depression, environmental adversity, or other stresses.

Making it through a difficult day or night

It can be hard to make it through the next hour, if you are feeling desperately unhappy, agitated, empty, worthless, or isolated, especially if you also feel disconnected from love, meaning, community, "belongingness," or relationships with others.

Such desperate places of mind can yet be familiar places, and a certain set of coping tactics may evolve. Sometimes social isolation or sleep can help the time pass; other times there can be addictive or compulsive behaviours of different sorts. These tactics may either be distractions from pain or distress, or may serve to anesthetize the symptoms in some way, to help the time pass.

Time can become an oppressive force to be battled continuously, one minute after the next.

I'd like to work on a set of ideas to help with situations like this. I realize a lot of these ideas may be things that are already very familiar, or that may seem trite or irrelevant. Maybe things that are much easier said than done. But I'd like to just sort of brainstorm here for a moment:

1) One of the most important things, I think, is to be able to hold onto something positive or good (large or small), in your mind, to focus on it, to rehearse it, to nurture its mental image, even if that good thing is not immediately present. The "good thing" could be anything -- a friend or loved one, a song, a place, a memory, a sensation, a dream, a goal, an idea. In the darkest of moments we are swept into the immediacy of suffering, and may lose touch with the internalized anchors which might help us to hold on, or to help us direct our behaviour safely through the next 24 hours.

In order to practice "holding on" I guess one would have to get over the skepticism many would have that such a tactic could actually help.

In order to address that, I would say that "covert imagery" is a well-established technique, with an evidence base in such areas as the treatment of phobias, learning new physical activities, practicing skills, even athletic training (imagining doing reps will actually strengthen muscles). The pianist Glenn Gould used covert imagery to practice the piano, and preferred to do much of his practice and rehearsal away from any keyboard; he preferred to learn new pieces entirely away from the piano. There is nothing mystical about the technique -- it is just a different way of exercising your brain, and therefore your body (which is an extension of your brain).

In order for covert imagery to work, it really does help to believe in it though (skepticism is highly demotivating).

Relationships can be "covertly imagined" as well -- and I think this is a great insight from the psychoanalysts. An internalized positive relationship can stay with us, consciously or unconsciously, even when we are physically alone. If you have not had many positive relationships, or your relationships have not been trustworthy, safe, or stable, then you may not have a positive internalized relationship to comfort you when you are in distress. You may feel comforted in the moment, if the situation is right, but when alone, you may be right back to a state of loneliness or torment.

The more trust and closeness that develops in your relationship life, the easier it will be to self-soothe, as you "internalize" these relationships.

Here are some ways to develop these ideas in practical ways:

-journaling, not just about distress, but about any healthy relationship or force in your life which helps soothe you and comfort you

-using healthy "transitional objects" which symbolize things which are soothing or comforting, without those things literally being present. These objects may serve to cue your memory, and help interrupt a cycle of depressive thinking or action.

-if there is a healthy, positive, or soothing relationship with someone in your life, imagine what that person might say to comfort or guide you in the present moment; and "save up" or "put aside" some of your immediate distress to discuss with that person when you next meet.

2) Healthy distraction.
e.g. music (listening or performing); reading (silently or aloud, or being read to); exercise (in healthy moderation); hobbies (e.g. crafts, knitting, art); baking
-consider starting a new hobby (e.g. photography)

3) Planning healthy structured activities
e.g. with community centres, organized hikes, volunteering, deliberately and consciously phoning friends

4) Creating healthy comforts
e.g. hot baths, aromatherapy, getting a massage, preparing or going out for a nice meal

5) Recognizing and blocking addictive behaviours
-there may be a lot of ambivalence about this, as the addictive behaviours may have a powerful or important role in your life; but freeing oneself from an addiction, or from recurrent harmful behaviour patterns, can be one of the most satisfying and liberating of therapeutic life changes.
An addictive process often "convinces" one that its presence is necessary and helpful, and that its absence would cause even worse distress.

6) Humour
-can anyone or anything make you laugh?
-can you make someone laugh?

7) Meditation
-takes a lot of practice, but can be a powerful tool for dealing safely with extreme pain
-could start with a few Kabat-Zinn books & tapes, or consider taking a class or seminar (might need to be patient to find a variety of meditation which suits you)

8) Being with animals (dogs, cats, horses, etc.). If you don't or can't have a pet, then volunteering with animals (e.g. at the SPCA) could be an option.

9) Caring for other living things (e.g. pets, plants, gardens)

10) Arranging for someone else to take care of you for a while (e.g. by friends, family, or in hospital if necessary)

11) Visiting psychiatry blogs
-(in moderation)


...I'm just writing this on the spur of the moment, I'll have to do some editing later, feel free to comment...

When your therapist makes a mistake

Sometimes your therapist will make a mistake:
- an insensitive or clumsy comment
- an intrusive line of questioning
- a failure to notice, attend to, or take seriously, something important in the session
- unwelcome or way-off-base advice.

If such problems are recurrent and severe, it may be a sign that you don't have a very good therapist, and that it is important to seek a referral to someone else.

Some problems could be forms of malpractice (e.g. being given dangerous medications inappropriately), and could be pursued through legal channels.

I think that a healthy therapy frame is one in which the therapist will be open to discussing any problems or mistakes.

The therapist should sincerely apologize for all mistakes, and be open to making a plan to prevent similar mistakes from happening again.

You deserve to feel safe, respected and cared for in therapy.

There are other types of conflicts that can arise in therapy, when one person or the other feels hurt, frustrated, or misunderstood. I can think of situations over the past ten years in which there have been tense conflicts, and in which my patient chose not to continue seeing me. In some of these cases, I have felt that there was a conflict--a problem in the relationship--which needed to be resolved. Sometimes these conflicts were made more likely by my own character style or behavioral quirks; other times I think these conflicts were at least partly "transferential," in that my actions triggered memories associated with conflicts from previous relationships (such as with parents growing up). In a few cases, I think the conflict was influenced by active mood symptoms (e.g. severe irritability). I think many conflicts have a mixture of different causes, and are not necessarily caused by just one thing.

In any case, I do strongly believe that resolving conflict in therapy is very important. And I believe a therapist must gently and empathically invite a dialog about conflicts, in a manner which is open, non-defensive, and "non-pushy." Such a moment of conflict-resolution, if it occurs, could be one of the most valuable parts of a therapy experience, a source of peace and freedom.

Language Learning Metaphor

I have often compared psychological change to language learning.

This could be appreciated on a metaphorical level, but I think that neurologically the processes are similar.

Many people approach psychological change as they would approach something like learning Spanish. Reasons for learning Spanish could be very practical (e.g. benefits at work, moving to a Spanish-speaking country, etc.), or could be more whimsical or esthetic (e.g. always enjoying Spanish music or movies). There is a curiosity and desire to learn and change, and steps are taken to begin changing. A Spanish language book would be acquired. An initial vigorous burst of energy would be spent learning some Spanish vocabulary.

This process often might last a few weeks or months. There might be a familiarity with certain phrases, an intellectual appreciation of the grammatical structure, and perhaps the ability to ask for something in a coffee shop.

Then the Spanish book would sit on the shelf, and never be opened again.

Another pathway could be like the French classes I remember during elementary school. We must have had some French lessons every week for eight years. I did well academically, and had high grades in French.

But I never learned to speak French.

And most people don't learn to speak Spanish either, despite their acquisition of instructional books.

So, there is a problem here: motivation exists to change or learn something new. There is a reasonable plan for change. Effort is invested into changing. But change doesn't really happen. Or the change only happens in a very superficial way.

Here is what I think is required to really learn a language:

1) Immersion is the optimal process. That is, you have to use only the new language, constantly, for weeks, months, or years at a time. This constrains one's mind to function in the new language. Without such a constraint, the mind shifts back automatically to the old language most of the time, and the process of change is much slower, or doesn't happen at all.
2) Even without immersion, there must be daily participation in the learning task, for long periods of time.
3) The process must include active participation. It is helpful to listen quietly, to read, to understand grammar intellectually -- but the most powerful acts of language learning require you to participate actively in conversation using the new language.
4) Perhaps 1000 hours of active practice are required for fluency. 100 hours of practice will help you to get by on a very basic level. 6-10 hours of work per week is a reasonable minimum.
5) Along the way, you have to be willing to function at what you believe is an infantile level of communication, and stumble through, making lots of mistakes, possibly being willing to embarrass yourself. It will feel awkward and slow at first.
6) It is probably necessary to have fellow speakers of the new language around you, to converse with during your "immersion" experience.
7) Part of the good news is that once you get started, even with a few hours' practice, there will be others around you to help you along enthusiastically.

I think that psychological change requires a similar approach. The brain is likely to change in a similar way. I am reminded of Taub's descriptions of constraint-induced rehabilitation from strokes: recovery of function, and neuroplastic brain change, can take place much more effectively if the person is in a state of physiologic "immersion."

Many people acquire books about psychological change (e.g. self-help books, CBT manuals, etc.) in the same way one might acquire a book about learning Spanish. People might read them through, learn a few things, then the books would sit unopened for the next five years.

Or many people might participate in psychotherapy similar to a weekly language lesson: it might be familiar, educational--if there was an exam to write, people might get high grades--but often the "new language" fluency never really develops.

So I encourage the idea of finding ways to create an "immersion" experience, with respect to psychological change. This requires daily work, preferably in an environment where you can set the "old language" aside completely. This work may feel artificial, slow, contrived, or superficial. But this is just like practicing phrases in a new language for the first time. Eventually, the work will feel more natural, spontaneous, and easy.

I think the greatest strength of cognitive-behavioural therapy is its emphasis on "homework," which calls upon people to focus every day on constructive psychological change. And the different columns of a CBT-style homework page remind me of the "columns" one might use to translate phrases from one language into another. In both cases, in order for this homework to work, it has to be practiced, not just on paper, but spoken out loud, or spoken inside your mind, with sincerity and repetition, and preferably also with other people in dialogs.

There's some interesting academic work out there on language acquisition--but for a start, here's a reference from a language-learning website (particularly the summary on the bottom half of this webpage):
http://www.200words-a-day.com/language-learning-reviews.html

Increasing Anxiety in Recent Decades

Another question from a visitor:

Shifts towards higher anxiety and neuroticism: Twenge** has noted an increase in anxiety and neuroticism in recent decades. Is this the failure of psychiatry/psychology?

Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/11138751

This is a good and important article by Twenge, showing that anxiety and neuroticism (the tendency to experience negative emotion) have increased substantially in the past 5 decades, such that, for example, normal children in the 90's had similar scores on anxiety tests as child psychiatric patients from the 50's. The author finds that economic factors are not associated with this change, but that decreased social connectedness, and an increased sense of environmental danger or threat, are associated.

Here's a related comment:

Baumeister* suggests that purpose, values, sense of efficacy, and self-worth are needed for a meaningful life. Religions and spiritual belief-systems have long provided meaning and more. Nietzsche has supposedly said: "He who has a why to live for can bear almost any how". How do you think one can live a meaningful life? *Baumeister, R. F., & Vohs, K. D. (2002). The pursuit of meaningfulness in life. In C. R. Snyder& S. J. Lopez (Eds.), Handbook of positive psychology (pp. 608-618). Oxford: OxfordUniversity Press.

I have always felt that a strong sense of belonging, safety, meaningfulness, and community is necessary for mental health. Modern culture supports independence. Perhaps modernity also encourages the solitary pursuit of wealth, educational success, etc., in an increasingly competitive and busy culture. People are less likely to join community organizations or visit friends. People are more likely to remain single or live alone for longer periods of their lifetime (in their 20's and beyond). There are more activities that can absorb time and attention while alone (e.g. video games, recreational drugs). Even music--an aspect of life that was previously associated strongly with social connection--has become a medium in which a person can disappear alone, disconnected from the social milieu, thanks to portable music players. A cost of sexual or relationship freedom, particularly in the internet age, can be a tendency for people to have brief, less committed relationships, in the quest for variety, or in the quest for an "ideal mate." Intellectual freedom and advanced knowledge, while possibly allowing for heightened meaningfulness and enlightenment, may also shatter previous bastions of meaningfulness (such as religious dogmas), and may finally cause one to confront the absurdity and seeming empty arbitrariness of the universe. Owen Barfield, in his book Saving the Appearances, described modernity as a "shattering of idols", leaving a spiritual emptiness which science cannot fill.

I guess this is a failure of psychiatry/psychology. Not because the therapies don't work, but because the issue is one of public health and culture. I think this type of evidence emphasizes the importance of encouraging social connectedness and community involvement--to whatever degree is possible--as essentials in a therapeutic prescription for treating anxiety or depression.

In this regard, I encourage involvement in volunteering, community organizations, churches, sports teams, activity clubs, etc. It may be necessary to change one's personal culture in order to change anxiety or depression. You must be wary about being swept up in the prevailing culture, and must instead make active choices about what is healthy and meaningful for you.

*As an addendum here, I have to say that research data of this type may be biased by a variety of factors which differ between one time period and another, including use of language, cultural acceptance of symptoms, etc. Therefore, the children in the 50's may have had lower anxiety scores because they were less familiar with the language associated with anxiety symptoms, were less likely to admit such symptoms on a questionnaire, were more likely to deal with the underlying cause of such symptoms in a different way, etc. We now realize many terrible problems which were going on in the 50's (such as abuse), but which people did not talk about as openly back then. A questionnaire on these issues done at that time might have underestimated the degree of such problems.

**Here's another article, showing increasing life satisfaction over the past decades:
http://www.ncbi.nlm.nih.gov/pubmed/19227700

Metaphors

Here's another question from a visitor:

You note that you like using metaphors in psychotherapy. Can you elaborate more on the use of metaphor. I personally find that using metaphors can have its downside. Some metaphors, once useful--or helpful to those who never heard of them--can become quite trite and cliché. They may even take on negative connotations if associated with unpleasant memory or a disagreeable person from the client's past.

To some degree it is a personal indulgence on my part to attempt to use metaphors. I think you're quite right that this could be unhelpful or annoying to others, and at the very least trite or cliché. I would need to keep this tendency of mine healthily reigned in when necessary. It is, however, very characteristic of me, and a pleasure of mine, to seek out a new metaphor, and therefore an aspect of genuineness that I would attempt to share with patients at times.

Theoretically, it has been part of a larger world-view of mine, that a great deal of wisdom is couched in metaphorical language, yet this language is often taken literally by dogmatic adherents. The dogmatism intensely suppresses the wisdom. This happens frequently in religion, politics, and even in science and medicine. Joseph Campbell was one of my influences: I think he had a great balance of wisdom, humour, and story-telling ability--these are qualities of a good physician, thinker, or healer. Campbell himself was influenced by psychoanalytic thinkers such as Freud, and particularly Jung, but in my opinion his writing never had the annoyingly dogmatic and preachy tone characteristic of these psychoanalysts. Yet, Campbell's ideas are intellectually limited, and I think one should be wary of going too far with them (I find many styles of therapy which are overtly about "exploring myths", etc. to be tiresome, ignorant of modern scientific evidence, and overburdened with jargon). But I liked Joseph Campbell's style, and maybe this is one of the reasons I like "indulging in metaphor" at times as part of my work.

Are Psychiatrists Professionals, Friends, or Healers?

Another question from a visitor:

Are psychiatrists professionals, friends, or healers? I personally believe that healing occurs in a time and place beyond professional rules and regulations. Even friendships can be healing. I wonder if professionalization of medicine is antithetical to a healing process that is dependent on...deep human connection.

This is a good question, one I've often thought about.

The standard of practice in psychiatry, and in other areas of medicine, is for the therapeutic relationship to be "well-boundaried." Mind you, this seems like an obvious truth; furthermore, any healthy friendship also needs to be "well-boundaried." Many unhealthy friendships or family dynamics are problematic due to unhealthy or absent boundaries. But in psychiatry, there are formal legal and professionally-mandated restrictions around the type of relationships permitted between therapist and patient, or between therapists and former patients. In general, I would say the rule is that any interaction between psychiatrist and patient (or between psychiatrist and former patient) needs to be considered a "therapeutic action," or at least an attempt to be a "therapeutic action," and if this interaction cannot be justified as such, it would be considered outside a healthy boundary. These rules protect patients from unethical practioners.

But I do consider any type of healthy human interaction to be a manifestation of a type of friendship. And I consider it a healthy way to live, to consider that all of one's interactions in the world are "friendship-building" activities. To experience the very personal relationship of psychotherapy as strictly bereft of "friendship" seems wrong to me.

Different individuals will have different needs or wishes in this regard. For many people, they prefer to interact with a psychiatrist or other professional in a polite but formal and distant way. Many people would not want to have a friendship with their psychiatrist or physician.

For many others, closeness and trust in a therapy relationship is extremely important to nurture.

One thing I strongly feel to be true is that the therapy relationship needs to be a setting in which growth of healthy relationships outside of the therapy relationship can be encouraged.

I am reminded of some of the psychiatric theory from the previous century about "object relations." This theory generally considers that relationships become "internalized" as abstract mental models, during the course of development. Relationships with parents during early childhood become the first internalized models. Recent evidence establishes that early peer relationships are extremely important in psychological development, perhaps having an equal or larger effect than parental relationships in many cases. Included in these internalized relationships are a sense of "other," a sense of "self," and a sense of expected dynamics between "self" and "other." Future relationships then develop which tend to be in synchrony, or in a type of resonance, with the internalized models. If these internalized models are disturbed by unhealthy relationships, absent or neglectful caregivers, abuse, environmental adversity, or inherent neuropsychiatric symptoms (such as innate tendencies to be anxious, irritable, depressed, etc.), then future relationships are likely also to be disturbed. This leads to a vicious cycle of unhealthy relationships and escalating symptoms.

In a therapeutic relationship, I think this "object relations" idea is important. The therapeutic relationship should aim to be one in which previous vicious cycles are not allowed to repeat. Over time, if the therapeutic relationship is healthy, it could perhaps become "internalized" as well, hopefully as a model of comfort, stability, nurturance, respect, trust, and healthy boundaries. In this way, I think the role of therapist is a bit more like the role of a parent, in that there is an element of friendship, a strong expectation of nurturance, a benevolent "paternalism" to some degree (some desire this element more or less than others), but also the observation that the "parent" becomes less and less necessary for meeting personal needs as the relationship develops over time.

There can sometimes be experiences of very great personal need. The experience of therapy can partially meet this need. The boundaries of the therapy can feel tremendously frustrating for a patient if this need is only partially met. Yet I feel that part of the growth experience in therapy can be to come to terms with this frustration, i.e. that the therapist is a positive, caring figure, but also that the therapist is limited and unable to meet any need completely or perfectly. If the therapy is to be truly effective or "healing," then the more complete or "perfect" satisfaction of needs eventually could occur outside of the therapy, during daily life.

Here's a light-hearted poem about this theme. It's by Hal Sirowitz, from the collection My Therapist Said.

BETTER THAN A FRIEND
You shouldn't tell everyone that you're
in therapy, my therapist said. Some people
might think you're crazy. If
someone asks why you go to the city
at the same time each week, you should
just tell him that you have an appointment
with a friend, which is not really a lie,
because I'm your friend. But I'm also
so much more. You can insult me, & I'll
never get mad. I'll just say that you're
transferring again. I'll never leave you,
but you can leave me. One day you'll
tell me that you don't need to see me anymore,
& instead of being mad, I'll be happy,
because that'll mean you're cured. But
I wouldn't advise you to do that
in the near future. You still have problems.

* I like this poem but it's okay with me if you tell people you're in therapy!
**Thank you to the reader who found the author's name & info for me.

Good News

Here are a few "good news" websites:

http://www.happynews.com/index.aspx
http://www.goodnewsnetwork.org/
http://www.only-positive-news.com/archives
http://globaldialoguecenter.blogs.com/jbgoodnews/

There is so much bad news in the world today...

Yet, of course, the bad news is accurate: many people are doing many horrible things; whole nations are behaving badly; the whole planet is at risk for irreversible deterioration... It is important and healthy for us to be aware of the truth, even if the truth is difficult to hear.

This reminds me of the way depression can work, particularly chronic depression: the negative, cynical, painful, or pessimistic thoughts associated with depression may represent accurate truths about one's life or about the world.

It can feel frustrating, irritating, and shallow to simply ignore the negative thoughts or negative truths, and focus strictly on "happy thoughts." It can feel like mental manipulation to try to convert a negative observation into a positive one.

I believe that part of the solution is not necessarily to try to negate negative thinking. This would be like refusing to learn about the realities of global hunger, environmental pollution, or about a child being bullied in your neighbourhood, and just simply carrying on with a smile as though everything was fine. This is just denial--things have to be done about hunger, pollution, and bullies.

But I do believe that part of the solution is to be informed about positive news that is going on in the world...this requires very deliberate effort.

Human nature, and the human brain, tends to focus on things that are going wrong. This is a vital safety mechanism...it has kept us safe from predators and other environmental dangers over millions of years of evolution. This tendency shows up in news reporting--headlines are all about disasters, not about moments of sublime beauty or courage or hope. Disaster reporting sells more papers, it grabs our attention more strongly--that's the way our brains are made.

In order to have a healthy and balanced lifestyle we must actively inform ourselves of things that are going right, alongside whatever information comes to us about things that are going wrong. We must do this on a global scale, a local community scale, and on a personal scale (within our own thoughts or minds).

Many anxious negative thoughts represent strong over-estimations of risk (e.g. a fearful airline passenger may feel that the likelihood of crashing is 90%, when in fact the likelihood is 0.0001%); in cases like this an objective "cognitive therapy style" analysis and challenging of thoughts can be therapeutic and reassuring.

Cognitive therapy need not discount negative thoughts. An acknowledgment of a very negative reality may be an honest and frank therapeutic step.

But I think cognitive therapy for depression must allow space for seeking out things that are positive.

I invite you to check out some of the websites above, and seek out more (or better) sources of good news (let me know if you find some). I also invite you to pay attention to examples of "good news" in your community, in your daily life, and in your thinking.

Preparing for a psychiatry interview

There are many reasons to see a psychiatrist. There are different types of psychiatric interviews, depending on the situation and on the individuals involved.

A psychiatric interview is a chance to describe your history, examine your problems, review your symptoms in detail, and hopefully to make a plan for things to change.

You may feel reserved about sharing your personal history in detail until you have built up a greater trust in the therapeutic relationship. I think it is important to feel comfortable with your psychiatrist, and to know that you don't have to talk about certain things, or to answer certain questions, unless it is your wish to do so.

There are some elements of a psychiatric history which you can organize or prepare in advance, if you wish, and if these things are relevant to you:


1) charts or chronologies of specific symptoms
-if you have had a history of mood symptoms, it can be informative to prepare a chart showing how your symptoms have changed over time.
-your chart might start literally at your birth, continuing up to the present, with a graph showing how your mood has changed (e.g. showing when your mood has felt good, felt anxious, felt depressed, felt manic, etc.)
-a closer examination of the past few months, or past few years, could allow you to show mood changes in more detail
-underneath the graph of your symptom, you might include significant life events (e.g. losses, changes or problems in school, work, relationships, family, finances, etc.). This allows an examination of the relationship between life events and symptoms
-in another row underneath the graph of your symptoms, you might include any treatments you have attempted (e.g. starting, changing, or stopping any counseling, medications, or self-help)
-these charts could illustrate the long-term pattern of your mood, and illustrate what things might have helped or hindered your problems over the years
-if you have had medication treatments, it can be especially useful to see how your symptoms have changed in association with starting or stopping the medication

Here is an on-line example of a so-called "restrospective life chart":http://www.bipolarnews.org/pdfs/Patient%20Retrospective%20Form%20.pdf I find this particular chart cumbersome and cluttered--I invite you to make your own simple, personalized version of such a chart, with areas on the chart pertinent to your own specific symptoms or treatments.

There are various monthly mood symptom charts you can find on-line. I have included my own version of a monthly mood chart, which you could adapt according to your own symptoms. You can right-click on the chart above, select "copy image", then open your word processor and paste the image onto a new empty word processing file. To use my chart, you could circle the number most representative of how your symptom is on a given day; or make an oval over several numbers at once to show symptoms that have fluctuated during the same day; or you could gradually trace a line showing symptom changes, without circling the numbers, etc. I made my chart in a few minutes using Excel--you could make your own, with different categories relevant to your situation.

2) sometimes writing a narrative essay about your life can be a useful exercise to prepare for a psychiatric interview; however, you may wish to speak out this narrative during therapy sessions, rather than write it down in advance. You may find that you can do both: in the course of therapy, you may find elements of your written narrative to expand upon or emphasize more strongly, other new elements to write about for the first time, and other elements you may wish to retire from the foreground.

Predictably Irrational - a book review with ideas about psychiatric applications

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

I have one major complaint about this book:

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

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

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

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

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