A recent article in the major, prestigious medical journal Lancet concluded that
"Clinically important differences exist between commonly prescribed antidepressants for both efficacy and acceptability in favour of escitalopram and sertraline. Sertraline might be the best choice when starting treatment for moderate to severe major depression in adults because it has the most favourable balance between benefits, acceptability, and acquisition cost."
Here is a link to the abstract: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60046-5/fulltext
Predictably the news headlines about this article read something like this: "Zoloft and Cipralex better than other drugs"
Taking a closer look at the data, as presented in the abstract, reveals the following:
1) mirtazapine (Remeron) was actually the most "efficacious" drug of all the drugs studied. But its side-effect profile/tolerability was less favourable than some of the others.
2) mirtazapine, escitalopram (Cipralex), venlafaxine (Effexor), and sertraline (Zoloft) were all quite similar in terms of "efficacy", and were all significantly superior to duloxetine (Cymbalta), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and reboxetine.
The study is impressive, in that it was a meta-analysis including the data from over 25 000 patients.
But the study is substantially weakened by the fact that it does not look at long-term outcomes (over a year or more).
As I've written before, I feel that the best assessments of effectiveness for conditions such as depression, which recur over a period of years, require data that also cover a period of years, rather than just months.
Oddly, the findings about bupropion are not mentioned in the abstract.
The paper is further weakened by not looking at tricyclics at all.
I think the results of the study should not be overvalued. The study may reasonably guide a first choice of antidepressant, though. A few very particular points to take from this study are that venlafaxine was not shown to be dramatically superior to all other antidepressants (despite what their advertising has inferred quite often), also that the new antidepressant duloxetine is clearly not dramatically superior either (which encourages us to be wary of the marketing hype behind it -- see my previous entry on Cymbalta).
Another result from this study confirms an observation I've had in my practice, that mirtazapine (Remeron) can be a very good antidepressant, provided its side effects can be tolerated (sedation and weight gain).
The authors wisely note that the study ought not to prompt someone to change a medication that is working well for them. The study measures differences between groups; for a given individual sometimes one particular medication can work best (e.g. fluvoxamine, duloxetine, or fluoxetine), even if it is not the most effective for a group.
Thursday, January 29, 2009
Sunday, January 25, 2009
Reservoir Metaphor
We have "emotional reservoirs" of different types. Some supply "energy", others supply "calm", "happiness", or "well-being".
If the reservoirs are full, we may maintain our energy, calm, happiness, or well-being, even in times of stress. If there is a drought (such as a bad day or week, or other varieties of stress), we maintain a healthy state, even though there is environmental adversity.
If the reservoirs are dry, we become dependent upon the immediate environmental circumstances: there may be energy or happiness, but only if daily events are going well.
The combination of a "dry reservoir" and a "bad day" could be intense symptoms: an emotional crash, lost temper, sometimes thoughts of suicide.
Various psychiatric and medical conditions lead to a "dry reservoir" condition. Depression itself is depleting. "Personality disorders" could be understood as a "reservoir" problem in some cases. Chronic pain conditions of any sort can be depleting. And chronic environmental adversity, of course (e.g. ongoing abuse, oppression, etc.) can keep a "structurally intact" reservoir constantly dry.
To run wild with this metaphor a bit, I suppose there are different varieties of reservoir problems:
1) the "leaky reservoir" : good experiences are not internalized, noticed, or remembered
2) the "too small reservoir": only recent events (over days or weeks) determine the fullness of the reservoir
3) the "blocked reservoir" : there is an abundant inner supply of positivity, but symptoms persist, and the reservoir seems inaccessible
I suppose therapeutically, this reservoir notion could be worked on in several ways:
1) learning ways to "fill one's reservoir" on an ongoing basis -- so that one becomes less dependent on the immediate situation for well-being
2) "reservoir maintenance" : repairing leaks or blockages--there may be ways to consciously maintain, notice, hold onto, positive experience, instead of allowing it too "leak away" or be inaccessible.
3) discovering a reservoir that was always there, but that lay outside of awareness (here's a kind of psychoanalytic idea--though more about uncovering something positive rather than uncovering a hidden problem).
I intend this reservoir idea as a broad life metaphor, but there are direct analogies to be made between the "reservoir metaphor" and neurophysiology. For example, if neurotransmitter reservoirs within neurons are depleted (literally) by a drug such as reserpine, a depressed state will ensue (examples such as this are strong elements of support for neurotransmitter-based hypotheses--such as the serotonin hypothesis-- about depression). One of the problems about neuropharmacologic theory, though, is that it may focus excessively on quantities (such as "reservoir volume", or more literally, "serotonin function") while failing to attend to structure (structural change in the brain must be achieved through thoughts, actions, and relationships, not merely through changing "reservoir levels").
If the reservoirs are full, we may maintain our energy, calm, happiness, or well-being, even in times of stress. If there is a drought (such as a bad day or week, or other varieties of stress), we maintain a healthy state, even though there is environmental adversity.
If the reservoirs are dry, we become dependent upon the immediate environmental circumstances: there may be energy or happiness, but only if daily events are going well.
The combination of a "dry reservoir" and a "bad day" could be intense symptoms: an emotional crash, lost temper, sometimes thoughts of suicide.
Various psychiatric and medical conditions lead to a "dry reservoir" condition. Depression itself is depleting. "Personality disorders" could be understood as a "reservoir" problem in some cases. Chronic pain conditions of any sort can be depleting. And chronic environmental adversity, of course (e.g. ongoing abuse, oppression, etc.) can keep a "structurally intact" reservoir constantly dry.
To run wild with this metaphor a bit, I suppose there are different varieties of reservoir problems:
1) the "leaky reservoir" : good experiences are not internalized, noticed, or remembered
2) the "too small reservoir": only recent events (over days or weeks) determine the fullness of the reservoir
3) the "blocked reservoir" : there is an abundant inner supply of positivity, but symptoms persist, and the reservoir seems inaccessible
I suppose therapeutically, this reservoir notion could be worked on in several ways:
1) learning ways to "fill one's reservoir" on an ongoing basis -- so that one becomes less dependent on the immediate situation for well-being
2) "reservoir maintenance" : repairing leaks or blockages--there may be ways to consciously maintain, notice, hold onto, positive experience, instead of allowing it too "leak away" or be inaccessible.
3) discovering a reservoir that was always there, but that lay outside of awareness (here's a kind of psychoanalytic idea--though more about uncovering something positive rather than uncovering a hidden problem).
I intend this reservoir idea as a broad life metaphor, but there are direct analogies to be made between the "reservoir metaphor" and neurophysiology. For example, if neurotransmitter reservoirs within neurons are depleted (literally) by a drug such as reserpine, a depressed state will ensue (examples such as this are strong elements of support for neurotransmitter-based hypotheses--such as the serotonin hypothesis-- about depression). One of the problems about neuropharmacologic theory, though, is that it may focus excessively on quantities (such as "reservoir volume", or more literally, "serotonin function") while failing to attend to structure (structural change in the brain must be achieved through thoughts, actions, and relationships, not merely through changing "reservoir levels").
Friday, January 23, 2009
Desert Metaphor
A journey through life, especially if affected by mental illness, can be like a journey through a desert.
You may feel lost or starved. The view may be exactly the same, despite having invested days, weeks, or months, trying to forge ahead.
There may be life-threatening moments of intense thirst, and an uncertainty whether you will make it through the day.
The light of day may be intolerable and oppressive, and you may out of necessity have to work only at night, even though you may fear the darkness.
In psychotherapy, it has often been the common practice to examine the past, as part of a key to escaping the desert. In a desert, there may be some value to examining your past, but on the other hand this information may not be relevant to your immediate needs, and may be a distraction impeding your progress. Furthermore, in a desert, sometimes your "past" cannot truly be known, since the shifting sands cover up your path. The search for "past" can be a frustrating, fruitless diversion, punctuated by misleading mirages.
Cognitive-behavioural therapies, or "here and now" psychodynamic therapies, are more likely to help when lost in a desert. Some kind of desert guide may greatly ease the journey, even if the journey does not become any shorter (here I suggest the role of therapist as "desert guide" or "camel").
An immediate source of water and food helps a great deal too, and so does a good sun hat. The most basic needs have to be met first.
A psychodynamic style of therapy focusing extensively on the past is more likely to be helpful once you are already out of the desert, and are perhaps trying to make sense of the whole experience.
You may feel lost or starved. The view may be exactly the same, despite having invested days, weeks, or months, trying to forge ahead.
There may be life-threatening moments of intense thirst, and an uncertainty whether you will make it through the day.
The light of day may be intolerable and oppressive, and you may out of necessity have to work only at night, even though you may fear the darkness.
In psychotherapy, it has often been the common practice to examine the past, as part of a key to escaping the desert. In a desert, there may be some value to examining your past, but on the other hand this information may not be relevant to your immediate needs, and may be a distraction impeding your progress. Furthermore, in a desert, sometimes your "past" cannot truly be known, since the shifting sands cover up your path. The search for "past" can be a frustrating, fruitless diversion, punctuated by misleading mirages.
Cognitive-behavioural therapies, or "here and now" psychodynamic therapies, are more likely to help when lost in a desert. Some kind of desert guide may greatly ease the journey, even if the journey does not become any shorter (here I suggest the role of therapist as "desert guide" or "camel").
An immediate source of water and food helps a great deal too, and so does a good sun hat. The most basic needs have to be met first.
A psychodynamic style of therapy focusing extensively on the past is more likely to be helpful once you are already out of the desert, and are perhaps trying to make sense of the whole experience.
Thursday, January 22, 2009
Antisocial Personality
Many people use the term "antisocial" in daily language to describe a feeling of not wanting to socialize, or of reclusiveness.
In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.
I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.
For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.
A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.
However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".
The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.
There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.
And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.
Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.
Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.
Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.
Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/16291212
Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.
The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".
In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.
So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.
Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.
There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).
Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).
In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.
The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.
I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.
In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.
I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.
For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.
A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.
However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".
The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.
There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.
And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.
Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.
Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.
Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.
Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/16291212
Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.
The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".
In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.
So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.
Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.
There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).
Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).
In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.
The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.
I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.
Tuesday, January 13, 2009
Procrastination
I've been putting off publishing this post.
But to follow some of the behavioural advice about solving procrastination problems, I realize that I have to just publish what I've got, and maybe finish it or tune up the posting a little bit later.
Procrastination is often paralyzing. The motivational force to initiate an action is just not there, or there seems to be a lot of "friction" keeping things stalled. So, time passes, guilt about inaction increases, or denial is engaged in, as though the task to do doesn't even exist. UNTIL -- the day before something is due, or until some deadline approaches -- then there is a frantic pressure leading to a frenzied, exhausting all-nighter.
Some people actually produce good work this way -- or at least they claim they do -- but I think for most of us we produce less work, both in quantity and quality, and we condition ourselves to experience the process of work as negative, frenzied, stressful, or exhausting.
I'm pretty sure that if people who do interesting work despite procrastinating were to actually work on changing or improving their procrastination habit, they would end up doing even more interesting work. It may not necessarily be true that some kind of manic-depressive pattern is a key to creative inspiration.
Yet we may also condition ourselves to require high external pressure as a motivator.
This cycle needs to be broken, in order to solve the problem of procrastination.
Simple behavioural tactics include always doing a little bit of work every day -- especially the types of work that you are putting off. The key is consistency and daily regularity, rather than amount. If there is more continuity of effort, it makes the task much easier. Not only does more work get done, it also gets done more enjoyably. Once again, it is like learning a language or a musical instrument ( tasks which really cannot ever be procrastinated).
David Burns has a chapter on procrastination in The Feeling Good Handbook. Someone recently recommended to me a different resource--see what you think of this website:
http://www.procrastinus.com/
Addendum:
In response to some of the comments, here are a few more points to add:
-different people may have different reasons for procrastinating, or different patterns of procrastination. It is important to look at, and address, the underlying reasons, whatever they may be. Part of a "cognitive therapy" or "psychodynamic" approach would certainly involve examining this closely.
-Other phenomena, such as anxiety, depression, ADHD, and OCD, may be strong contributing factors to a pattern of procrastination, and in fact may lead to procrastination being a more effective, tolerable, and comfortable strategy for completing tasks under these conditions. It is important to address these other issues. Medical and psychological strategies to treat anxiety, depression, OCD, etc. may be necessary in order for strategies addressing procrastination to be helpful.
-I do stand by the claim that daily work (as opposed to "last minute work") on anything leads to a deeper, more enjoyable, and more lasting effect on the brain and on learning, for the same reason that language learning requires daily work, and cannot be done on a last-minute basis. But I agree that there may be numerous reasons why this type of daily work could be difficult or not feasible for different individuals or circumstances.
-I suppose one exception to this would be if the "learning" has already been done, and if the individual's personal style is such that intensive bursts of activity are enjoyable. Some people may like to immerse themselves in one particular thing for days or weeks at a time (while procrastinating a whole bunch of other things, I guess), and this strategy may work very well for them. Some artists or authors like to work this way, for example. I don't think it would work well, though, unless the people were already skilled at the area in which they were immersing themselves.
-Another proviso about the "daily work" idea is that there needs to be some focus on joy in the activity itself. If the daily work is merely a burdensome, unrewarding chore, from beginning to end, then the mind gets consistently conditioned to hate the activity (this is one reason, for example, why many children learn to hate piano lessons or math -- they are made to practice or study joylessly and alone--though consistently-- by parents who may have well-meaning ideas about daily discipline, etc.). Finding ways to experience an activity with some element of joy is a particular therapeutic challenge -- conventional behaviourism neglects this. I think that more "Eastern" systems of thought and practice have a little more wisdom to offer in this area, with respect to finding ways to teach ourselves to experience, or rediscover, some joy and contentment in a seemingly or previously joyless moment or activity.
But to follow some of the behavioural advice about solving procrastination problems, I realize that I have to just publish what I've got, and maybe finish it or tune up the posting a little bit later.
Procrastination is often paralyzing. The motivational force to initiate an action is just not there, or there seems to be a lot of "friction" keeping things stalled. So, time passes, guilt about inaction increases, or denial is engaged in, as though the task to do doesn't even exist. UNTIL -- the day before something is due, or until some deadline approaches -- then there is a frantic pressure leading to a frenzied, exhausting all-nighter.
Some people actually produce good work this way -- or at least they claim they do -- but I think for most of us we produce less work, both in quantity and quality, and we condition ourselves to experience the process of work as negative, frenzied, stressful, or exhausting.
I'm pretty sure that if people who do interesting work despite procrastinating were to actually work on changing or improving their procrastination habit, they would end up doing even more interesting work. It may not necessarily be true that some kind of manic-depressive pattern is a key to creative inspiration.
Yet we may also condition ourselves to require high external pressure as a motivator.
This cycle needs to be broken, in order to solve the problem of procrastination.
Simple behavioural tactics include always doing a little bit of work every day -- especially the types of work that you are putting off. The key is consistency and daily regularity, rather than amount. If there is more continuity of effort, it makes the task much easier. Not only does more work get done, it also gets done more enjoyably. Once again, it is like learning a language or a musical instrument ( tasks which really cannot ever be procrastinated).
David Burns has a chapter on procrastination in The Feeling Good Handbook. Someone recently recommended to me a different resource--see what you think of this website:
http://www.procrastinus.com/
Addendum:
In response to some of the comments, here are a few more points to add:
-different people may have different reasons for procrastinating, or different patterns of procrastination. It is important to look at, and address, the underlying reasons, whatever they may be. Part of a "cognitive therapy" or "psychodynamic" approach would certainly involve examining this closely.
-Other phenomena, such as anxiety, depression, ADHD, and OCD, may be strong contributing factors to a pattern of procrastination, and in fact may lead to procrastination being a more effective, tolerable, and comfortable strategy for completing tasks under these conditions. It is important to address these other issues. Medical and psychological strategies to treat anxiety, depression, OCD, etc. may be necessary in order for strategies addressing procrastination to be helpful.
-I do stand by the claim that daily work (as opposed to "last minute work") on anything leads to a deeper, more enjoyable, and more lasting effect on the brain and on learning, for the same reason that language learning requires daily work, and cannot be done on a last-minute basis. But I agree that there may be numerous reasons why this type of daily work could be difficult or not feasible for different individuals or circumstances.
-I suppose one exception to this would be if the "learning" has already been done, and if the individual's personal style is such that intensive bursts of activity are enjoyable. Some people may like to immerse themselves in one particular thing for days or weeks at a time (while procrastinating a whole bunch of other things, I guess), and this strategy may work very well for them. Some artists or authors like to work this way, for example. I don't think it would work well, though, unless the people were already skilled at the area in which they were immersing themselves.
-Another proviso about the "daily work" idea is that there needs to be some focus on joy in the activity itself. If the daily work is merely a burdensome, unrewarding chore, from beginning to end, then the mind gets consistently conditioned to hate the activity (this is one reason, for example, why many children learn to hate piano lessons or math -- they are made to practice or study joylessly and alone--though consistently-- by parents who may have well-meaning ideas about daily discipline, etc.). Finding ways to experience an activity with some element of joy is a particular therapeutic challenge -- conventional behaviourism neglects this. I think that more "Eastern" systems of thought and practice have a little more wisdom to offer in this area, with respect to finding ways to teach ourselves to experience, or rediscover, some joy and contentment in a seemingly or previously joyless moment or activity.
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