This is another interesting therapy style, pioneered by the Australian social worker Michael White (1948-2008).
Here is my condensed account of narrative therapy: the main idea that I appreciate in this style is the application of a "story metaphor" to a person's life and problems. The patient becomes an author. Problems in the person's life (such as depression or eating disorders) become characters, and each of these characters gets a name. These characters are understood to have voices in the narrative, and to influence the story. The ways in which the different characters exert influence upon the story are examined, by the patient and by others. The role of the character--its purpose in the plot, so to speak--is considered. The question is considered of whether the story requires the character in some way, whether the character needs to be present, or what the story would be like without the character at all. The next step is to creatively "re-author" the story, addressing the problems externally as characters to deal with. The motives could be considered about why the different characters are behaving as they do. Elements which empower or weaken the character are considered. Important messages the characters might have to communicate could be considered or validated. The different "antics" of the characters (problems) could be anticipated, "spoken back to", or thwarted, through a creative act of "re-authoring".
The idea is really quite similar to cognitive-behavioural therapy, but perhaps with a more imaginative infusion of literary theory.
I find much of the written theory about this style incredibly cumbersome and laden with unnecessary jargon. Also I think this style, like many others, tended to see the founder as a sort of guru. There is a phenomenon I call the "guru effect" in which people with complex problems report significant change when they encounter some wise, charismatic figure, often in a public setting (I guess we can see this on certain types of TV shows these days).
I don't mean to be too critical of the "guru effect" because I acknowledge that there are some people who can share their charisma and wisdom very effectively, in a way that can be dramatically helpful. The word "guru" itself, and its origins, ought to be treated with respect, and the existence of this phenomenon can be appreciated as a gift to the world.
However, the "guru effect" can sometimes lead to a lot of dogma and a type of religious fervour that can foster overvalued ideas about what it is that is actually helping. This is especially problematic, in my opinion, if the adherents to a particular style begin to reject or criticize other styles or ideas, in ways that are not founded upon good evidence.
In any case, I think there are some imaginative and helpful ideas in narrative therapy--I'm always on the lookout for variations of cognitive-behavioural therapy or other therapies that are a little bit more imaginative, creative, or even fun (therapy isn't always fun, but humour, enjoyment, creativity, and playfulness can be immensely important elements at times).
Friday, January 30, 2009
Thursday, January 29, 2009
Anxiety Hierarchies
The idea of an "anxiety hierarchy" is simple and powerful.
It is an application of behavioural therapy, and is analogous to a well-designed educational or athletic training program.
In education--for example, learning to read, or learning arithmetic--a well-designed workbook would call for you to start with some exercises that you would find very easy. If the initial exercises are too hard, then it would be necessary to go to the previous workbook, and try something easier. If you can do the easier ones fluently, you can move on to the next page, and try some exercises that are just a little bit harder, and so on...the pace could be self-directed; some people might want to leap ahead quickly, others might want to linger on the easier pages, or practice doing them faster, etc.
In athletic training--for example, training for a marathon--one might have to start with just a few minutes of jogging, alternating with a few minutes of walking, a few times per week--once this feels comfortable, the intensity and duration could be increased.
An anxiety hierarchy is basically a "workout schedule" or "curriculum" for overcoming a phobia or an inhibition.
A prerequisite to engaging in this process is a clear wish to overcome the anxiety. It may well be possible to practice the skills necessary to become a skydiver, but unless you really want to skydive, you probably shouldn't do the training!
If the anxiety is social phobia, for example, the prerequisite for this approach is that you truly want to be able to interact socially with greater ease. If you have a phobia of bridges, you have to truly want to be able to cross bridges easily.
To do an anxiety hierarchy, it is necessary to consider tasks which involve your anxiety in some way, and rank them in difficulty, say from 1 to 100.
For social phobia, a rating of 100 might be warranted for the task of showing up for a group function, consisting of strangers, introducing yourself to everyone, striking up a conversation with the person who interests you most, and asking for that person's phone number. A rating of 50 might be for the task of asking a stranger in a crowded cafeteria for the time. A rating of 10 might be for reading a book in a crowded place, instead of at home. The details of how you do the ratings are up to you and how you feel.
It helps to think of as many tasks as you can along the "hierarchy", covering as many numbers as possible from 1 to 100.
The next step is--just like learning arithmetic or training for the marathon--to start with the easiest task, and practice it daily until you feel comfortable with it.
Then move on to the next harder step, and continue gradually working your way up the hierarchy. It is important to do the work every day, if possible; consistency and regularity are extremely important, just as in other learning tasks.
It is important to really take this seriously, and to put in your hours of work and practice. Just like marathon training or language learning, it won't happen unless you do it regularly, at a moderate level of difficulty, for solid blocks of time (e.g. one hour every day).
The pace of change may be quite similar to an educational or athletic task--after all, it is your brain that is changing, just the same way as your brain changes with learning anything else. Also your body learns to change--when you are more physically fit, the same athletic task can be done more efficiently, with less effort, and with less physiological stress. With anxiety tasks, your body will learn not to react with the same anxiety symptoms (e.g. racing heart, sweating, shortness of breath), as you train yourself.
It is an application of behavioural therapy, and is analogous to a well-designed educational or athletic training program.
In education--for example, learning to read, or learning arithmetic--a well-designed workbook would call for you to start with some exercises that you would find very easy. If the initial exercises are too hard, then it would be necessary to go to the previous workbook, and try something easier. If you can do the easier ones fluently, you can move on to the next page, and try some exercises that are just a little bit harder, and so on...the pace could be self-directed; some people might want to leap ahead quickly, others might want to linger on the easier pages, or practice doing them faster, etc.
In athletic training--for example, training for a marathon--one might have to start with just a few minutes of jogging, alternating with a few minutes of walking, a few times per week--once this feels comfortable, the intensity and duration could be increased.
An anxiety hierarchy is basically a "workout schedule" or "curriculum" for overcoming a phobia or an inhibition.
A prerequisite to engaging in this process is a clear wish to overcome the anxiety. It may well be possible to practice the skills necessary to become a skydiver, but unless you really want to skydive, you probably shouldn't do the training!
If the anxiety is social phobia, for example, the prerequisite for this approach is that you truly want to be able to interact socially with greater ease. If you have a phobia of bridges, you have to truly want to be able to cross bridges easily.
To do an anxiety hierarchy, it is necessary to consider tasks which involve your anxiety in some way, and rank them in difficulty, say from 1 to 100.
For social phobia, a rating of 100 might be warranted for the task of showing up for a group function, consisting of strangers, introducing yourself to everyone, striking up a conversation with the person who interests you most, and asking for that person's phone number. A rating of 50 might be for the task of asking a stranger in a crowded cafeteria for the time. A rating of 10 might be for reading a book in a crowded place, instead of at home. The details of how you do the ratings are up to you and how you feel.
It helps to think of as many tasks as you can along the "hierarchy", covering as many numbers as possible from 1 to 100.
The next step is--just like learning arithmetic or training for the marathon--to start with the easiest task, and practice it daily until you feel comfortable with it.
Then move on to the next harder step, and continue gradually working your way up the hierarchy. It is important to do the work every day, if possible; consistency and regularity are extremely important, just as in other learning tasks.
It is important to really take this seriously, and to put in your hours of work and practice. Just like marathon training or language learning, it won't happen unless you do it regularly, at a moderate level of difficulty, for solid blocks of time (e.g. one hour every day).
The pace of change may be quite similar to an educational or athletic task--after all, it is your brain that is changing, just the same way as your brain changes with learning anything else. Also your body learns to change--when you are more physically fit, the same athletic task can be done more efficiently, with less effort, and with less physiological stress. With anxiety tasks, your body will learn not to react with the same anxiety symptoms (e.g. racing heart, sweating, shortness of breath), as you train yourself.
Zoloft and Cipralex best?
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.
"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.
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.
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