Mindfulness-based techniques are now mainstream in psychotherapy.
A recent review and look at the evidence, published by Nicholas Van Dam et al. (Perspectives on Psychological Science, October 10, 2017, doi 10.1177/1745691617709589) is worth reading. This article is discussed by Bret Stetka in Scientific American Mental Health today.
I believe there are very important points to consider:
1) Mindfulness itself could mean different things to different people.
2) People are earning a lot of money from mindfulness education, groups, books, etc.
We come to a theme that I have often found, in so many other areas of life, and specifically in psychiatry: "dogma."
In a therapeutic encounter, or in a long-term course of therapy, the patient or client may feel better. In the process of this therapy, the client or patient may adopt new ideas, habits, or beliefs, based on the subject matter of therapy. We see this in CBT, in psychodynamic therapy, and in meditation-based therapies. In other areas of life, such as in religion, in exercise training, in education, and in nutritional change, we also see people adopt new ideas, habits, or beliefs. The benefits of these experiences are often attributed to the specific changes in ideas, habits, or beliefs.
But I believe that in many cases, the specific ideas, habits, or beliefs are less important (sometimes totally unimportant, or at worst even harmful) than the process.
In meditation, people adopt a quiet behavioural habit, which is then practiced diligently. Time and effort is committed to learning the skill, perhaps paying money take lessons, and to meet others who share the same practice.
The process here is of diligent commitment, daily behavioural practice which differs from the status quo, and often different social affiliation.
The actual theory or literal practice of the meditation might sometimes not be important at all. These details are part of the dogma of the practice, and may not be required for the practice to be helpful. Yet, we humans can become more committed to a practice if we believe there is some strong theoretical foundation behind it.
I see this phenomenon in other therapeutic styles. CBT has a strong theoretical foundation, yet I have to wonder if much of the benefits from CBT occur irrespective of the theory, but rather simply because of the diligent practice of exercises. Psychodynamic theory features many dogmatic beliefs (such as about the impact of certain childhood events), but yet the process of the therapy (of warmth, communicative freedom, invitation to reflect) is probably the key factor in its benefits, irrespective of the theoretical dogma.
In this post, I am not meaning at all to be critical of meditation-based techniques. I actually think that meditation could be quite a wonderful and transformative practice. But I do encourage people to question the theoretical dogma. Your own personal version of meditation may be equally effective or better than some other formally prescribed method, provided you are engaging with it in a way which feels comfortable, meaningful, useful, and enjoyable.
Another implication is that positive disciplined activity can be very therapeutic, but perhaps we can be free to choose the specifics according to our interests and proclivities. So it may be that a Tango class or art lessons or nature photography or horseback riding could be more therapeutically "meditative" than an actual mindfulness or yoga class. But others might prefer the mindfulness class. I encourage us to be open-minded. I also encourage us to have a little bit of healthy skepticism about therapeutic trends, especially when there is a lot of money and salesmanship involved.
Wednesday, October 11, 2017
Wednesday, June 14, 2017
Twitter in mental health
I wanted to learn a little bit about Twitter recently, so I started a Twitter account (@DrGarthK).
In past years I assumed that the Twitter format would be very limiting, and would tend to favour very superficial chatter.
But despite this issue, I have found Twitter to be an interesting way to connect a little bit with people in the world whose ideas and wisdom you admire. There are leading theorists, researchers, poets, authors, therapists, and scientists who contribute to Twitter regularly. Of course, there are political leaders as well (one of my favourite contributors is the Dalai Lama,@DalaiLama).
The very brief format of tweets does constrain expression very much, but on the other hand there can be a sort of concise poetry to them, at their best. Furthermore, it is possible for your tweets to introduce a piece of lengthier writing.
Positives about Twitter
Here are some of the positives with Twitter I have discovered so far:
1) Interesting to hear what some famous people or great scholars are saying or doing. It's possible to actually participate in a conversation with them, and give feedback about their ideas.
2) It is easy to engage with Twitter over a very short period of time, such as during a break.
3) The 140-character limit makes you practice framing ideas in a brief, concise manner.
4) It is interesting to appreciate Twitter as an art form, which some people have done very creative things with.
Negatives about Twitter
Here are some of the negatives or problems I have seen:
1) Even some famous people or leaders in a scholarly community contribute posts which can be rambling smalltalk, ranting/complaining, or disparaging other people, which I think is less enjoyable and makes less of a positive impact.
2) I realize that Twitter is commonly used for self-promotion, but an overtly self-promoting agenda comes across like an unwelcome sales pitch. I find it a bit tiresome to see a lot of tweets trying to market a new book or seminar etc. I think I'd be more interested in someone's book if it wasn't advertised so directly.
3) Twitter, like many other forms of social media or electronics, can have an "addictive" quality, which might make you spend more time on it than is healthy for you. Also the brevity of the content may condition people to expect morsels of knowledge or conversation that only require a few moments of attention. I worry that this would make people gradually more impatient with a deeper, lengthier conversation.
Uses of Twitter for mental health:
There are many people who post psychoeducational material, affirmations, meditations, encouragements, testimonial accounts about recovery and healing, etc. In many cases, a person with psychological symptoms may have only the time or attention to spend reading something very brief. So it is good that there is a medium favouring such brevity.
Conclusion
So far, after using Twitter for a few weeks, I am not quite sure if it has been worthwhile. There's been some interesting content and discussion about things, but I have had a tendency to check it a little too often, at the expense of reading more substantial things... Maybe a little too much time spent absorbed on a device, instead of enjoying the present moment, going outside, or enjoying the scenery.
But it's been a learning experience, and I may continue to use it a little bit, in moderation.
In past years I assumed that the Twitter format would be very limiting, and would tend to favour very superficial chatter.
But despite this issue, I have found Twitter to be an interesting way to connect a little bit with people in the world whose ideas and wisdom you admire. There are leading theorists, researchers, poets, authors, therapists, and scientists who contribute to Twitter regularly. Of course, there are political leaders as well (one of my favourite contributors is the Dalai Lama,
The very brief format of tweets does constrain expression very much, but on the other hand there can be a sort of concise poetry to them, at their best. Furthermore, it is possible for your tweets to introduce a piece of lengthier writing.
Positives about Twitter
Here are some of the positives with Twitter I have discovered so far:
1) Interesting to hear what some famous people or great scholars are saying or doing. It's possible to actually participate in a conversation with them, and give feedback about their ideas.
2) It is easy to engage with Twitter over a very short period of time, such as during a break.
3) The 140-character limit makes you practice framing ideas in a brief, concise manner.
4) It is interesting to appreciate Twitter as an art form, which some people have done very creative things with.
Negatives about Twitter
Here are some of the negatives or problems I have seen:
1) Even some famous people or leaders in a scholarly community contribute posts which can be rambling smalltalk, ranting/complaining, or disparaging other people, which I think is less enjoyable and makes less of a positive impact.
2) I realize that Twitter is commonly used for self-promotion, but an overtly self-promoting agenda comes across like an unwelcome sales pitch. I find it a bit tiresome to see a lot of tweets trying to market a new book or seminar etc. I think I'd be more interested in someone's book if it wasn't advertised so directly.
3) Twitter, like many other forms of social media or electronics, can have an "addictive" quality, which might make you spend more time on it than is healthy for you. Also the brevity of the content may condition people to expect morsels of knowledge or conversation that only require a few moments of attention. I worry that this would make people gradually more impatient with a deeper, lengthier conversation.
Uses of Twitter for mental health:
There are many people who post psychoeducational material, affirmations, meditations, encouragements, testimonial accounts about recovery and healing, etc. In many cases, a person with psychological symptoms may have only the time or attention to spend reading something very brief. So it is good that there is a medium favouring such brevity.
Conclusion
So far, after using Twitter for a few weeks, I am not quite sure if it has been worthwhile. There's been some interesting content and discussion about things, but I have had a tendency to check it a little too often, at the expense of reading more substantial things... Maybe a little too much time spent absorbed on a device, instead of enjoying the present moment, going outside, or enjoying the scenery.
But it's been a learning experience, and I may continue to use it a little bit, in moderation.
Monday, March 13, 2017
Helping Patients with Schoolwork
In my clinic, I mainly see university students. I believe it is important, and therapeutic, to invite students to bring their schoolwork to their psychiatry appointments, so that we can sometimes look at it together and discuss it.
Last year, I mentioned this practice to a reviewer, and I suspect it was considered an inappropriate use of time in a medical appointment, and a waste of resources -- a psychiatrist "helping with homework."
I would like to make a case for why "helping with homework" is useful, and part of a good therapy relationship:
In order to help with a mental health issue, it is good to understand what your client, patient, or friend is doing with their time. University students often spend thousands of hours studying, writing, and thinking about academic subjects. Sometimes this work is experienced as a joy of life, a passion, or as a source of meaning. For others, the work can be experienced as a burden, a chore, or as meaningless "jumping through hoops." In many cases, a student's academic work is a reflection of health status (both mental and physical), For many students, academic performance affects self-esteem: low grades can cause a person to feel like a failure. Perfectionism in schoolwork can cause almost any grade to feel like a sign of failure or inadequacy.
In order to understand another person's emotional life, it is very important to learn about how he or she is spending time. Is the schoolwork a meaningful life pleasure? Is it only a chore, a burden, or a stress?
It deepens understanding of this issue to explore it in more than a superficial way. I believe it is valuable for understanding and rapport to encourage patients to show their notebooks, textbooks, and assignments, to talk about them a little bit. Often this leads to a much better understanding of a whole range of other issues, including mood, attention, motivation, anxiety symptoms, learning disabilities (often never previously recognized), relationship problems, and existential uncertainty about direction in life.
Many students I have seen have been passionately engrossed in their studies for many years, including at a graduate level. But sometimes, they have almost no social conversation about their studies, with a person who shows interest. The academic study becomes an insular, lonely experience, rather than a source of potential social interest. Sometimes this lack of social sharing is due to an entrenched habit...the therapy setting can be a place to change this. Not only does such a conversation boost rapport, it is also a practice for the patient to be able to converse with other people about their work, for the benefit of their social life.
Also I believe it is psychologically beneficial for a patient or client to have an experience of sharing their own expertise, and learned scholarship, rather than only being on the "receiving end" of such expertise. It is a humble and respectful position for the therapist to take, which can only improve a therapeutic alliance.
All mental health issues affect cognitive functioning and academic performance. A direct discussion about academic matters is relevant to the assessment of overall mental health. Sometimes cognitive and academic function is good, but a person's feelings about this functioning is very negative. In this case, looking together at academic work leads to a very direct focus on an active set of symptoms.
Cognitive therapy is a type of "academic" process: it requires note-taking, reflection, analysis, and homework. Many students might not have time for diligent cognitive therapy. But they do have time for their schoolwork! Cognitive therapy can take place while doing schoolwork! It could be rewarding in a therapy session for a patient to have a successful experience of completing an academic task, while having a chance to reflect on the emotional changes or barriers happening at the same time. A creatively constructed regime of cognitive therapy could involve combining it with academic study.
Reading and Oration
It has been remarkably common to find students who have trouble reading. Often they have other cognitive strengths, which have allowed them to manage with this reading difficulty all their lives, while still doing well in school. But in advanced academics, a reading difficulty can greatly slow down the rate at which a student can study. Reading textbooks becomes a gruelling chore. Reading out loud, or giving presentations, can become a source of dread.
The most effective therapies for reading difficulties are very similar to therapies for mental health issues: it involves practice, in a safe setting, with tasks that are easy enough to be enjoyable and easily mastered, but challenging enough to foster growth. Reading out loud is very literally an exercise to strengthen one's voice. Such voice-strengthening is a metaphorical cornerstone of all progress in psychotherapy. Practicing this literally, in a psychotherapy session, is simple, relevant, enjoyable, diagnostically informative, and therapeutically useful, often in a very immediate way.
I think it is important to discuss other areas of work, with patients, and to be willing to look together at the work very directly at times, if desired. I like to see examples of some of the work my patients do, and I think this relates to health in a similar way.
If a therapist takes sincere interest in a patient's work, study, and other activities, it is also beneficial for the therapist. What a delight it is to vicariously be part of an educational journey! The therapist's health will therefore also be better. This, in turn, will improve care within the system as a whole. And this goodness will "bounce back" to the clients or patients, and continue a cycle of interpersonal positivity.
Last year, I mentioned this practice to a reviewer, and I suspect it was considered an inappropriate use of time in a medical appointment, and a waste of resources -- a psychiatrist "helping with homework."
I would like to make a case for why "helping with homework" is useful, and part of a good therapy relationship:
Understanding
In order to help with a mental health issue, it is good to understand what your client, patient, or friend is doing with their time. University students often spend thousands of hours studying, writing, and thinking about academic subjects. Sometimes this work is experienced as a joy of life, a passion, or as a source of meaning. For others, the work can be experienced as a burden, a chore, or as meaningless "jumping through hoops." In many cases, a student's academic work is a reflection of health status (both mental and physical), For many students, academic performance affects self-esteem: low grades can cause a person to feel like a failure. Perfectionism in schoolwork can cause almost any grade to feel like a sign of failure or inadequacy.
In order to understand another person's emotional life, it is very important to learn about how he or she is spending time. Is the schoolwork a meaningful life pleasure? Is it only a chore, a burden, or a stress?
It deepens understanding of this issue to explore it in more than a superficial way. I believe it is valuable for understanding and rapport to encourage patients to show their notebooks, textbooks, and assignments, to talk about them a little bit. Often this leads to a much better understanding of a whole range of other issues, including mood, attention, motivation, anxiety symptoms, learning disabilities (often never previously recognized), relationship problems, and existential uncertainty about direction in life.
Shared Interest
Many students I have seen have been passionately engrossed in their studies for many years, including at a graduate level. But sometimes, they have almost no social conversation about their studies, with a person who shows interest. The academic study becomes an insular, lonely experience, rather than a source of potential social interest. Sometimes this lack of social sharing is due to an entrenched habit...the therapy setting can be a place to change this. Not only does such a conversation boost rapport, it is also a practice for the patient to be able to converse with other people about their work, for the benefit of their social life.
Also I believe it is psychologically beneficial for a patient or client to have an experience of sharing their own expertise, and learned scholarship, rather than only being on the "receiving end" of such expertise. It is a humble and respectful position for the therapist to take, which can only improve a therapeutic alliance.
Diagnosis
All mental health issues affect cognitive functioning and academic performance. A direct discussion about academic matters is relevant to the assessment of overall mental health. Sometimes cognitive and academic function is good, but a person's feelings about this functioning is very negative. In this case, looking together at academic work leads to a very direct focus on an active set of symptoms.
What do Notes Look Like?
The manner in which a person might keep notes, or organize essays, or surf the internet doing research, gives us better understanding of psychological health. Are notes tidy, meticulous, or disorganized? Do the notes fluctuate a lot from one week to the next? Are the notes clear for someone else to read and understand? Are there gaps where notes are missed entirely? Is writing fluent once started, but just difficult to start? Is there evidence of tremor or other neurological symptoms manifest in handwriting?Cognitive Testing
If cognitive testing is to be done, it is most useful to refer to subject matter that the person is actually interested in, and experienced with. A mathematician or engineer might not show any decrement on a simple arithmetic test (such as "serial sevens") despite having significant cognitive problems. It would be more appropriate to ask them to solve a complicated mathematical problem having to do with their current work. A literature student might not show any decrement on a simple verbal test (such as memorizing words, or reading a sentence) but might have difficulty describing the themes or dynamics of a current novel on the curriculum. Another benefit to "testing" this way is that it can highlight unusual strengths and talents, which can then be a subject of positive feedback and encouragement.Practical Therapy
Cognitive therapy is a type of "academic" process: it requires note-taking, reflection, analysis, and homework. Many students might not have time for diligent cognitive therapy. But they do have time for their schoolwork! Cognitive therapy can take place while doing schoolwork! It could be rewarding in a therapy session for a patient to have a successful experience of completing an academic task, while having a chance to reflect on the emotional changes or barriers happening at the same time. A creatively constructed regime of cognitive therapy could involve combining it with academic study.
Behaviour Therapy for performance anxiety
Many students have anxiety about sharing their work, being called on by a professor, speaking out loud in class, presenting in front of others, etc. The therapy session is a chance to directly practice these things, in a supported setting. It is a simple CBT exercise!Therapy for Procrastination
Procrastination is one of the most common problems faced by almost all students. This is often much worse when there are other mental health issues going on. The increased stress, and decreased grades, caused by procrastination, often cause further worsening of mental health symptoms. Procrastination is sometimes even a critical part of a deteriorating cascade of events, leading to leaving school unsuccessfully. The core necessity in treating procrastination is to do the procrastinated thing as soon as possible! In a therapy session, if this subject comes up, I believe it is optimally therapeutic for the patient to have an opportunity to do the procrastinated activity right in the session, immediately! It is an incredibly simple way for a therapy hour to be directly helpful. Otherwise, sometimes visiting a therapist can be yet another way to procrastinate work, and feel even worse! If a patient of mine does agree to do some procrastinated schoolwork during a session, it is my goal to help the patient enjoy the activity, feel supported and encouraged, and to have an experience of success.Study Techniques
Many students work or study inefficiently, which is an underlying cause of worse academic stress, then leading to worse mental health. Discussion and practice of better studying techniques is directly relevant to mental health therapy. I like to discuss various memory and time-management techniques with patients, and try them out right in the session. These ideas are applicable to other life activities, including CBT exercises.Reading and Oration
It has been remarkably common to find students who have trouble reading. Often they have other cognitive strengths, which have allowed them to manage with this reading difficulty all their lives, while still doing well in school. But in advanced academics, a reading difficulty can greatly slow down the rate at which a student can study. Reading textbooks becomes a gruelling chore. Reading out loud, or giving presentations, can become a source of dread.
The most effective therapies for reading difficulties are very similar to therapies for mental health issues: it involves practice, in a safe setting, with tasks that are easy enough to be enjoyable and easily mastered, but challenging enough to foster growth. Reading out loud is very literally an exercise to strengthen one's voice. Such voice-strengthening is a metaphorical cornerstone of all progress in psychotherapy. Practicing this literally, in a psychotherapy session, is simple, relevant, enjoyable, diagnostically informative, and therapeutically useful, often in a very immediate way.
Study as Mood Therapy
I believe that studying and other intellectual work can be intrinsically therapeutic for mood. It can be a meditative and meaningful experience, and a healthy coping technique or psychological defense. But some students have study practices which are far from meditative. The therapy session can be a chance to help people regain a sense of meaning and meditative joy in study, to recapture "flow."Oliver Sacks
I am reminded of the famous neurologist, Oliver Sacks. He spent time really learning to know his patients well, and in doing so became not only a great therapist and physician, but also a wise and insightful scholar about the ways of the mind. Part of his technique was to always engage deeply with his patient's work and study interests. In doing so, often he would discover phenomena that would never have otherwise been noticed or attended to. I would hope to be a clinician more like him.Other Work (not just study)
I think it is important to discuss other areas of work, with patients, and to be willing to look together at the work very directly at times, if desired. I like to see examples of some of the work my patients do, and I think this relates to health in a similar way.
Benefit for the therapist
If a therapist takes sincere interest in a patient's work, study, and other activities, it is also beneficial for the therapist. What a delight it is to vicariously be part of an educational journey! The therapist's health will therefore also be better. This, in turn, will improve care within the system as a whole. And this goodness will "bounce back" to the clients or patients, and continue a cycle of interpersonal positivity.
Wednesday, March 8, 2017
Biases in Psychotherapy Research
Biases in Research
Pharmaceutical Research
We are much more familiar these days with biases in pharmaceutical research studies. A clinical study of a medication treatment is more likely to show an exaggerated beneficial effect, if the study is sponsored by the manufacturer. This doesn't mean industry-sponsored research is "bad," and it doesn't mean that pharmaceutical products are "bad," but it does mean that we have to look with a careful, skeptical eye at research results--not just at impressive tables or graphs, but also at the sources of funding for the study, and the authors' past relationships with the manufacturers. There could indeed be overt "badness" if there are examples of flagrant profiteering on the part of people involved. But the more salient issue, in my opinion, is simply the need to question the authority of results from such studies.
Alternative Medicine
This same critical eye is very much needed for looking at research evidence regarding alternative treatments. There are very strong sales tactics used to market supplements, herbal remedies, and other treatments, and the standards of evidence presented are often much lower than those from pharmaceutical studies. For example, simple testimonial accounts are much more common in alternative medication marketing, as are impressive-sounding but clinically irrelevant scientific or pseudo-scientific claims.
Psychotherapy Too!
We may assume that studies of psychotherapy would be relatively free of these biases. After all, there is no big company that is profiting from psychotherapy!
But we must maintain a critical eye even for studies of psychotherapy. Here are some reasons:
1) A positive study of a psychotherapy technique may not bring obvious financial profit to anyone, but it is likely to increase the prestige of the authors. A big part of the "currency" in a Ph.D. researcher's career relates to impressive publications. A study showing a significant treatment effect of a psychotherapy technique is likely to add to the fame and career advancement of the authors. This career advancement is analogous to direct financial gain.
2) Many psychotherapy researchers have spent many years of study devoted to their therapy technique. Imagine if you had spent 10 years studying a particular thing, and that you had strong feelings about it. You could imagine that you might have a bias in favour of the technique that you had studied all those years. You would really want to show that it works! If a study showed that it didn't work so well, it might lead you to question the value of all those years of your career! In Cialdini's terms, this bias would have to do with "consistency." If someone has been consistently committed to a particular thing for a long time, they are biased to maintain support of that thing, beyond what would otherwise be reasonable. Furthermore, if you had worked all those years studying one particular technique, your social and professional community of peers would be more likely to share similar opinions. You might have frequently attended conferences devoted to your area of specialty. You might have even taught students the technique, who appreciated your help and mentorship. This would lead to Cialdini's "social pressure" effect -- since the people around you support your idea, you will be more likely to hold onto the idea yourself, beyond what would otherwise be reasonable.
3) There is more and more direct financial gain related to therapy techniques. We see a lot of books, self-help guides, paid seminars and workshops, etc. Charismatic marketing, including through publishing of research studies, is likely to increase the financial profit of those involved.
4) In the psychotherapy research community, CBT is the most common modality. CBT is intrinsically easier to research, since it is more easily standardized, the techniques themselves involve a lot of measurement, and the style tends to be more precisely time-limited. CBT is more "scientific" and therefore attracts researchers whose background is more strongly analytical and scientific. There is nothing intrinsically wrong with this , but it leads to more bias in the research. Therapy styles other than CBT are studied less frequently. Therefore there will be fewer positive studies of other styles. This gives the impression that CBT is best. It is not because comparative studies have actually shown it is best. New versions or variations of CBT (with different fancy-sounding names) are also frequently marketed, and often show good results in research, but once again this does not really prove that the techniques are best. The research study becomes an advertising tool for those who have designed the technique.
Conclusion
I do not mean to sound too cynical here...I think that CBT, as well as all other therapy techniques, are interesting, important, and helpful. We should all learn about them, and make use of some of their principles. But I do not think that any one style is necessarily "best." We should not allow biases in research, including simple marketing effects, to cause a large change in our judgment with respect to helping people.
I feel that the more important foundation in trying to help people is spending the time getting to know them, and hearing from the person you are with (whether it be a client, a patient, a family member, or a friend) what type of help they would actually like.
Also, different individual therapists have different personalities, interests, experiences, weaknesses, and skills. I think it is unhealthy for a community of therapists or healers to be pushed into offering a very narrow range of techniques or therapeutic strategies. Instead, I think that the individual talents and strengths of each therapist should be honoured, and there should be room in any health care system to allow for this.
Pharmaceutical Research
We are much more familiar these days with biases in pharmaceutical research studies. A clinical study of a medication treatment is more likely to show an exaggerated beneficial effect, if the study is sponsored by the manufacturer. This doesn't mean industry-sponsored research is "bad," and it doesn't mean that pharmaceutical products are "bad," but it does mean that we have to look with a careful, skeptical eye at research results--not just at impressive tables or graphs, but also at the sources of funding for the study, and the authors' past relationships with the manufacturers. There could indeed be overt "badness" if there are examples of flagrant profiteering on the part of people involved. But the more salient issue, in my opinion, is simply the need to question the authority of results from such studies.
Alternative Medicine
This same critical eye is very much needed for looking at research evidence regarding alternative treatments. There are very strong sales tactics used to market supplements, herbal remedies, and other treatments, and the standards of evidence presented are often much lower than those from pharmaceutical studies. For example, simple testimonial accounts are much more common in alternative medication marketing, as are impressive-sounding but clinically irrelevant scientific or pseudo-scientific claims.
Psychotherapy Too!
We may assume that studies of psychotherapy would be relatively free of these biases. After all, there is no big company that is profiting from psychotherapy!
But we must maintain a critical eye even for studies of psychotherapy. Here are some reasons:
1) A positive study of a psychotherapy technique may not bring obvious financial profit to anyone, but it is likely to increase the prestige of the authors. A big part of the "currency" in a Ph.D. researcher's career relates to impressive publications. A study showing a significant treatment effect of a psychotherapy technique is likely to add to the fame and career advancement of the authors. This career advancement is analogous to direct financial gain.
2) Many psychotherapy researchers have spent many years of study devoted to their therapy technique. Imagine if you had spent 10 years studying a particular thing, and that you had strong feelings about it. You could imagine that you might have a bias in favour of the technique that you had studied all those years. You would really want to show that it works! If a study showed that it didn't work so well, it might lead you to question the value of all those years of your career! In Cialdini's terms, this bias would have to do with "consistency." If someone has been consistently committed to a particular thing for a long time, they are biased to maintain support of that thing, beyond what would otherwise be reasonable. Furthermore, if you had worked all those years studying one particular technique, your social and professional community of peers would be more likely to share similar opinions. You might have frequently attended conferences devoted to your area of specialty. You might have even taught students the technique, who appreciated your help and mentorship. This would lead to Cialdini's "social pressure" effect -- since the people around you support your idea, you will be more likely to hold onto the idea yourself, beyond what would otherwise be reasonable.
3) There is more and more direct financial gain related to therapy techniques. We see a lot of books, self-help guides, paid seminars and workshops, etc. Charismatic marketing, including through publishing of research studies, is likely to increase the financial profit of those involved.
4) In the psychotherapy research community, CBT is the most common modality. CBT is intrinsically easier to research, since it is more easily standardized, the techniques themselves involve a lot of measurement, and the style tends to be more precisely time-limited. CBT is more "scientific" and therefore attracts researchers whose background is more strongly analytical and scientific. There is nothing intrinsically wrong with this , but it leads to more bias in the research. Therapy styles other than CBT are studied less frequently. Therefore there will be fewer positive studies of other styles. This gives the impression that CBT is best. It is not because comparative studies have actually shown it is best. New versions or variations of CBT (with different fancy-sounding names) are also frequently marketed, and often show good results in research, but once again this does not really prove that the techniques are best. The research study becomes an advertising tool for those who have designed the technique.
Conclusion
I do not mean to sound too cynical here...I think that CBT, as well as all other therapy techniques, are interesting, important, and helpful. We should all learn about them, and make use of some of their principles. But I do not think that any one style is necessarily "best." We should not allow biases in research, including simple marketing effects, to cause a large change in our judgment with respect to helping people.
I feel that the more important foundation in trying to help people is spending the time getting to know them, and hearing from the person you are with (whether it be a client, a patient, a family member, or a friend) what type of help they would actually like.
Also, different individual therapists have different personalities, interests, experiences, weaknesses, and skills. I think it is unhealthy for a community of therapists or healers to be pushed into offering a very narrow range of techniques or therapeutic strategies. Instead, I think that the individual talents and strengths of each therapist should be honoured, and there should be room in any health care system to allow for this.
Friday, February 24, 2017
Always Question
The freedom to question is a foundation of healthy living.
In our nation, we experience this freedom in the form of constitutional rights to express ourselves, and in the form of enjoying a free press.
For many of us, these freedoms may nevertheless seem fairly abstract, and maybe not that pertinent to daily living. Other issues may seem much more important in daily life. This is especially true if we are struggling with poverty, illness, or other consuming life stresses. Sometimes there may not seem to be time to protect our freedoms, when there are other urgent matters to attend to. Whole nations may feel the same way.
I would like to make a case that this type of freedom must be exercised, on a daily basis, in a wide range of daily activities. This is not just a matter of protecting fundamental human rights, but it is a matter of thinking clearly and rationally about daily, practical decisions, so that we may make these decisions in a way which guides us towards better health and happiness, and education.
Once again, I would like to refer to the work of the great psychologist and Nobel laureate, Daniel Kahneman: he showed us how the human mind is deeply prone to cognitive biases, which affect all of our decisions, often outside of our conscious awareness. His work also suggests ways that we can protect ourselves from being misguided by our biases.
Let's look at an example situation, of a public educational lecture. How do biases occur in such a setting, and how can we exercise our freedoms in a healthy way as audience members?
Most of us would understand a public scholarly lecture to be an entirely benign educational event, in which we could all expand our minds...this would be especially true if the speaker were articulate, expressive, passionate, and experienced with giving lectures!
But here are a variety of biases that occur in lectures:
The Focusing Illusion
In order for a lecture to be narratively interesting, it should probably have a "thesis." This is not unlike a well-written essay (actually, this is one of the ethical problems of the conventionally encouraged format of essays that most students are called upon to produce). If the speaker is vacillating between several positions, the audience may view him or her as weak-minded or lacking confidence. An essayist who vacillates will probably receive a lower grade.
But in order to propose a single thesis, we already are at risk of a bias called the "focusing illusion." This is akin to experiencing a salesman trying to sell you a used car, or a vacation package, or a set of encyclopedias, or an opportunity to contribute to a charity: if we are presented with one single thing, whether it be a consumer item or an idea, we are more likely to accept it, compared to being offered a variety of options, each given equal time and persuasive effort.
A lecture, even if it is being given by a famous, experienced, wise scholar, is quite possibly biased due to the focusing illusion. The audience is more likely to accept the message of the speaker, beyond the acceptance that would be reasonable based on rational thought alone.
Cialdini's Persuasive Factors
Cialdini described the following elements which magnify persuasive power, beyond the rational content of any message or appeal:
a) liking b) authority c) social pressure d)consistency e)reciprocity f)scarcity
A public speaker's persuasiveness will be bolstered by a wide variety of elements which have nothing to do with the accuracy or content of the thesis. An enthusiastic or passionate speaker who is a well-liked and respected authority (or who at least seems to be), will have greater power to persuade an audience, irrespective of the content of the lecture. If many others in the audience are enchanted with the speaker, and are smiling, nodding, or applauding, then you as an audience member will be more likely to go along with this spirit of approval, through social pressure.
A speaker who is wearing more expensive clothing, who physically looks more like you, or has some other coincidental common background (such as hometown, ethnic heritage, or cultural interests), has a more attractive video presentation, with more attractive fonts, elements of humour, and perhaps musical accompaniment, is more likely to be persuasive.
If you have already agreed, particularly in a public way, or through agreements made in previous meetings, to elements of what you are hearing in a current lecture, you are more likely to go further with what the lecturer is saying, even if you would have otherwise disagreed. This is due to the factor of consistency. If you are served snacks and coffee during the lecture, and if the speaker gives you warm compliments, you will be more persuaded by the speaker's message, due to reciprocity. And if the speaker is heavily booked across North America, and if it was hard to even get a ticket to attend the lecture, then you will be more persuaded, since the lecturer will seem more rare and special (scarcity).
Suppression of Counterargument
Kahneman and others have made the case that the most powerful persuasive bias of all is caused by suppression of counter-argument.
If you are attending a lecture, a presentation, a meeting, or a political rally, in which opposing views are not allowed, then this is a strongly loaded environment for biased persuasion. We have seen this phenomenon in political rallies across the world in the past year. When dissent is discouraged, suppressed, or even forbidden, then we as individuals, and we as a society, have lost our authority to make free decisions. Decision-making under such conditions cannot be rational. It would be like a court case in which only the prosecutor or defense would be allowed to speak, rather than allowing both sides an equal opportunity. Or, imagine a NASA team designing a new space station, in which it was not encouraged for engineers or technicians to express concerns about design flaws or safety issues.
Sometimes counter-argument seems to be encouraged, but the actual time and space for this to occur is not actually present. It is freedom in word only, not in action--which really is not freedom at all. A lecturer may allow some time for questions or debate, but often only a few minutes near the end. And the old familiar forces, stated above, may subtly suppress debate. Most audience members would consider it impolite to express disagreement with the speaker, especially if dissenting comments would receive negative non-verbal feedback from fellow audience members.
Zimbardo's Heroism
Philip Zimbardo, another great psychologist of our generation, has made it part of his life's work to study negative behaviours that occur in groups, in conjunction with the types of social psychological dynamics (such as group persuasion) that we've discussed above.
He calls for us to be "heroic": what he means is that we should truly exercise our freedom, to always question. It is easy to question things when we are strongly invited to do so. It is harder to practice this freedom in an environment where questioning is discouraged.
The Risks of Questioning
If you raise questions, it is possible that you could get criticized by others in the group around you. You might be labelled as being difficult, oppositional, or disloyal. Some people may believe that you are being resistant to change, stubborn, or disrespectful. Some might even think you are being narcissistic, as though you are aggrandizing your own opinions while devaluing the opinions of others. The fear of such group disapproval, or of receiving such labels, often deters people from speaking out about things that need to be said.
I think this is a risk worth taking. You can show in other ways that you are not difficult, oppositional, disloyal, disrespectful, stubborn, or narcissistic. The process of freely questioning actually prevents such problems...because freedom of speech, particularly when used in the service of ethical principles and practical problem-solving, causes a growth and strengthening of healthy character traits, both in the individual, and in the group.
I have experienced this type of dynamic, to my surprise and dismay, this past year, and I have decided to try to use this blog as a vehicle to practice and encourage free speech in this way.
Relevance to Psychotherapy & Mental Health
All mental health problems could be understood, in part, to reflect a lack of freedom. Symptoms, such as anxiety or depression or insomnia or fatigue, may limit our freedom to experience life in a meaningful, enjoyable way.
Practicing our freedom of expression is an integral part of cultivating mental health, on a personal level. This freedom could occur, for example, in the form of being able to initiate a conversation which was previously suppressed due to social anxiety or low self-esteem.
In therapy, the counselor or psychiatrist is an authority figure, but this force of authority should not be something that suppresses free expression. Rather, the therapy environment should encourage freedom, including the freedom to dissent! It should feel ok to completely disagree with your therapist, without fear of rejection or argument! I think it should be accepted that it would also be ok, or necessary, for your therapist to sometimes continue a gentle debate with you, rather than simply agree with what you are saying all the time. But this dialog must occur with kindness, compassion, and respect, in a spirit of true openness.
If you are a student, or a member of the audience for meetings, sermons, or lectures, I encourage you always to nurture your freedoms, and to exercise your right to question. It will not only be of great benefit to you, but it will be of great service to other members of the audience, and to the educational process.
Cognitive Therapy
At its best, cognitive therapy is a formal mechanism to question one's own thoughts! Anxiety, depression, trauma, and other adversity give rise to changes in thought, which can often end up causing suffering or oppression. If your own thoughts are frequently bullying you, putting you down, or telling you that you can't do certain things, then this is akin to attending a biased presentation at a lecture, political rally, sermon, or policy planning meeting.
Negative thoughts often could be understood to have some positive motivations--with many anxious thoughts, there may be a sincere motive to be protective. Your thoughts may be trying to warn you about potential dangers, based on learning from the past. It is just that the voice of these thoughts can become too powerful and persuasive, like a demagogue at a political rally.
These negative thoughts are bolstered by the same familiar factors described above:
1) negative self-talk is often presented without comparisons -- leading to the focusing illusion
2) negative self-talk can seem authoritative, which makes it more believable
3) negative self-talk may have been around for a very long time, which bolsters the persuasive factor of "consistency." You may have even made certain "commitments" to the negative thought, or perhaps have been using them as motivational tools (e.g. studying to avoid guilt, rather than to pursue joy).
4) negative self-talk often does not invite questioning or dialog in your mind...it likes to have the final word...attempts to question it can seem futile
So, cognitive therapy can be framed as a type of personal liberation movement, which requires a practice of active questioning. You can become a civil rights leader in your own mind! I think it is important to view cognitive therapy exercises in this way, as the techniques can otherwise seem somewhat oppressive in themselves...the point in cognitive therapy should not be simply to do the exercises your therapist or self-help book is prescribing for you, or to criticize your "cognitive distortions"--this sounds disturbingly like the type of talk yet another oppressor might use. Analogously, in many oppressive political systems, we see one tyrant simply being replaced by another...it is necessary instead to strive for freedom. So I encourage your work in cognitive therapy to be an exercise in compassionately developing and asserting your freedom, through courageous questioning of your self-talk.
I am not meaning to encourage reflexive defiance, however. Sometimes, after a period of debate, it is time to make a decision, and to move forward with that. It can be unhelpful to debate every step of the way in every change process or learning event. But it is very important to make sure that there is space and time given, in all situations, for freedom of speech, free opportunity for dissent, and for balanced, unbiased decision making. I encourage you to protect your own freedoms this way, and also to protect the freedoms of others, by practicing a lifestyle of intellectual openness, curiosity, and free questioning.
In our nation, we experience this freedom in the form of constitutional rights to express ourselves, and in the form of enjoying a free press.
For many of us, these freedoms may nevertheless seem fairly abstract, and maybe not that pertinent to daily living. Other issues may seem much more important in daily life. This is especially true if we are struggling with poverty, illness, or other consuming life stresses. Sometimes there may not seem to be time to protect our freedoms, when there are other urgent matters to attend to. Whole nations may feel the same way.
I would like to make a case that this type of freedom must be exercised, on a daily basis, in a wide range of daily activities. This is not just a matter of protecting fundamental human rights, but it is a matter of thinking clearly and rationally about daily, practical decisions, so that we may make these decisions in a way which guides us towards better health and happiness, and education.
Once again, I would like to refer to the work of the great psychologist and Nobel laureate, Daniel Kahneman: he showed us how the human mind is deeply prone to cognitive biases, which affect all of our decisions, often outside of our conscious awareness. His work also suggests ways that we can protect ourselves from being misguided by our biases.
Let's look at an example situation, of a public educational lecture. How do biases occur in such a setting, and how can we exercise our freedoms in a healthy way as audience members?
Most of us would understand a public scholarly lecture to be an entirely benign educational event, in which we could all expand our minds...this would be especially true if the speaker were articulate, expressive, passionate, and experienced with giving lectures!
But here are a variety of biases that occur in lectures:
The Focusing Illusion
In order for a lecture to be narratively interesting, it should probably have a "thesis." This is not unlike a well-written essay (actually, this is one of the ethical problems of the conventionally encouraged format of essays that most students are called upon to produce). If the speaker is vacillating between several positions, the audience may view him or her as weak-minded or lacking confidence. An essayist who vacillates will probably receive a lower grade.
But in order to propose a single thesis, we already are at risk of a bias called the "focusing illusion." This is akin to experiencing a salesman trying to sell you a used car, or a vacation package, or a set of encyclopedias, or an opportunity to contribute to a charity: if we are presented with one single thing, whether it be a consumer item or an idea, we are more likely to accept it, compared to being offered a variety of options, each given equal time and persuasive effort.
A lecture, even if it is being given by a famous, experienced, wise scholar, is quite possibly biased due to the focusing illusion. The audience is more likely to accept the message of the speaker, beyond the acceptance that would be reasonable based on rational thought alone.
Cialdini's Persuasive Factors
Cialdini described the following elements which magnify persuasive power, beyond the rational content of any message or appeal:
a) liking b) authority c) social pressure d)consistency e)reciprocity f)scarcity
A public speaker's persuasiveness will be bolstered by a wide variety of elements which have nothing to do with the accuracy or content of the thesis. An enthusiastic or passionate speaker who is a well-liked and respected authority (or who at least seems to be), will have greater power to persuade an audience, irrespective of the content of the lecture. If many others in the audience are enchanted with the speaker, and are smiling, nodding, or applauding, then you as an audience member will be more likely to go along with this spirit of approval, through social pressure.
A speaker who is wearing more expensive clothing, who physically looks more like you, or has some other coincidental common background (such as hometown, ethnic heritage, or cultural interests), has a more attractive video presentation, with more attractive fonts, elements of humour, and perhaps musical accompaniment, is more likely to be persuasive.
If you have already agreed, particularly in a public way, or through agreements made in previous meetings, to elements of what you are hearing in a current lecture, you are more likely to go further with what the lecturer is saying, even if you would have otherwise disagreed. This is due to the factor of consistency. If you are served snacks and coffee during the lecture, and if the speaker gives you warm compliments, you will be more persuaded by the speaker's message, due to reciprocity. And if the speaker is heavily booked across North America, and if it was hard to even get a ticket to attend the lecture, then you will be more persuaded, since the lecturer will seem more rare and special (scarcity).
Suppression of Counterargument
Kahneman and others have made the case that the most powerful persuasive bias of all is caused by suppression of counter-argument.
If you are attending a lecture, a presentation, a meeting, or a political rally, in which opposing views are not allowed, then this is a strongly loaded environment for biased persuasion. We have seen this phenomenon in political rallies across the world in the past year. When dissent is discouraged, suppressed, or even forbidden, then we as individuals, and we as a society, have lost our authority to make free decisions. Decision-making under such conditions cannot be rational. It would be like a court case in which only the prosecutor or defense would be allowed to speak, rather than allowing both sides an equal opportunity. Or, imagine a NASA team designing a new space station, in which it was not encouraged for engineers or technicians to express concerns about design flaws or safety issues.
Sometimes counter-argument seems to be encouraged, but the actual time and space for this to occur is not actually present. It is freedom in word only, not in action--which really is not freedom at all. A lecturer may allow some time for questions or debate, but often only a few minutes near the end. And the old familiar forces, stated above, may subtly suppress debate. Most audience members would consider it impolite to express disagreement with the speaker, especially if dissenting comments would receive negative non-verbal feedback from fellow audience members.
Zimbardo's Heroism
Philip Zimbardo, another great psychologist of our generation, has made it part of his life's work to study negative behaviours that occur in groups, in conjunction with the types of social psychological dynamics (such as group persuasion) that we've discussed above.
He calls for us to be "heroic": what he means is that we should truly exercise our freedom, to always question. It is easy to question things when we are strongly invited to do so. It is harder to practice this freedom in an environment where questioning is discouraged.
The Risks of Questioning
If you raise questions, it is possible that you could get criticized by others in the group around you. You might be labelled as being difficult, oppositional, or disloyal. Some people may believe that you are being resistant to change, stubborn, or disrespectful. Some might even think you are being narcissistic, as though you are aggrandizing your own opinions while devaluing the opinions of others. The fear of such group disapproval, or of receiving such labels, often deters people from speaking out about things that need to be said.
I think this is a risk worth taking. You can show in other ways that you are not difficult, oppositional, disloyal, disrespectful, stubborn, or narcissistic. The process of freely questioning actually prevents such problems...because freedom of speech, particularly when used in the service of ethical principles and practical problem-solving, causes a growth and strengthening of healthy character traits, both in the individual, and in the group.
I have experienced this type of dynamic, to my surprise and dismay, this past year, and I have decided to try to use this blog as a vehicle to practice and encourage free speech in this way.
Relevance to Psychotherapy & Mental Health
All mental health problems could be understood, in part, to reflect a lack of freedom. Symptoms, such as anxiety or depression or insomnia or fatigue, may limit our freedom to experience life in a meaningful, enjoyable way.
Practicing our freedom of expression is an integral part of cultivating mental health, on a personal level. This freedom could occur, for example, in the form of being able to initiate a conversation which was previously suppressed due to social anxiety or low self-esteem.
In therapy, the counselor or psychiatrist is an authority figure, but this force of authority should not be something that suppresses free expression. Rather, the therapy environment should encourage freedom, including the freedom to dissent! It should feel ok to completely disagree with your therapist, without fear of rejection or argument! I think it should be accepted that it would also be ok, or necessary, for your therapist to sometimes continue a gentle debate with you, rather than simply agree with what you are saying all the time. But this dialog must occur with kindness, compassion, and respect, in a spirit of true openness.
If you are a student, or a member of the audience for meetings, sermons, or lectures, I encourage you always to nurture your freedoms, and to exercise your right to question. It will not only be of great benefit to you, but it will be of great service to other members of the audience, and to the educational process.
Cognitive Therapy
At its best, cognitive therapy is a formal mechanism to question one's own thoughts! Anxiety, depression, trauma, and other adversity give rise to changes in thought, which can often end up causing suffering or oppression. If your own thoughts are frequently bullying you, putting you down, or telling you that you can't do certain things, then this is akin to attending a biased presentation at a lecture, political rally, sermon, or policy planning meeting.
Negative thoughts often could be understood to have some positive motivations--with many anxious thoughts, there may be a sincere motive to be protective. Your thoughts may be trying to warn you about potential dangers, based on learning from the past. It is just that the voice of these thoughts can become too powerful and persuasive, like a demagogue at a political rally.
These negative thoughts are bolstered by the same familiar factors described above:
1) negative self-talk is often presented without comparisons -- leading to the focusing illusion
2) negative self-talk can seem authoritative, which makes it more believable
3) negative self-talk may have been around for a very long time, which bolsters the persuasive factor of "consistency." You may have even made certain "commitments" to the negative thought, or perhaps have been using them as motivational tools (e.g. studying to avoid guilt, rather than to pursue joy).
4) negative self-talk often does not invite questioning or dialog in your mind...it likes to have the final word...attempts to question it can seem futile
So, cognitive therapy can be framed as a type of personal liberation movement, which requires a practice of active questioning. You can become a civil rights leader in your own mind! I think it is important to view cognitive therapy exercises in this way, as the techniques can otherwise seem somewhat oppressive in themselves...the point in cognitive therapy should not be simply to do the exercises your therapist or self-help book is prescribing for you, or to criticize your "cognitive distortions"--this sounds disturbingly like the type of talk yet another oppressor might use. Analogously, in many oppressive political systems, we see one tyrant simply being replaced by another...it is necessary instead to strive for freedom. So I encourage your work in cognitive therapy to be an exercise in compassionately developing and asserting your freedom, through courageous questioning of your self-talk.
I am not meaning to encourage reflexive defiance, however. Sometimes, after a period of debate, it is time to make a decision, and to move forward with that. It can be unhelpful to debate every step of the way in every change process or learning event. But it is very important to make sure that there is space and time given, in all situations, for freedom of speech, free opportunity for dissent, and for balanced, unbiased decision making. I encourage you to protect your own freedoms this way, and also to protect the freedoms of others, by practicing a lifestyle of intellectual openness, curiosity, and free questioning.
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