Thursday, July 31, 2008

Fishing Metaphor

I find this metaphor applicable especially to social anxiety, shyness, and frustrations finding new relationships.

The aspect of this metaphor I don't fully like is that it is a little bit "predatory". And I also feel badly for creatures that are hunted or raised for food, including fish. Yet, fishing has been an important human activity for thousands of years, and similar processes occur in all other domains of nature. Also, the metaphor of fishing has been used elsewhere in literature & religion (e.g. in a story from the Bible, Jesus' disciples are called to be "fishers of men"). In adopting this metaphor, I would insist that people maintain healthy, honourable respect for other individuals ("fish"), just as they would expect others to treat them honourably. But here is the metaphor:

Forming relationships is like fishing.

In order for fishing to be a positive and successful experience, it helps to enjoy the process: getting up early, traveling to the lake, organizing your equipment, sitting in the boat. If you enjoy the process itself, your emotions will be more relaxed and positive, and you will be less vulnerable to feeling hurt or disappointed if you don't actually catch any fish.

You should be well-fed, not hungry, when you get into your boat.

Once you are in the boat, you need to have your line in the water.

If you are not getting any bites, you may need to move your boat, or try a different lure.

If you have many bites, but no fish, it is usually a good sign, not a bad sign. Keep trying. Mind you, there may be a problem with your technique that is causing this problem, so you may need to assess this or get advice about it.

It is a recipe for disappointment if you expect to catch a particular individual fish that you see in the lake (you can always try, though, as long as the effort is enjoyable for you). Be open to assessing the bites that you actually get.

It can help immensely to have a "guide" to help you fish.

It is vitally important to learn about safety on the water, and to take all appropriate steps to stay safe (e.g. life jackets, learning boating skills, letting people know where you are, etc.).

It is necessary, healthy, and appropriate, to "throw back" fish that are not the right ones for you. You should be skilled at this practice, so that you do not unnecessarily injure yourself, or the fish you throw back.

Fishing is probably more enjoyable and a more successful activity if it is something you do regularly as part of a healthy lifestyle, instead of something you do only once every few years.

Defective steering wheel metaphor

We all have the capacity to "steer" our lives.

Yet the "steering wheel" never works perfectly. It may steer better at certain moments, but later on may seem to barely work at all.

Imagine driving a car like this. It could lead to moments of calm, confident driving, but then when the steering is failing, it would lead to frantic efforts to steer harder. You would see that your efforts produced some result (since the steering wheel still works a bit), so you would step up the frantic efforts. Yet the car might continue to lose directional control.

To manage this situation, you must be prepared to steer well when you can. When the steering wheel is not working so well, resist the vicious cycle of frantically attempting to regain control. You may need to slow the car down enough so that you can keep it on track even with limited steering capacity.

People panic when they can't control their lives. Often the panic is worse when they see that they are not TOTALLY out of control, but only partially. The panicked person observes that they have PARTIAL control, so they frantically try to exert this partial control on their lives. The frantic quality of this action increases the panic and exhaustion. It may cause the person to forget to slow the car down, and that's when major accidents can happen.

Ship at Sea metaphor

Your situation may be like a ship in the middle of the sea.

You may not know where you are.

You may not know if you are progressing or not.

You may be struggling hard to push forward, but are unsure whether you are going in the right direction, if you are going in circles, or if you are making any headway at all against the current or the wind.

Your frantic efforts to push the ship forward may result in the structural integrity of the ship starting to fail -- leaks here and there may not be addressed, or you might not notice the broken rudder.

It helps to know a few things:
1) there are ways to navigate, and these techniques need to be learned. You may be so focused on the task of propelling your ship, that you forget to look up at the stars at night, to see where you are. You may need to learn from others in order to navigate efficiently. The learning may need to take place through receiving advice, reading books, and practicing (with the expectation of making mistakes along the way).
2) Your efforts across the vast sea may be very significant, you may be making tremendous progress in your journey, but when you look out of your ship you may still see exactly the same blank, empty horizon with no sign of land. Be patient. You may be farther along than you think you are. Your efforts may have helped you more than you think they have.
3) you have to do regular maintenance on your ship -- resist the urge to frantically push forward, and reserve time for self-care.
4) the wind can be your ally, even if it is blowing against you. In sailing, one can use the power of a headwind to propel oneself forward--it requires a tactical change though, you have to "tack" by moving at an angle away from your desired direction, and "zig-zag" instead of going straight. Many goals in life require "tacking" instead of a direct approach.


I like to think of myself as a non-dogmatic intellectual with an open mind. I tend to interpret stories about mystical or supernatural experience as phenomena of the mind that may have some metaphorical truths contained within them, while not actually being literally "true". Dreams are another example--often times dreams can be intensely meaningful and relevant, yet my standard belief is that they are not literally predictive of the future, etc. I like to think of such experiences as most often being neutral structures of the mind, onto which we can consciously apply or project meaning, as opposed to being intrinsic sources of meaning. Dreams are like the canvas; our conscious mind may apply direct meaning to the canvas.

There are some specific instances, though, in which some of these phenomena can influence subsequent events. For example, if thousands of people read the same horoscopes in a newspaper, and the horoscope advises Capricorns to wear red, and to be prepared to smile and make friends with a stranger wearing yellow; and Libras are advised to wear yellow, and to be prepared to make friends with a stranger wearing red -- then you can see that the horoscope may end up influencing subsequent social behaviour, and the prediction may come to pass with greater likelihood. If it does come to pass, the Capricorns and Libras who meet each other will even more strongly believe in the mystical power of the horoscope. Perhaps some other mystical experiences can work in a similar way, that the heightened expectation leads to a higher likelihood of certain experiences coming to pass.

Yet, I have to acknowledge, in my work with many patients, that there are experiences in the mind in a sort of mystical realm, that can be very significant, eerily predictive, powerfully moving, and unexplainable through conventional logic. There are some people who seem to have these kinds of experiences more often than others. A quality of these kinds of experiences is that they may defy logical testing, replication, or "proof". I think we should all be open-minded about this, and embrace the truth that we can't explain everything, perhaps some things are intrinsically unexplainable, and while we should never suspend our intellectual faculties, we may sometimes have the opportunity to embrace, enjoy, or be moved by, a special "mystical" experience. History is certainly full of stories of individuals moved and inspired by such experiences.

Due to the elusive nature of such experience, though, I do think it is important not to fall into dogmatic interpretations if they should happen. Delusional or psychotic phenomena are quite frequent, and when such experiences strongly influence behaviour, or are held to be literal external truths, there can be all sorts of problems. I think what distinguishes an unexplainable or poignant "mystical" moment from a delusional belief is that the former is poetic or symbolic, and the meaning is understandable by peers, while delusions lead to concrete, ongoing changes of belief and behaviour which are highly dissonant from the perspective of others (e.g. a delusion that aliens are monitoring one's movements with cameras and secret agents).

Wednesday, July 30, 2008

Healthy Eating

-lots of fresh vegetables & fruits (except for root vegetables), in amount and variety
-lots of high-fiber foods
-less meat, if any
-fish is healthy, especially fatty red fish such as salmon (an omega-3 source)
-but this has to be moderated due to the unfortunate risk of heavy metal contamination from eating a lot of fish, and due to the environmental problem of worldwide overfishing
-tea is good, in moderation (green & black), unless the caffeine is interfering with sleep
-dark chocolate is good for you; but it has to be in moderation, since it contains a lot of saturated fat
-carbohydrates (carbs) are probably important and necessary for mental health; low-carb ketotic diets are probably hard on the brain. But it is important to choose complex carbs that are released more gradually into your body. Sprouted whole grain breads are better. White bread or rice is almost like pure sugar, in terms of its rate of digestion into simple carbohydrates. Sugar itself should be cut down substantially (it has addictive properties; once you have gradually weaned sugar from cooking and baking, perhaps to 1/3 or 1/4 of what most recipes recommend, you will enjoy the intrinsic flavour of the baking more, and find the higher-sugar recipes unpleasantly sweet).
-components of the "Mediterranean" diet in which there is abundant use of olive oil, is probably healthy
-eliminate trans-fatty-acids from the diet (e.g. hydrogenated oils, often present in many packaged foods to prolong shelf life -- remember this may prolong the oil's "shelf life" on the inside of your arteries as well).
-there is some evidence that there is an excess of omega-6 fatty acids in the typical North American diet; this can be addressed by reducing use of omega-6 rich oils such as sunflower and corn oils, and instead using oils such as canola. Walnuts and flax are other natural sources of healthier omega-3 oils.
-1 to 2 glasses of wine (125-250 mL) per day may improve health compared to abstainers, and compared to those who drink more. But some individuals may have health problems as a result of drinking even small amounts of alcohol. In this case it is best to abstain.
-drinking water is great, but you really don't have to drink huge amounts. Keep yourself well-hydrated, but you only need to drink if you're thirsty.
-I do encourage people to leave all soft drinks behind -- the sugary ones are obviously bad for you. The ones with artificial sweeteners are probably not great for you either, and are also training you to expect sweetness while you hydrate yourself--this conditioning may exacerbate an unhealthy dependence upon simple carbohydrates and sweets, and cause you to be perceive the simple joy of drinking pure water to be unpleasantly mundane. Also do you really want to financially support the big soft-drink companies, with their expanding presence in children's schools, developing countries (many of whose people are dying from starvation), etc.?
-minimize the use of salt
-high-temperature cooking such as barbecuing adds flavour to food, but may result in higher levels of unhealthy chemicals, so it is probably best to reduce the intake of charred food.
-if you are a vegetarian or have other dietary restrictions, make sure you get an adequate intake of vitamins and minerals. A simple daily vitamin supplement should usually be sufficient. I do not see compelling evidence that "megadose" vitamins are beneficial.
-but there is some evidence that the RDA for vitamin D ought to be higher, perhaps up to 1000 IU per day or more.
-extra calcium supplementation may also be needed for many people on a long-term basis, to maintain bone health

While much of this advice is part of basic general health, I think that basic general health is also beneficial to mental health. And there may possibly be specific direct benefits to mental health from a very healthy diet.

I do qualify the above remarks, by saying that extremely clear, direct evidence linking healthy nutritional habits to improved mental health, is lacking. Much of the evidence is indirect or anecdotal. Many exaggerated claims are made in the advertising found in health-food stores. There are a few small studies looking at specific supplements, such as omega-3 supplements, which show some modest evidence that this can improve mood.

Some useful links:
1) the USDA nutrient database (detailed nutritional data about different foods):

2) the Cornell University food psychology page:

The American Journal of Clinical Nutrition is a good academic journal to browse through, to get a good sense of what is going on in food & nutrition research. You can head to an academic library, and leaf through the past year's issues.


After reading the excellent comment on this entry, I feel compelled to add a few things to what I now recognize has been a very dry and pedantic set of comments:
I forgot to mention that I think food is one of the great joys and pleasures of life!
As with other joys, it is wonderful and healthy to develop and nurture a rich culinary experience.
Not only are food, cooking, and eating sources of sensual pleasure, they are also part of a rich and healthy culture (and a way to introduce oneself to new cultures), a part of a social and community life, and a part of an active intellectual life. It is a delight of human nature that we can start with something basic (e.g. an onion, or a grape), and keep refining it, transforming it, and using it in new ways, until we derive more and more art and pleasure from it. There is something very basic about the meaning of life itself in this kind of dynamic.

So I wholeheartedly endorse the idea of embracing and developing a rich culinary culture as part of healthy living. I do still maintain, however, that every culture ought to be informed by science and evidence, and perhaps adaptations can be made to certain cultural practices if we learn that they are harmful (to ourselves, to others, or to the environment). Sometimes the symbolic or esthetic value of a cultural practice can be preserved while the unhealthy aspects can be minimized.

Dietary Extremism

This is a sensitive topic, as many people feel badly about their weight, body image, and dietary habits. And many people have eating disorders, in which difficult relationships with food and with body image lead to a variety of behaviours that can do severe physical and emotional harm.
In this post, I wanted to address the specific phenomenon of what I call "dietary extremism". I consider the phenomenon to be similar to dogmatic religious belief.

Dietary extremism occurs as a result of people struggling to find some change in their lives that truly makes a difference for the better. They may have tried a wide variety of "standard routes" but continue to struggle with the same problems.

Extremism can often yield results for people, because it involves a radical change in lifestyle. It is something like joining a monastery. The lifestyle becomes more sustainable because of the community of fellow extremists (the other "monks in the monastery"), and because the community sets itself apart from the mainstream. The extremist beliefs are entrenched within the community, especially when members of the community are seeing significant changes within themselves for the first time.

Yet, the beliefs themselves are often extremely dogmatic and inaccurate. While I am a fan of permanent, positive life change, I believe that we must always stay attuned with the truth, always be open-minded to hear the facts, always be willing to question and challenge, always be wary of being told what to do by a guru-like figure (who, incidentally, may be making a lot of money and enjoying a lot of attention from fans, by selling books or running retreats).

A specific example that has come to my attention is the "raw food diet". Adherents have made substantial changes to their lifestyle. And, in my opinion, they are usually healthier for it. There is quite a bit of evidence that eating more fruits & vegetables, eating less meat, eating fewer animal products, etc. is part of good self-care. Furthermore, it is better for the environment, better to address world hunger (since raising animals instead of plants on agricultural land produces less nutritional energy per acre), and more humane (fewer sentient creatures need to be killed).

But most informational tracts about "raw food" are filled with claims that sound "scientific". The use of false or misleading pseudo-scientific claims is a typical tool used in charlatanism. This is one of the pathways that makes this potentially healthy dietary idea stultified by dogma. If you encounter statements about various types of nutritional degradation caused by heating, or about the miraculous virtues of some kind of oil (e.g. coconut oil), or about the advantages of choosing foods that are "less acidic", etc. I encourage you to be aware that there may be some dogmatic, charismatic salesmanship going on. The fact that these statements sound "scientific" may simply be fooling you. If you really want to know the truth, or what the evidence shows, then I think it is important to look closely yourself, at primary sources in reputable research journals.

The concern I have about the dogma doesn't necessarily mean that I think "raw food" (or some other diet) is a bad thing. I think it is a cultural practice, which has healthy aspects to it. Like other cultural practices, there may be a well-developed estheticism within it, leading, for example, to some really good recipes with raw food ingredients. The cultural practice crosses the line, though, into dogmatism, when it pronounces itself better than all other practices, and starts to support this claim using spurious or misleading information. All the while, many people are probably making quite a profit by marketing these ideas.

One of the phenomena often described in extremist groups is a collection of testimonial accounts from people whose lives have been radically changed for the better (e.g. cured of cancer, reached their ideal weight, felt healthy for the first time in their lives, etc.). While it may well be true that these individuals are genuinely thriving as a result of their new cultural practice, the mechanism of this change may be the result of very different factors than what they believe. Most any radical life change that leads to a sense of purpose, community, consistency, and meaning can have a transformative positive effect on an individual's health. I encourage such quests for purpose, community, and meaning -- but I encourage people to keep an open mind and to avoid dogma.

There are some good journals of scientific nutrition, such as the American Journal of Clinical Nutrition, and others. Abstracts are available on-line for free, and you can search on medical databases for information. Once again I encourage you to explore the evidence first-hand. When you read a claim about the nutritional virtues about this or that food, or this or that diet, be aware that you may be reading an ad, or an "info-mercial", and be prepared to search further yourself to clarify this kind of information before you make a needless change in your health behaviours.

Tuesday, July 29, 2008


The intersection between music and emotion is complex.

Musical preferences or predilections are often very personal and individual, and are often coloured by a person's past history (e.g. some songs may be associated with positive or negative past life events). Of course, the musical styles that you grow up with often become those you permanently prefer.

I've noticed quite often that patients of mine who struggle with sadness or anger may choose music that has a sad or angry emotional tone. In these situations I worry sometimes about whether the music itself is "feeding" the negative emotion. An extreme example of this would be music in which the performer is screaming, often about how bad life is, where the listener--often using headphones that are socially isolative--is absorbed for hours every day.

But I think that music is an external experience that can touch us, or resonate with emotions. In this way a musical experience can help us feel less alone, more understood, more "in synchrony" with something outside of ourselves, even if the music is laden with the same kind of sadness that we may experience internally.

Therapeutically, I have to acknowledge the value and power of this kind of "synchrony". So I generally would never try to dissuade the fan of "screaming angry music" from continuing their choice of genre (besides, I would be just one more person unsuccessfully attempting such subjectively intrusive and unwelcome advice). Yet I encourage people to gently explore types of music outside of their familiar territory, and to search for music which goes further than emotional synchrony alone, but also soothes, calms, inspires, provides hope, gives energy, or gives a thrill of joy. Some of the great works of music can touch us in our sadness, and therefore "resonate", while also guiding us towards hope or even making us smile with delight.

Here are some specific examples (off the top of my head) which work for me (everyone will have different tastes, of course, but if you're looking for something different, give these a try) :

-anything by W.A. Mozart. the piano sonatas (exquisite, sweet); the piano concertos (poignant and sometimes sad but always ending with hope and joy -- and the tunes stay in your mind); the wind concertos (clarinet & oboe).

And very specifically a vocal piece by Mozart called "Exsultate, Jubilate"; the piece in its entirety is a distillation of the joy of life. The last item in this piece is the perfectly beautiful and energetic "Alleluia". In fact, I would go so far as to make this whole piece--including the composition itself as well as the performers and their backgrounds--a metaphor for joy in life: to have joy, one must work at it for years (as the performers have done). One must hear others and learn from others. One must pursue poignancy as well as virtuosity. One must have moments of tension and dissonance, but they must always be relieved imaginatively and beautifully. Some of the joyous moments may be brief, but they stay with us forever even after they are literally over. My favourite performer of this piece is now Carolyn Sampson. Kiri Te Kanawa was my previous favourite. I'd recommend listening to it on the best possible stereo system available to you.

Another specific selection is the Goldberg Variations by J.S. Bach as played by Glenn Gould (who made two recordings of this piece, in 1955 and in 1980 -- I'd recommend hearing them both, starting with the 1955 version; the final aria at the end of the 1980 version is like a sweetly beautiful farewell from one of the great musical geniuses of the century). Also there's a version by Murray Perahia which is extremely good too, in case you find Glenn Gould's playing too eccentric. This piece is another metaphor for life: it starts with something simple and beautiful; it moves through many variations with different degrees of motion, emotion, and energy, yet always with the same underlying grounding theme; then it ends beautifully and serenely, almost just as it began. Implying a cycle that continues yet changes, beginning and ending at peace, but with lots of work and tension and playfulness and growth in-between.

Other specific suggestions:
1) Chopin, Piano Concerto #1 in E minor, Opus 11. The second movement is an example of sublime beauty.
2) Beethoven: Violin Concerto. Beethoven had a difficult life as a result of his own inner emotional problems (lots of depression, irritability, anger, relationship disappointment) in conjunction with various external sorrows, especially the total loss of his hearing. His music is full of emotion and power; underneath the sorrow there is sweetly touching beauty and joy, and I think the violin concerto is one of my favourite examples. Anne-Sophie Mutter is a great performer of this piece.
3) Beethoven: slow movements from many of the piano sonatas, such as "Pathetique" and "Moonlight".

With all of these suggestions, I realize that for some people, they would just rather listen to something else (musical taste is such a personal thing). Also, when feeling very unwell in any way (emotionally or physically), sometimes even your favourite music can feel irritating or can make you feel worse (it may remind you, for example, of how much you could be enjoying it if you were feeling well; your lack of enjoyment when ill could then remind you again of your illness and make you feel worse).

Tuesday, July 22, 2008


Obsessive-compulsive disorder (OCD) is a common anxiety disorder. It is characterized by recurrent, bothersome mental or behavioural habits. "Obsessions" are recurrent, unwelcome thoughts or images, and "compulsions" are habitual behaviours (physical actions or sequences of thoughts) which often relieve the anxiety induced by obsessions. The symptoms can arise at almost any time in life, but often begin during childhood or during young adulthood. The symptoms often wax and wane over time, sometimes changing slightly from one type to another, sometimes becoming worse during stressful situations.

There are certain types of symptoms that are most common:
1) obsessive concern about germs or dirt, leading to compulsive washing
-this pattern can become so extreme that hours of the day can be spent cleaning, hands getting badly chapped from overwashing; there can be a lot of avoidance of situations (e.g. crowds, public transit, washrooms, shaking hands with people) where there may be a perceived abundance of germs

2) obsessive doubt, leading to compulsive checking
-those with this symptom frequently feel that they have made a mistake--sometimes a catastrophic mistake such as having left the oven on, or having hit someone with their car--leading to a compulsive need to go back and check to make sure this hasn't happened. A lot of time can be wasted going back to check and re-check. Often times people with this symptom realize their behaviour is irrational or excessive, but the feelings are so strong that they can't stop the pattern.

3) obsessive or compulsive symmetry: a need to assess the symmetry of things, or to make things symmetric. Sometimes there may be a need to do an activity (e.g. brushing teeth, or tying shoes) in a very particular way, and if something interrupts the behaviour, the symptom makes the person want to go back and start again from the beginning. A related symptom is a feeling of needing to count things in multiples, or do things a certain number of times (e.g. things have to be in threes).

4) obsessional thoughts: often these are thoughts about doing something forbidden or inappropriate; they often have a violent or sexual nature, and can be hard for people to talk about (people can be embarrassed or ashamed at having the thoughts). Symptomatic people often will interpret their thoughts as evidence that they are not safe or that they are losing their mind. The symptom can lead to avoidance of many situations (e.g. if the obsessional thought is about doing something aggressive, it may lead to avoidance of being around other people).

There are many other varieties of obsessions & compulsions, and it can be helpful to read an educational book on the subject. The OCD Workbook by Bruce Hyman is a good example.

There are two types of therapy that help most with OCD:

Cognitive-behavioural therapy is extremely important and has been shown to work. The main principles here are to educate oneself about OCD, to be able to recognize and pronounce the symptoms as they occur (i.e. to recognize in one's mind that "this is an OCD symptom, not a sign of insanity or dangerousness"), to stop oneself from doing the compulsive behaviours, and to practice exposure to situations that induce the symptoms (e.g. for the germ phobic person, the exposure therapy may be spending time with bare hands scooping soil in a garden).

Antidepressant medications which act on the serotonin system in the brain also reduce OCD symptoms.

Typically, any treatment for OCD reduces symptoms by about 30%. For some people the treatments work much better. Often times, combinations of therapy techniques, continued for longer periods of time, are needed to tame the symptoms more completely.

Monday, July 21, 2008

Projective Identification

This is an idea introduced by psychoanalysts. I think it is a wise illustration of a common emotional and behavioural pathway that we all experience.

Here's an example:

Person 1 (in an irritable mood): "You're angry at me!"
Person 2 (in an neutral mood): "No, I'm not angry."
Person 1 (more angry): "Yes you are, I can hear it in your voice."
Person 2 (defensively): "I think I'm speaking the same as always."
Person 1 (more angry): "Now you're denying it!"
Person 2 (getting upset): "I'm not angry!"
Person 1: "Now you're shouting!"
etc. (the point here is that initially calm person 2 is becoming angry, due to projective identification originating from person 1)

In various emotional states, our emotions may strongly colour our perception of social exchanges. In "projective identification" our own emotion (most commonly anger) can cause us to perceive others as threatening. This perception may lead to an action. The action, especially if repeated, may cause the other person to actually become angry or irritated. From the initially angry person's point of view, the exchange appears to prove that his or her angry belief was correct all along.

This phenomenon causes the emotionally upset person to inaccurately attribute emotions to external events. Also it can lead to a vicious cycle in which stronger and stronger negative emotions are generated, "projected out" into the environment, then bolstered further by the consequences which follow. Also the upset person is bound to have more and more negative experiences, which further entrench the feeling of upset.

One of the tasks in a therapy environment is to gently consider the possibility of projective identification going on, and to prevent the vicious cycle from happening. This requires understanding, empathy, and a trusting therapy relationship. I think many such phenomena have to be pronounced, described, and discussed, in the here and now, in order for them to lose their power.

Reasons for Psychiatric Hospitalization

A psychiatric hospital stay often begins with an emergency room visit, though sometimes can be arranged in advance.

There are different reasons for a hospital stay:
-a high or immediate risk of suicide
-inability to safely care for self at home
-diagnostic uncertainty with serious symptoms requiring a more urgent, comprehensive medical evaluation (e.g. delirium)
-behaving dangerously due to psychiatric symptoms (e.g. a manic state)
-initiating a treatment that is difficult as an outpatient (e.g. ECT, major medication changes)
-respite for self and for other caregivers
-a comprehensive inpatient reassessment of complex or chronic problems (e.g. refractory depression or psychosis)

Many psychiatric hospital stays nowadays are brief--perhaps a few days-- with an aim to be just long enough to help someone through an immediate crisis, while quickly ensuring that there is some kind of follow-up outside the hospital.

Other stays average 2 weeks, allowing for a more thorough evaluation and change in treatments.

Sometimes there are longer stay hospitalizations, which can last for months. Manic states often require longer stays of this type.

There are chronic psychiatric hospitals for those who have severe, active, long-lasting illness and who cannot manage outside the hospital. In general, chronic psychiatric hospitalization is becoming much more uncommon, partly due to a philosophy of trying to optimize outpatient help and community resources, but partly due to budget cutting. It may be that some persons who may benefit from chronic inpatient care, and who are not doing well with other community resources, may be at risk of "falling through the cracks" in the system, and may end up struggling with a very poor quality of life, often in a homeless state.

The Emergency Room

Hospital emergency rooms are always open; emergency help is always available. If you can't make it through the day, or through the hour, and your other resources are not sufficient, you can always be seen and taken care of in the hospital.

There are several points of entry to the hospital system. Sometimes an admission to a psychiatric ward can be arranged in advance, but quite often the entry point is the hospital emergency room.

Emergency rooms are chaotic places. There are a variety of frustrations that one might have to deal with. There may be a long wait to be seen by a physician. There might be a lot of noise, and a lot of upset due to various other emergencies being dealt with. The seats or beds may be physically uncomfortable. You would probably be seen by a variety of different people, and it may be very frustrating and exhausting to have to tell your story several times: first to a triage nurse, then to an emergency physician. If psychiatry is consulted, then there might be a student or resident who would see you next, prior to the actual psychiatrist. Along the way, each interviewer may be different in their level of comfort, thoroughness, or rapport with psychiatric interviewing. You may encounter an interviewer who is tired or impatient.

If you are in a time of urgent emotional distress, these frustrations can be especially hard to deal with. I encourage you to bear with it. At the very least, the emergency room is safe, and it can be the beginning of a powerful, sometimes life-saving therapeutic experience.

Here are two suggestions that can make an emergency room visit a little easier:
1) bring a friend or loved one with you, if possible
2) if you have a doctor, therapist, or psychiatrist, ask him or her to call or fax the emergency room, to better inform them about you in advance. This can often make a big difference, and help the process proceed more smoothly.

Thursday, July 17, 2008


The area of addiction and substance abuse is challenging for me.

One simple definition of addiction is "continuing a behaviour despite harm".
In this sense, I suppose a broad range of human activities could be considered addictions.

The more obvious examples of addiction include more specific symptoms:
-developing tolerance (one has to do more and more of the addictive behaviour to get the same effect from it)
-withdrawal symptoms (discomfort--physical or emotional--if the behaviour is stopped)
-feeling psychologically or physically dependent upon the addictive behaviour
-wanting or trying to stop or cut down, but feeling powerless or unable to do so

One core aspect of addiction in my opinion involves a relationship analogy. The addictive behaviour is a relationship. An addictive relationship is one in which other relationships become less and less important or enjoyable, while the addictive relationship consumes more and more time, energy, commitment, and money. In severe addiction, all of the person's other relationships (with people, work, hobbies, other pleasures, and with self) atrophy, while the addictive behaviour monopolizes. Associated relationships may foster the addiction (e.g. the addict's only social supports may eventually only be fellow addicts). An addictive behaviour often starts off being pleasurable, but eventually the pleasure usually fades. It is a trap. Once inside the trap, it is hard to get out. One of the most powerful, exquisitely difficult aspects of the addictive trap can be that the person entangled in it might not be aware of being in the trap; or so much identity or will may be bound in the addictive relationship, that the person might not want to take any steps to escape, and may angrily reject offers of help.

I have often felt that various symptoms of depression and other mental illnesses have addictive features: in depression, for example, there can be behavioural habits, or habits of thought, that can monopolize a person's life, sapping energy that could otherwise be directed in healthier directions. Like other addictions, these habits can be very hard to change without external help.
In chemical addictions (alcohol or drug), the addictive trap can have an overtly pharmacological aspect, which may need to be treated medically. For example, severe alcohol withdrawal can cause death if it is not treated medically.

Aside from treating withdrawal symptoms, pharmacological treatments for addiction have been less successful or useful, although there are some new medications that are showing some modest benefit.

In heroin addiction, one of the most effective treatments of all is not to "escape the trap" at all, but to provide a continuous supply of the addictive agent or analog (e.g. methadone), so that the addict does not have to live a life of desperation, constantly battling with withdrawal symptoms, or needing to engage in dangerous behaviours to seek the daily supply of heroin.

Treatments for addiction need to address a variety of factors:
-the behaviour itself needs to either stop or be reduced substantially (abstinence)
-or the addictive need has to be provided continuously ("harm reduction")
-Once these changes have taken place, the relationships outside of the addiction need to be rebuilt -- if there are no such external relationships left, then an addicted person is isolated, and understandably drawn quickly back into the familiarity of the addictive behaviour.

One common resource for addictions is a "12-step group". I think the greatest strength of such groups is the mutual understanding among members, and the daily community support. Addictive behaviours have a magnetic allure, that often draws a person back into the addiction on an hourly or daily basis, and so a therapeutic resource that is available on an hourly or daily basis can be extremely important and necessary. A problem with 12-step groups can be that they may be quite dogmatic, they have a specific belief system not unlike a religion, and the views may conflict with other resources (e.g. some groups may be strongly opposed to the use of psychiatric medication).

Yet, in approaching addictive problems, I encourage people to give 12-step groups a try, to try repeatedly, perhaps to try several different groups to find one that suits them best.

There are other resources out there as well, and once again I think that finding good primary medical care (a gp) is an excellent first step. In severe chemical addictions, a detox centre may be needed to discontinue the addiction in a medically safe setting.

A day away from an addictive behaviour is a powerful start. A week away is a path away from the trap of withdrawal symptoms. A month away is the start of rebuilding healthy relationships. And a year away seems to be a qualitatively powerful and significant period of abstinence; rates of successful long-term abstinence are much higher for those who can be abstinent for a year. But a single day at a time is a good place to start. And you may need help to get through that day, don't be afraid to seek it. Here is a link to the Vancouver AA meeting schedule:

Wednesday, July 16, 2008

Bipolar Disorder

I have neglected so far to discuss a very important diagnostic category: bipolar disorder.

In bipolar disorder, there can be episodes of severe depression, in fact this may be the presenting or initial problem. Bipolar disorder is strongly heritable (it runs in families), even more strongly than other types of mental illness. Yet there are cases in which bipolar disorder can arise in an individual without an obvious family history.

The other "pole" in bipolar disorder is mania: this is a state in which mood is abnormally elevated or irritable, with a variety of other accompanying symptoms-
-increased energy (in its extreme form, severe uncontrollable physical agitation)
-decreased need for sleep (in its extreme form, no sleep at all despite high energy)
-racing thoughts or speech (in its extreme form, leading to incomprehensible speech)
-elevated self-esteem (in its extreme form, delusions of grandeur such as believing oneself to have supernatural powers)
-reckless and uncharacteristic behaviour (such as driving dangerously, taking other unusual risks such as substance use or gambling)
-uncharacteristic increase or change in social behaviour (e.g. promiscuity, socializing freely with strangers)
-increased spending (sometimes this leads to financial catastrophe, giving away one's savings, buying new cars, etc.)
-there may be psychotic symptoms such as hallucinations, paranoia, or severely disorganized thinking
-increased "goal-directed activity": many new plans, ideas, and actions, but often these are disorganized and chaotic
-usually these symptoms last for weeks or months at a time. For some people their symptoms fluctuate much more rapidly, sometimes between depressed symptoms and manic symptoms, or some combination simultaneously. This is so-called "rapid cycling".

A manic state can be very severe, leading to the police needing to bring the afflicted person to the hospital. There can be catastrophic life consequences, affecting relationships, finances, or physical health.

In other cases, though, a manic state can be quite mild (a so-called "hypomanic" state), and may even be quite a pleasant and productive period of time.

For any person seeking treatment for depression, it is extremely important to examine closely whether there have been any manic symptoms in the past--even mild ones--or if there is a family history of bipolar disorder. One important reason for this is that antidepressants can provoke manic episodes in persons with bipolar disorder. Treating depression in bipolar disorder requires extra care to prevent a manic episode from arising. This can involve a so-called "mood-stabilizer" drug such as lithium carbonate. Or, it can involve choosing a different type of treatment for the depression, such as a newer drug called lamotrigine, which can help with bipolar depression without causing mania.

Tuesday, July 15, 2008

Some alternative ideas that can be worth a try

1) Learn to meditate. Mindfulness-based meditation has a growing evidence-base, showing benefits for psychiatric problems as well as other physical problems such as chronic pain. You may need to attend a course, or several courses, to find the best setting for you to learn (there might be variations in the quality of teaching offered, so you may need to try several different times). Some of my patients did not benefit immediately from meditation techniques, but after many months of practice are now finding the skills very useful in managing ongoing symptoms.
2) Have a pet. It can help to care for, and bond with, another living creature. But, of course, you do need to be well enough to handle the responsibility. If you can't have a pet, consider finding a place to be around animals -- e.g. volunteer to do some dog-walking; or take some horseback riding lessons. Or visit your friend's pet once in a while.
3) Exercise. Try different types. Weightlifting can be great for some, endurance training (running or cycling) could be best for another. Swimming is often uniquely therapeutic. It can help to try a different exercise activity than what you're used to. Consider hiring a personal trainer to get you going, if you can afford one.
4) Activity clubs. There are groups out there dedicated to various activities, such as hiking, cycling, chess, reading books, gourmet cooking, etc. This could be a good way to make new friends and get going with a healthy activity. Local community centres often have classes, groups, or programs of all sorts to attend. Some groups of this type now advertise on internet community discussion boards, etc. Remember that you may have to try several times to find a group that "clicks" with you; it can be disappointing if you work up the nerve to join a group, only to find that it doesn't feel right.
5) Toastmaster's. A place to practice public speaking. This is excellent "behavioural therapy" for the great many of us who have some social anxiety. Attending can build confidence, speaking skill, and other social skills.
6) Consider taking an acting or theatre class. The theory of theatre & acting technique reminds me of psychotherapeutic theory. And the practice is excellent behavioural therapy, in that you are communicating clearly in a group, conveying emotion deliberately, and opening yourself to a bit of vulnerability. Sometimes it can also be quite liberating for a shy person to discover that they can perform theatre with relative ease. You can find these at community centres, continuing education groups, as well as acting schools & colleges.

7) Art therapy: another wonderful resource, if you have the chance to try it out. I think art therapy is underutilized in the therapeutic community these days. At the very least it can be a helpful and enjoyable adjunct to other therapy.
8) Music therapy: music can be powerfully soothing and therapeutic. Consider music therapy, or take a music lesson, or join a choir (you don't have to have strong musical skills to benefit). Also there is a phenomenon called "drum circles" in which a percussionist/therapist leads a group in pounding African drums, creating rhythms. A wonderful experience, and there are good therapeutic results in a variety of different populations. Once again, no prior musical experience is necessary.

Here's a link to Vancouver community centres; you can find the various courses they offer:

Here's a link to other classes & programs through the Vancouver school board:


Well, of course, here's another subject that most of us have strong feelings about, one way or another. I realize it's a dicey issue for me to wade into this one as a psychiatrist.

Here are my frank opinions:

There are many varieties of religious belief and practice. Many religions hold views that are quite opposite or contradictory to what other religions hold. Even subgroups of the same religious group can have vigorous differences in belief.

As far as the literal beliefs themselves go, I as a scientist would be closest in my view to Richard Dawkins, who boldly pronounces a belief in God to be a "delusion."

Yet I think there is a lot of wisdom, beauty, and truth that Dawkins misses with his pronouncement (accurate though it may be on one level) of delusiveness. Here, I think someone like Joseph Campbell is a wiser figure, in that his analysis of religious belief is anthropological, where religious stories are understood as metaphors, often with pearls of wisdom or insights about the human condition. His view is that most every religion or mythological system shares similar stories and insights.

This is my own view -- religious stories contain metaphorical insights and truths, which can teach, guide, warn, or comfort us. In a sense these insights and truths could be understood as part of what "God" is (literally). Interesting phrases such as "the Word made flesh" found in the Bible (John 1:14) exemplify the concept that the application or vivification of ideas or metaphors can be understood as the core of what "God" is.

Mind you, many religious stories may be very much coloured by the impressions or cultural values of the human authors of the stories--and perhaps of the subsequent editors over the years or centuries. Some of these values may in some cases be quite idiosyncratic or highly influenced by the conservatism or liberalism of the individuals in their time, and not very reflective of deep truths about humanity or life.

In any case, I do think that many religious stories contain valuable insights, also their familiarity to people over many centuries or even millenia, have caused the stories to become more richly ingrained in the culture. Perhaps the passage of time, of many generations, acts as a sort of "cultural filter" through which religious texts pass, allowing the texts to acquire more universal relevance. I encourage the interested reader to look at some of Northrop Frye's work: he was an important scholar who looked at the deep impact of religious texts on literature, with the keen eye of a literary critic.

Some of the richer psychiatric theory of the past century looks deeply at the human condition, at unconscious drives & motivations; art, literature, and religious mythology are important illuminations in this psychological exploration. The creative act of participating in the arts, literature, and in religious metaphor, can be a healing act--from a psychiatric point of view, or in a broader way-- provided the experience is not simply part of a neurotic defense (e.g. projection, suppression, distraction, rationalization, denial, etc.).

There are several advantages to "organized religion":
1) there is a community of people who care about each other, who care about the community itself, and hopefully who care about other external communities. This is healthy, and there are not enough such communities outside of religion in our culture today. So organized religion can be a source of friendship, social warmth, an antidote to loneliness.
2) Also, most religious groups are devoted to altruistic service in some way; there is absolutely no doubt that altruistic service is psychologically healthy. It can be hard to find satisfying altruistic opportunities outside of such an organized setting
3) Many religious groups celebrate a long cultural heritage of its members; this can add to a sense of meaningfulness and a connection to the past, and to family. Unfortunately, many individuals may feel excluded by, or that they do not fit in with, the group's cultural heritage. I think it is important to find a group that suits your own personal culture, and I think there are more choices in this regard nowadays. Many religious groups are trying harder to address this need.
4) Many religious groups have particular expressions of faith using media such as music and the other creative arts. This element alone can be comforting, enjoyable, and inspiring. (an example for me would be listening to the music of Bach, or to simple a cappella choral songs in an acoustically-perfect church building).
5) Religious buildings can be soothing, comforting, calming, safe, beautiful, and meditative. A physical place which helps calm the mind.
6) Certain religious practices and symbolism can become calming, meditative habits that teach one to relax the mind, be gently and quietly, reverently present. It is a form of relaxation therapy, yet imbued with a stronger sense of meaning in most cases, and therefore can be more appealing and effective.
7) Religious involvements can help frame major life events, such as births, marriages, and deaths. The community can come together in celebration or in grief. These events then can become accepted with greater meaning, and less loneliness.

There is one main disadvantage to "organized religion", in my opinion:
Dogma. When an inspired piece of wisdom or a metaphorical truth is understood as a literal fact, it becomes dogmatic. It would be like reading a fascinating, insightful, and enjoyable novel, but then starting to believe that the events in the novel are literally true, and acting accordingly. Many religious groups are quite dogmatic. The problem here is that dogmatism is an innate psychological tendency, which leads to different groups opposing and fighting with one another. It is understandable that most religions become dogmatic, because the founding of the religion and its texts is usually based on characters who really lived and stories which really happened -- it's just that the characters become idealized and the stories become more legendary and fictionalized over time.

The focus on dogma tends to distract attention away from whatever metaphorical truths may underlie the dogma. It would be like reading a fairy tale in a concrete or literal way, without considering whether there is a "moral to the story". Religious ideas can then also become judgmental and paternalistic, phenomena which can add to the already robust burden of self-judgment and self-criticism experienced by those going through a mental illness.

One can see in the world today a lot of religious dogma, leading to a lot of fighting about religion, all the while some of the core wisdom, such as "love one another", etc. falls by the wayside. Through history, a substantial portion of large-scale and small-scale human cruelty, catastrophe, political manipulation, and war, have been driven at least in part by religious dogmatism (even if seemingly well-meaning). We don't have to look far in today's news to find ongoing examples.

Dogmatism, from a psychiatric perspective, is fed by a variety of innate human personality traits, such as "obsessive-compulsiveness" (the tendency to require very clear, strict, or rigid pronouncements about what is right and what is wrong); also many dogmas are fed by narcissism (those who proclaim dogmatic statements are often doing so arrogantly, egotistically, forcefully, unempathically, in a grandiose way, or with an intent to control). Even without these two traits at play, it can be psychologically comforting to pronounce something as an absolute truth, because it may soothe the uncertainty and fear we may have about a variety of deep issues (such as dealing with death or mortality, finding meaning in life, explaining senseless tragedy, etc.). The difficulty is that the soothing effect may occur even if the "absolute truth" is an arbitrary--and fictional-- dogmatic pronouncement.

Ironically, some of the poignant themes in major religions such as Christianity, or Buddhism (others too, I suspect--though I do not feel well-enough informed to list them), encourage humility, gentleness, openness, acceptance, and encourage us to move away from obsessive-compulsiveness, narcissism, and absolutism in our thinking. Unfortunately, many self-proclaimed adherents of these belief systems may not actually embrace, perceive, or live out these themes. I suppose, within any set of beliefs, individuals may "pick out" selective elements which happen to suit them, while perhaps missing a broader perception of the whole. (I recognize I'm being a bit judgmental here, and I need to continue examining my thinking on this matter, to prevent my own dogmas from entrenching themselves)

So I think religion can be quite positive, with certain provisos. Nowadays, I do find that there are opportunities to participate in something religious without having to be dogmatic.

Here is a link to a recent Canadian Journal of Psychiatry article on religion, spirituality, and mental health:

While these articles are quite enthusiastic about the role of religion in mental health, I should point out several confounding variables:
1) Those who are more religious may also have more conservative beliefs, and a more conservative lifestyle. These traits are likely to be partially heritable, partially learned or chosen. This conservatism may protect individuals from various forms of life adversity. The problem is, many individuals do not fit into a conservative lifestyle paradigm, and may feel strongly excluded. Furthermore, the health of society as a whole would be strongly compromised by having such uniformity or constraint in lifestyle variables. We can look to nations with very strict moral or religious codes to observe the decrement in cultural and intellectual life that results.
2) Other lifestyle factors among the more religious may include a stronger focus on community, stable relationships, healthy diet, less substance abuse, etc. -- all these factors could mediate better mental health, rather than the religious faith per se. (From my own personal point of view about "God", though, I consider factors such as community, relationship, care for self & others, healthy lifestyle, etc. to be equivalent to "relationship with [or love for] God")
3) Those who already have better mental health may be more likely to form a stable, long-term relationship with religious (or other community or group) involvement. Thus, the relationship between mental health and religiosity may be associative, not causative.

Stepping out of this critique, though, I do genuinely believe that religious involvement is likely to benefit mental health directly in many cases, for the other reasons I've summarized above (e.g regarding community, meditation, friendship, support, having a setting to contemplate moral issues, etc.).

For some people, religion will not be "their thing", and in that case, I do think it will be important for them to find other sources of community, altruism, meditative calm, etc. Hopefully there will be more cultural development in this area in the coming generations.

As a recent addendum (today in April 2015), I have become a great fan of Richard Dawkins as a scientist and writer.  I had been hesitant to read or discuss some of his work which specifically addresses religion (such as The God Delusion) but having read this recently, I have to say that I don't find his work very controversial at all.   He summarizes a lot of reasoned discourse and insightful historical summary of quite convoluted, biased thinking that has influenced religious belief and practice for millenia.  Richard Dawkins' greatest gift, though, in my opinion, is that he is a wonderful storyteller.  In some ways I think he shares this talent in common with some thinkers about religion or mythology, such as C.S. Lewis or Joseph Campbell:  in Dawkins' case, his best stories are about the joy and wonder of the way life works, in terms of genetics, biology, and natural selection.  Dawkins is very passionate about science, and has become very passionate about challenging dogmatic belief systems which obscure the pursuit and joy of scientific understanding.   In fact, he as well as others such as Stephen Pinker, show that obscuration of knowledge through dogmatic or mystical belief systems is a major hindrance to the health and peacefulness of society, and a major unnecessary cause of strife and conflict in the world.    One element about religion, though, which Dawkins may not have attended to enough, is of the tendency for the brain to project idealizations or personifications of issues and desires, as a core element of religiosity, which then could be experienced in a psychologically healthy way, particularly if combined with a supportive community, tradition, and adornment from the creative arts.   It is a human psychological capacity to personify metaphors or ideas, and treat them as external characters.   I think it is easier to adapt existing religious cultures, to maintain positive elements of these traditions and possibly beneficial meditative practices and opportunities for ethical reflection in religious services, while moving away from a focus on dogmatic or fictional mystical beliefs.  In this way, religious practice could move away any sort of conflict with science.  Otherwise, there is very little at this point in atheistic culture which offers as much focused, organized opportunity for supportive community, meditative reflection, altruistic involvement, ethical discussions, infused by great art, music, and architecture.

Monday, July 14, 2008

Behavioural Therapy

This is the "B"in CBT. The core principal here is "face your fear".

I think this is one of the most basic truths in all of psychology. Even psychoanalysis is founded upon this idea -- but in psychoanalysis the fears to be faced may be thought of as inner, unpronounced, unconscious fears, to be faced by searching verbally for them in the therapy sessions.

In CBT the facing of fear is taken more literally and concretely. If someone is socially anxious, or shy, the task is to design a "workout program" in which the person must practice starting conversations, approaching strangers, asking people for things, etc. Here, CBT is like athletic training. The work is often physical, but the workouts need to planned so as to be challenging, but gradual, easy enough tasks to guarantee success most of the time, but challenging enough to induce anxiety (there has to be some "weight on the bar"). It can help in behavioural therapy to keep a "workout" journal, just like you see athletes doing in the gym.

Behavioural therapy is best suited to approach anxiety problems. The ideas apply to approaching depression as well, and might involve setting up schedules or "workout plans" to counter depressive behaviours (such as social or behavioural withdrawal). But often times in depression, people are too tired to engage in a behavioural regimen. For them, such ideas sound like being told to "pull yourself up by your bootstraps" by an unempathic advisor. Yet, I think some behavioural principles can help in depression, especially when the depression also has anxiety symptoms. And just like with athletic training, the work is most important and effective if maintained on a regular, consistent basis. So, just a few minutes of work daily might be a place to start for a tired, lethargic depressed person, as long as it becomes a few minutes of a new healthy daily habit.

Once again, there are many good ideas in behavioural therapy that can be found in books or workbooks, and they are certainly worth looking at to get you started.

Cognitive Therapy

It is important for all of us to know about Cognitive-Behavioural Therapy (CBT). It is a set of ideas and skills that ought to be part of an "instruction manual" for living a healthy life. The ideas contained within CBT are simple and, for the most part, common-sensical. CBT has been shown to be a very effective therapy for mood & anxiety disorders, and a wide variety of other life problems, including insomnia, marital discord, addiction, and even for psychosis.

Here is my nutshell account of the "cognitive" part of CBT: every symptom can be associated with a thought. So if you are anxious, or depressed, or fighting with someone, or craving a drug, or hallucinating, there will be a thought or a set of thoughts associated with that feeling. In cognitive therapy, the task is to pay attention to the thought, and write it down in a journal.

The next step is where cognitive therapy veers away from simple journaling. My recommendation for a cognitive therapy journal is to divide a journal page into at least two columns. The anxious or negative thoughts are recorded in one column. But then, it is your task to "talk back" to the negative thoughts, in the next column. In this column you might write down evidence for or against your negative thought, or you might write down some reassurances or calming statements, even if the negative thought was true. The negative thought no longer gets the last word. A gentle debate ensues instead.

This process must become a practice, much like a scholarly exercise. I have compared it to the process of learning a new language. The old language is the "negative talk" or "depressed talk" or "anxious talk" or "can't sleep talk". The new language must be painstakingly translated in the next column, and it will take a lot of work. The facility to use the "new language" will improve at the same rate that it takes to learn any other new language--so it will involve hundreds, or thousands, of hours of work.

As you begin cognitive therapy exercises, they may seem artificial, contrived, not very genuine. Just like learning your first few phrases of Russian or Greek. But after you have practiced hundreds or thousands of times, and have put in your hours, the phrases will become natural to you, just as you will gradually become fluent in a new language. Negative thoughts will be naturally balanced by a positive, reassuring, or soothing counterpart. You may always continue to have the negative thoughts, but they will lose their monopoly on your thoughts and feelings.

Cognitive therapists have come up with a lot of practical ideas about how to make the cognitive exercises more specific or effective, and have come up with a lot of examples about ways to "talk back" to negative thoughts. So it is worthwhile to read some books about cognitive therapy, including some hands-on workbooks. Many of these workbooks may seem like trite or shallow pop-psychology, but despite the stylistic limitations of some of them, it can be very important to actually sit down with one and work through it, cover to cover. The beauty of cognitive therapy is that all the work, and all the ideas that change you, are your own. The therapy style is just a frame, a structure in which to do the work.

I believe that cognitive therapy ideas could work very well in a preventative sense--so that if children in grade school were introduced to these ideas, it could help them deal with a variety of stresses and negative emotions, and reduce the rates of anxiety & mood disorders.


ECT (electroconvulsive therapy) is a hospital procedure in which the patient undergoes general anesthesia, after which an electric current is passed through the brain using externally-applied electrodes. In order for the treatment to work, a generalized seizure must be induced by the current.

This treatment arouses a lot of strong feeling and controversy in the public.

In my opinion, ECT can be almost miraculous in how well it works. There are a few instances in my career in which I have watched someone who had languished in a severe depressive state for months, wasting away, despite the intense caring efforts of family, nursing, perhaps many other types of treatment -- in these cases it appeared that the person was about to die from malnutrition. Sometimes it was believed that these individuals were in fact dying of "natural causes" or were simply elderly and terminally ill.

I can remember instances of clinical situations like this in which ECT caused the person to have a complete recovery from such a state. Truly miraculous. And no complaint of ECT-induced side-effects either.

ECT is used only for very treatment-resistant depression nowadays. It can also work particularly well for individuals who have depression with psychotic features (i.e. they have symptoms such as hallucinations or delusions with their depression). It can also work well to treat severe manic states.

Unfortunately, individuals in the treatment-resistant depressed group less frequently respond to any new therapy (though it is important to continue the search until something is found that works!). So when ECT is used in a treatment-resistant population, even ECT may not work. The people who have had ECT yet remain unwell may feel worse still. It is much like cardiac disease (in fact cardiology is one of the other branches of medicine in which a radically effective treatment, such as cardioversion, involves a carefully applied electric current passing through human tissue)--in chronic cardiac disease, the disease may worsen despite best efforts. The best treatment may not work, and the patient may even do worse afterwards. Likewise, with ECT, sometimes it does not work.

Yet the evidence does show that it has an important role in treating severe, resistant depression. It can sometimes work miraculously well. It is not without side-effects, but a careful look at the evidence will show that sustained measurable cognitive side-effects are uncommon. A recent article demonstrated some possible cognitive side-effects attributed to ECT in bipolar patients. Yet these side-effects were subtle, and quantitatively far less severe than the symptoms of the primary mental illness.

Ironically, ECT is also an anti-seizure treatment. ECT treatments cause the brain to subsequently be more resistant to having a seizure. It is sometimes used to treat seizure disorders. It is ironic this way. People need to acquaint themselves with what the research shows on this subject, and not assume in advance that an invasive treatment such as ECT must cause tissue damage. There is even some evidence that ECT treatments promote the growth of new nervous system tissue, rather than cause tissue destruction. Once again, I invite the reader to study the evidence. There is certainly no one who has an agenda to profit from giving or promoting ECT (independent of it being an actual helpful treatment), so I can't see any reason for bias in the evidence; ECT equipment is not expensive, there are no huge drug companies at play here, there is no one earning a fortune giving ECT, and there are long waits for patients needing anesthesia or psychiatric care for other reasons.

I do not mean to celebrate ECT as a perfect treatment. It certainly is not. But I think it has been demonized in the public, perhaps causing many people to rule out a therapeutic possibility that can be remarkably effective, often life-saving.

Light Therapy

A Light box -- produces 10 000 lux of light intensity, mimics a sunny summer afternoon. For some people their moods really do respond noticeably to light stimulation, and external weather. A light box could be tried adjunctively even for people who do not clearly have seasonal depression, since this treatment involves very little risk. It is important to get a light box that produces 10 000 lux of bright white light. The more convenient, smaller, coloured, or lesser intensity models may not be sufficient.


If an antidepressant is not working, what can be added to make the drug work better?

1) a second antidepressant, usually from a different class
2) lithium
3) an atypical antipsychotic such as risperidone, olanzapine, or quetiapine
4) a type of thyroid hormone (tri-iodothyronine)
5) a stimulant

One or more of these options can be systematically tried. Before adding anything new, though, it is important to give the first drug a good chance at the highest possible dose, and for a trial of at least 2-3 months in cases of resistant depression.

Which antidepressants have no sexual side effects?

1) Bupropion - minimal sexual side effects
2) Mirtazapine - probably no sexual side effects; but this drug is quite sedating and often leads to a lot of weight gain
3) Trazodone - does not diminish sexual function, but can cause rare instances of priapism in men (abnormally sustained erections, which could be a medical emergency). Trazodone on its own is probably not a potent enough antidepressant though, or at least for it to be effective the dose would have to be raised so high that there would be a lot of sedation. It may be a useful adjunctive medication, perhaps to add on to something else to help with sleep.
4) Moclobemide -- often forgotten! No sexual side effects. There is a good body of literature from Scandinavia demonstrating its effectiveness in controlled trials. This drug is available in Canada, perhaps not in the U.S. This drug is an example of an antidepressant that has "fallen out of fashion"--it isn't prescribed very often. Yet the evidence base is similar to that of the other antidepressants. Such phenomena are self-perpetuating: because moclobemide is prescribed less often, and people are less familiar with it, it will be more often prescribed as a second or third-line treatment option. Any treatment used after something else has NOT worked will automatically tend to have a smaller chance of working. So we see moclobemide work less often, and falsely assume that it is an inferior antidepressant. If it were prescribed with equal frequency as a first-line agent, people would probably see that it works as well as the other antidepressants.

Which Antidepressant is Best?

A lot of people have strong opinions on this one.
Here is my opinion, based on experience and a review of the evidence:
1) there is no single antidepressant on the market today that is consistently or markedly superior to any other, in terms of its ability to treat depressive symptoms or reduce depressive relapses
2) statement -1- is true in general, yet it is possible that for a given individual, there may well be one particular antidepressant, or combination of antidepressants, that does work best
3) many of the comparative statements made about antidepressants in advertising try to emphasize differences which are often clinically irrelevant
4) differences in pharmacology (e.g. receptor binding, etc.) can be prominently described in advertising, yet in many cases these facts are not clinically relevant
5) there are few if any consistent differences in side effects between the different SSRI's. There may be differences for a given individual, however.
6) For a given individual, the evidence is clear that if one antidepressant fails to work, there is a reasonable chance that a different antidepressant or combination could work, even if the new drug has a similar mechanism of action.
7) There are side effect differences between the different subtypes of antidepressants. SSRI's may cause nausea, mild fatigue, mild sleep disturbance, etc. Tricyclic antidepressants have "anticholinergic" side effects of dry mouth, constipation, faintness due to blood pressure drops, etc. Mirtazapine causes sedation and weight gain. Bupropion can have more "stimulating" side-effects sometimes, such as nervousness or insomnia. The newer antidepressants are safer in overdose, but the old tricyclics can be dangerous or lethal in overdose.
8) Venlafaxine XR and Escitalopram are both vying for the position of "best antidepressant", in terms of being an antidepressant that has the highest chance of leading to total remission of symptoms. It is clear to me that these both can be good antidepressants, and for a given person may well end up working better than anything else. I have seen quite a few people react quite poorly to venlafaxine, though, in terms of side effects. And, if there are true advantages to these two drugs, I think the differences are small. It is worthwhile for any individual to give several different antidepressants a try, if one particular one is not working.
9) sometimes a particular antidepressant's side-effects can work well with a person's symptoms. For example, if a person is having severe insomnia, and has lost a lot of weight with a severe depression, than mirtazapine would be a good choice. If a person has a lot of fatigue, maybe some concentration problems, but not a lot of panic symptoms, with their depression, than bupropion could be a good choice (buproprion can help modestly with attention deficit problems). If a person has a chronic pain condition (e.g. neuropathic pain or recurrent migraine), then a tricyclic antidepressant could be a good choice (the tricyclics can help independently with chronic pain conditions).

Friday, July 11, 2008

A Rambling List of Helpful Ideas

This is just brainstorming now. Thinking of things that help with mental illness:
-find a good family physician
-have your overall health checked carefully
-have blood tests done to check thyroid, fasting glucose, ferritin (a measure of iron stores), B12 levels (a vitamin), and other basic bloodwork
-allow time in your daily life for rest, relaxation, hobbies, or other simple pleasures. It's particularly good to actually build this time right into your schedule
-have some structure in your day -- get up at roughly the same time, try to go to bed around the same time, eat meals consistently
-try to appreciate the simple pleasures of life -- the taste of your toast in the morning, the colour of the flowers, the texture of the sidewalk -- see, feel, experience, enjoy what you can
-do meditative things. For some this is a meditation class, for others it might be listening to music, a quiet evening walk, for others it could be a workout, for others it could be prayer or another religious activity
-examine your willing to make changes, to let go of things (small and large) that are unhealthy for you, inconsistent with your personality or lifestyle; be willing to add things (small and large) that are healthy for you, consistent with your personality, values, and lifestyle. Be careful about these decisions though, because a depressive state can cause you to feel unhappy about every external thing, and your depressive symptoms may therefore prompt you to make changes that are not really helpful to you. Imagine that your mind is like the "senate", make sure all the different opinions are heard, from a depressed perspective, to an intellectual perspective, to a happy perspective, etc. Then decide & make changes if necessary. Some changes are hard to make -- e.g. letting go of the need to keep up with the mortgage by maintaining an extremely unpleasant job -- maybe you need to consider letting go of the house, simplifying your life, and doing something with your time that is more enjoyable or meaningful.
-do altruistic activities, in some way. Volunteer. Help others out. Do what you can.
Here's a link to search for volunteer opportunities in Vancouver:
-exercise. every day. in moderation.
-eat healthy food. learn about nutrition. insist on the best quality your budget will allow. If you indulge once in a while in decadent foods, make it something REALLY GOOD. Not McDonalds.
-no more than 1 or 2 drinks of alcohol per day, ever. (it is possible that very light regular drinking is healthier than not drinking at all. But if you ever drink more than 2 per day, it is very bad for your emotional and physical health; also some people may not be able to healthily drink at all.
-don't smoke.
-don't use street drugs. There's a big marijuana lobby out there that makes claims about the health virtues of cannabis. Go examine the evidence for yourself. It's not good for you!
-reserve a little bit of energy, every day, or every week, for friendships. For many of us, this is an energy-consuming activity, and we neglect this. The energy could be spent in conversation, in doing an activity, or in expressing something positive about your friendship.
-be willing to move away from, or let go of, friendships that are not healthy for you.
-be willing to make new friends. This can be hard to do. You may need to try many different ways to meet new friends, such as joining recreational groups, clubs, churches (in my opinion, one need not have to espouse the literal belief system of a church to benefit from its social community, altruistic focus, and positive values), formal or informal educational classes (e.g. an acting class, or an art class, etc.), or internet sites (be careful of course!)
-be willing to try new things. a new activity. a new hobby. a new skill. a new language. a new place to travel. a new group.
Here's a link to Vancouver community centres; you can find the various programs & services they offer:
Here's a link to other classes & programs through the Vancouver school board:

-some people change their lives for the better through months or years of slow, steady open to this. Others can make a "radical life change", where improvements in life, meaning, and joy can happen almost immediately. Be open to this too.
-consider finding a therapist. you may need to give this time, just like any new experience. But be willing to change therapists, if the one you find doesn't feel right, or if you feel that you aren't getting anywhere after giving it a good chance.
-consider other types of therapy: if you have had only open-ended, "classical" psychotherapy, consider trying cognitive-behavioural therapy. And vice-versa.
-consider seeing a psychiatrist. You may need to give this time too, and may need to see a different one if the experience doesn't feel right to you.
-consider medications. Some patients I've seen have had life stories that sound like their problems would be solved by talking things through, by working things out in talking therapy. Sometimes they have given this years of effort, but have not improved. Then they try an antidepressant, or find a combination of medications, and feel truly well for the first time in their lives. For others, they have the opposite story: they may have tried one medication after another to treat their symptoms. Nothing works. Then they engage in a good psychotherapy experience, and this becomes the first treatment that helps; sometimes these patients may discontinue their medications. For the majority of patients I see with chronic or recurrent depression, though, what seems to help best is a mixture of psychotherapy, a medication combination, and healthy lifestyle changes.

Tuesday, July 8, 2008


For some people, simple changes of environment or lifestyle can permit the body & mind to heal itself. In this way, perhaps depression or anxiety can be the body's signal to make a healthier change. Perhaps this might be the "normal" role of negative emotions, to influence us to make a necessary or protective life change.

Many medical illnesses feature an over-reaction of the body's natural protective mechanism. In autoimmune or inflammatory disorders, for example, the body's protective mechanisms attack and harm normal tissue. It is not a matter of simply making a positive life change -- the protective mechanism itself is malfunctioning. In treating such disorders, steps have to be taken to change the abnormal inner process, not to change the environment.

Likewise, in depression or anxiety disorders (and probably many other types of mental illnesses too), the mind's normal tendency to experience negative emotion, perhaps in reaction to adverse events -- malfunctions, and becomes out of control.

There are a variety of treatments:
1) wait for the symptoms to pass. This is painful, the symptoms may be highly disruptive while they last, and they may cause other life disruptions that could take many years to repair.
2) Learn mental or behavioural techniques to calm the mind or control the symptoms. So-called "cognitive-behavioural therapy" is one of the most well-researched techniques for managing symptoms of the mind, and the results are very robust.
3) Medications. The various medications for mental illnesses can help substantially. Some of them relieve symptoms immediately (e.g. benzodiazepines), while others are thought to be "disease-modifying agents" that can relieve symptoms in the long-term and prevent relapses (e.g. antidepressants, mood stabilizers, and antipsychotics). This reminds me of the treatment of inflammatory diseases such as rheumatoid arthritis, in which there can be immediate anti-inflammatory treatments (e.g. prednisone), while there are long-term treatments which reduce relapses (e.g. gold salts and immunosuppressives). With arthritis, treatments such as prednisone can be powerful reliefs, but should be minimized because such treatments weaken the body if used frequently. Similarly, the acute treatments in psychiatry, such as benzodiazepines, are very important, but can be counterproductive if used long-term, unless an individual patient cannot manage without them.

4) Psychotherapy
A supportive relationship with a therapist can be a powerful source of comfort, safety, security, and a framework in which to focus on growth & wellness. There are many styles of therapy, some styles perhaps more theoretically dogmatic than others, but I think the most important features of a healthy therapy relationship are feelings of safety, confidence, reliability, feelings of being heard and understood. Sometimes this supportive relationship itself becomes the strongest factor leading to recovery.

Causes of Depression & other mental illnesses

When we discuss causation, it is important to consider that every individual has his or her own story, perhaps his or her own unique causation. It is like the life of a tree, in which many individual and unique factors from the tree's history have caused the tree to grow as it did (e.g. what species of tree it was, what soil the seed was planted on, the climate conditions over time, fires or insect problems at certain times, other trees protecting the tree from wind damage, or competing with the tree for sunlight, etc.) Yet despite the unique stories of causation for every creature, we can study common factors that tend to influence the present state.

One of the risk factors for mental illness is a family history. It is clear, from an abundance of careful research, that the tendency to develop specific mental illnesses is inherited. Yet, we also know that the "heritability" is never 100% (often it is about 50%); thus, many people with a strong family history will never develop depression. And some people with no family history will develop depression.

My analogy with the biology of trees would be to comment on "tendency to die in a forest fire". Clearly this type of event, for a tree, depends on an external contingency (lightning strikes, or other causes for forest fires starting). But suppose the inherited quality is the thickness of heat-resistant bark. Trees with the thicker bark will less frequently die in forest fires. Likewise, there may be inherited factors for various types of resilience or sensitivity in the mind, such that some individuals may be able to tolerate more or less environmental life adversity, with different consequences to their mental health.

There are other more immediate, medical causes, for depression and many other mental illnesses. Physical diseases of various types can cause emotional symptoms directly. For example, thyroid disease, neurological diseases, anemia, and many other illnesses, can cause symptoms in the mind, and many of the related symptoms of mental illnesses, such as fatigue, lethargy, poor concentration, trouble sleeping, etc. A thorough medical investigation is always warranted when assessing someone with psychiatric symptoms.

The adverse events of a person's life can have a very important role in causation, I think. Much of the psychiatric theory of the past 100 years has been devoted to attributing psychiatric symptoms and personality styles to the events of earlier life (often the events of childhood & infancy). I think it is extremely important, and often highly relevant, to explore an individual's personal life story; a life story is a very personal, intimate narrative. Yet it is important to know that the data on causation is actually quite weak, with respect to connecting particular past life events with current psychiatric symptoms. Much of the psychiatric theory about causation is, in my opinion, very dogmatic. Traumatic life events are an exception, in that trauma can clearly lead to symptoms later on.

The nuances of a personal history, though, I think are therapeutically important, as they can be an intimate framework to discuss the themes and symptoms of mental illness, to search for meaning. The process of recalling, creating and narrating a life story is a psychotherapeutic event, and telling the full story can be cathartic, poignant, painful, perhaps with kernels of joy, and perhaps with clues about how to write the future chapters of one's life story in the most meaningful and joyful way.

Monday, July 7, 2008

What is Depression?

In my experience, everyone I've seen has a unique and individual experience of depression, in terms of their associated thoughts, and the impact of the depression on their life & behaviour.
Yet there are common factors, and the "DSM-IV" style symptom lists can be useful to review:

1) Depressed mood. This can vary from a continuous low mood, which might be coloured with sadness, tearfulness, anxiety, irritability, sometimes numbness or emotionlessness. Sometimes all of the above. Sometimes the mood is continuous, sometimes the feelings come in waves lasting minutes or hours. Sometimes the mood dips in reaction to external events (a daily frustration or stress), but sometimes the mood changes seem random. Some people can have other patterns, of good days & bad days, good months & bad months, good seasons & bad seasons. Some can display a cheerful mood for brief periods of time, while crashing immediately afterwards, or perhaps always feeling unhappy inside despite appearing cheerful. One common phenomenon is of a depressed mood that is consistently worst in the early morning.
2) Lack of interest or pleasure. Previous life joys feel boring, uninteresting, or unpleasant. A lack of drive to do pleasurable things (e.g. socializing, recreational activities, sex).
3) Sleep disturbance. Inability to sleep (difficulty falling or staying asleep, or waking too early in the morning). Or sleeping excessively. Sometimes both insomnia and excess sleep, at once, in which a person has fragmented, unrefreshing sleep, yet spends long periods of time in the day drifting in and out of sleep.
4) Appetite disturbance. Not wanting to eat, leading to weight loss. Or eating too much.
5) Lack of energy. Fatigue, lethargy, poor motivation.
6) Behaving in an agitated way, or in a very sluggish, slowed-down way.
7) Guilty thoughts. Blaming oneself for past events.
8) Indecisiveness. Trouble making small or large life decisions.
9) Trouble concentrating.
10) Thoughts about suicide.
11) Paranoid or delusional thoughts: for example, beliefs that there is a conspiracy going on, or that some terrible event is imminent.
12) Hallucinations: sometimes negative or derogatory voices can be part of a depressive episode.
13) "Low self-esteem": examples include thinking poorly of oneself most of the time, to self-hatred, self-loathing, feeling worthless. Often this is accompanied by so-called "negative self talk", in which one's own thoughts are critical or insulting to oneself.
14) Feeling helpless or powerless to effect any sort of change in self or circumstances
15) Somatic symptoms: many people have overt symptoms of physical pain, discomfort, reduced function, or other medical symptoms as part of their presentation of depression; this can lead to the person becoming worried about having a major medical disease such as cancer.
16) Frequently in depression there are also "comorbid" symptoms, especially anxiety symptoms such as severe worrying, panic attacks, and rumination (inability to stop thinking about a particular thing).

People can have different symptoms among this list at different times during their periods of depression, though quite often a similar pattern of symptoms repeats itself for a given person.

Links to Vancouver community resources

The Red Book Online is a good collection of community services for Vancouver; hopefully other communities have similar sites:

Here's a link to Vancouver community centres; you can find the various programs and services they offer:

Here's a link to other classes & programs through the Vancouver school board:

Here's a link to the Vancouver Alcoholics Anonymous (AA) meeting schedule:

Here's a link to Volunteer Vancouver (a place where you can search for volunteer opportunities):

Links to Research

Here are some sites I recommend when researching medical evidence:

1) the U.S. national institute of mental health; their research is funded by the U.S. government:

2) PubMed: this is a medical research database, with access to abstracts, sometimes to the full texts, of research papers. I invite you to go look at the research yourself, directly. I do think it is important to develop a critical eye, though, for the signs of strong vs. weak research evidence (e.g. size of study, randomization, length of follow-up, source of funding, etc.). If you have read a newspaper headline about a research finding, I think it is usually important to go to the primary source, and have a look at the findings yourself. Sometimes the media presentation of the research findings is misleading or incomplete.

What is Psychiatry?

Psychiatry is a branch of medicine which concerns itself with mental illness. Its inclusion among the branches of medicine, alongside neurology, cardiology, oncology, surgery, etc. reflects the belief in our modern scientific culture, that "symptoms of the mind" such as anxiety, depression, hallucinations, delusions, etc. can be approached using a "medical model": a full history of the symptoms is needed, an "examination" is made through spending time with the patient, appropriate tests are done to rule out various diagnostic possibilities, then a diagnosis is made, a name is given to what the problem is. Treatments can then begin. Just as in approaching a heart problem, the treatments may involve lifestyle change, rehabilitative efforts, but sometimes also medications, sometimes an urgent hospital stay. In psychiatry, one of the treatments can often be establishing a supportive and trusting psychotherapy relationship.

Why I'm posting a BLOG

I was reading an article the other day about a doctor who has his own blog, and I thought it was a good idea. A bit bold.

With regard to psychiatry and mental illness, I've had a lot of ideas about things I've wanted to share, to write about, opinions to express more publicly, but really I've never had the time, energy, audacity, or wherewithal, to publish these things in a journal or book.

I know a lot of my patients find out a lot of information on the internet, and I thought it would be fair to have my own opinions out there too. Sometimes I might not be available directly, and I wonder if it could be a comfort to at least be present in an indirect way, such as a blog?

I have also found this blog to be a good setting to document some of my continuing education activities.

One thing I know to be true is that I certainly do not have a monopoly on the truth. Many of my ideas could be vigorously challenged. I am a strong believer in always challenging dogmas, and I invite others to challenge my own. Yet, sometimes our dogmas--even if mistaken--can have valuable kernels of wisdom, and I think it is important not to automatically discount dogmas either.


I've read the "about me" description of myself numerous times, and sometimes I realize that it sounds quite arrogant, or at least a bit wordy or awkward. I consider arrogance--in myself or others--to be unhealthy, and I like to think that I aim and struggle not to be arrogant. I do realize, though, that my paragraph is typical of something that I would say or think (I can certainly be wordy and awkward), so I stand by it as a sincere introduction.

I deliberately named my blog "Garth Kroeker" so that people in search of me would be able to find me. I left out labels such as "Dr." or "MD" because I would rather be known or respected just for my name or for my thoughts, rather than for one of my labels or titles. Such labels can be useful at times, most often when I'm trying to reach someone in a hospital or lab quickly on the phone regarding one of my patients. I do not care for the practice of brandishing labels or credentials to persuade people about the value of one's ideas.

Sometimes there is a fine line between confidence and arrogance; despite my admission that I often don't know the answers that my patients seek, I do admit that I have become quite confident in my work over the years. I also admit that I have to be on the lookout not to cross the line into arrogant territory. I hope my patients will help and remind me about this one, as needed.