Friday, January 30, 2009

Narrative Therapy & the "Guru Effect"

This is another interesting therapy style, pioneered by the Australian social worker Michael White (1948-2008).

Here is my condensed account of narrative therapy: the main idea that I appreciate in this style is the application of a "story metaphor" to a person's life and problems. The patient becomes an author. Problems in the person's life (such as depression or eating disorders) become characters, and each of these characters gets a name. These characters are understood to have voices in the narrative, and to influence the story. The ways in which the different characters exert influence upon the story are examined, by the patient and by others. The role of the character--its purpose in the plot, so to speak--is considered. The question is considered of whether the story requires the character in some way, whether the character needs to be present, or what the story would be like without the character at all. The next step is to creatively "re-author" the story, addressing the problems externally as characters to deal with. The motives could be considered about why the different characters are behaving as they do. Elements which empower or weaken the character are considered. Important messages the characters might have to communicate could be considered or validated. The different "antics" of the characters (problems) could be anticipated, "spoken back to", or thwarted, through a creative act of "re-authoring".

The idea is really quite similar to cognitive-behavioural therapy, but perhaps with a more imaginative infusion of literary theory.

I find much of the written theory about this style incredibly cumbersome and laden with unnecessary jargon. Also I think this style, like many others, tended to see the founder as a sort of guru. There is a phenomenon I call the "guru effect" in which people with complex problems report significant change when they encounter some wise, charismatic figure, often in a public setting (I guess we can see this on certain types of TV shows these days).

I don't mean to be too critical of the "guru effect" because I acknowledge that there are some people who can share their charisma and wisdom very effectively, in a way that can be dramatically helpful. The word "guru" itself, and its origins, ought to be treated with respect, and the existence of this phenomenon can be appreciated as a gift to the world.

However, the "guru effect" can sometimes lead to a lot of dogma and a type of religious fervour that can foster overvalued ideas about what it is that is actually helping. This is especially problematic, in my opinion, if the adherents to a particular style begin to reject or criticize other styles or ideas, in ways that are not founded upon good evidence.

In any case, I think there are some imaginative and helpful ideas in narrative therapy--I'm always on the lookout for variations of cognitive-behavioural therapy or other therapies that are a little bit more imaginative, creative, or even fun (therapy isn't always fun, but humour, enjoyment, creativity, and playfulness can be immensely important elements at times).

Thursday, January 29, 2009

Anxiety Hierarchies

The idea of an "anxiety hierarchy" is simple and powerful.

It is an application of behavioural therapy, and is analogous to a well-designed educational or athletic training program.

In education--for example, learning to read, or learning arithmetic--a well-designed workbook would call for you to start with some exercises that you would find very easy. If the initial exercises are too hard, then it would be necessary to go to the previous workbook, and try something easier. If you can do the easier ones fluently, you can move on to the next page, and try some exercises that are just a little bit harder, and so on...the pace could be self-directed; some people might want to leap ahead quickly, others might want to linger on the easier pages, or practice doing them faster, etc.

In athletic training--for example, training for a marathon--one might have to start with just a few minutes of jogging, alternating with a few minutes of walking, a few times per week--once this feels comfortable, the intensity and duration could be increased.

An anxiety hierarchy is basically a "workout schedule" or "curriculum" for overcoming a phobia or an inhibition.

A prerequisite to engaging in this process is a clear wish to overcome the anxiety. It may well be possible to practice the skills necessary to become a skydiver, but unless you really want to skydive, you probably shouldn't do the training!

If the anxiety is social phobia, for example, the prerequisite for this approach is that you truly want to be able to interact socially with greater ease. If you have a phobia of bridges, you have to truly want to be able to cross bridges easily.

To do an anxiety hierarchy, it is necessary to consider tasks which involve your anxiety in some way, and rank them in difficulty, say from 1 to 100.

For social phobia, a rating of 100 might be warranted for the task of showing up for a group function, consisting of strangers, introducing yourself to everyone, striking up a conversation with the person who interests you most, and asking for that person's phone number. A rating of 50 might be for the task of asking a stranger in a crowded cafeteria for the time. A rating of 10 might be for reading a book in a crowded place, instead of at home. The details of how you do the ratings are up to you and how you feel.

It helps to think of as many tasks as you can along the "hierarchy", covering as many numbers as possible from 1 to 100.

The next step is--just like learning arithmetic or training for the marathon--to start with the easiest task, and practice it daily until you feel comfortable with it.

Then move on to the next harder step, and continue gradually working your way up the hierarchy. It is important to do the work every day, if possible; consistency and regularity are extremely important, just as in other learning tasks.

It is important to really take this seriously, and to put in your hours of work and practice. Just like marathon training or language learning, it won't happen unless you do it regularly, at a moderate level of difficulty, for solid blocks of time (e.g. one hour every day).

The pace of change may be quite similar to an educational or athletic task--after all, it is your brain that is changing, just the same way as your brain changes with learning anything else. Also your body learns to change--when you are more physically fit, the same athletic task can be done more efficiently, with less effort, and with less physiological stress. With anxiety tasks, your body will learn not to react with the same anxiety symptoms (e.g. racing heart, sweating, shortness of breath), as you train yourself.

Zoloft and Cipralex best?

A recent article in the major, prestigious medical journal Lancet concluded that

"Clinically important differences exist between commonly prescribed antidepressants for both efficacy and acceptability in favour of escitalopram and sertraline. Sertraline might be the best choice when starting treatment for moderate to severe major depression in adults because it has the most favourable balance between benefits, acceptability, and acquisition cost."

Here is a link to the abstract:

Predictably the news headlines about this article read something like this: "Zoloft and Cipralex better than other drugs"

Taking a closer look at the data, as presented in the abstract, reveals the following:
1) mirtazapine (Remeron) was actually the most "efficacious" drug of all the drugs studied. But its side-effect profile/tolerability was less favourable than some of the others.
2) mirtazapine, escitalopram (Cipralex), venlafaxine (Effexor), and sertraline (Zoloft) were all quite similar in terms of "efficacy", and were all significantly superior to duloxetine (Cymbalta), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and reboxetine.

The study is impressive, in that it was a meta-analysis including the data from over 25 000 patients.

But the study is substantially weakened by the fact that it does not look at long-term outcomes (over a year or more).

As I've written before, I feel that the best assessments of effectiveness for conditions such as depression, which recur over a period of years, require data that also cover a period of years, rather than just months.

Oddly, the findings about bupropion are not mentioned in the abstract.

The paper is further weakened by not looking at tricyclics at all.

I think the results of the study should not be overvalued. The study may reasonably guide a first choice of antidepressant, though. A few very particular points to take from this study are that venlafaxine was not shown to be dramatically superior to all other antidepressants (despite what their advertising has inferred quite often), also that the new antidepressant duloxetine is clearly not dramatically superior either (which encourages us to be wary of the marketing hype behind it -- see my previous entry on Cymbalta).

Another result from this study confirms an observation I've had in my practice, that mirtazapine (Remeron) can be a very good antidepressant, provided its side effects can be tolerated (sedation and weight gain).

The authors wisely note that the study ought not to prompt someone to change a medication that is working well for them. The study measures differences between groups; for a given individual sometimes one particular medication can work best (e.g. fluvoxamine, duloxetine, or fluoxetine), even if it is not the most effective for a group.

Sunday, January 25, 2009

Reservoir Metaphor

We have "emotional reservoirs" of different types. Some supply "energy", others supply "calm", "happiness", or "well-being".

If the reservoirs are full, we may maintain our energy, calm, happiness, or well-being, even in times of stress. If there is a drought (such as a bad day or week, or other varieties of stress), we maintain a healthy state, even though there is environmental adversity.

If the reservoirs are dry, we become dependent upon the immediate environmental circumstances: there may be energy or happiness, but only if daily events are going well.

The combination of a "dry reservoir" and a "bad day" could be intense symptoms: an emotional crash, lost temper, sometimes thoughts of suicide.

Various psychiatric and medical conditions lead to a "dry reservoir" condition. Depression itself is depleting. "Personality disorders" could be understood as a "reservoir" problem in some cases. Chronic pain conditions of any sort can be depleting. And chronic environmental adversity, of course (e.g. ongoing abuse, oppression, etc.) can keep a "structurally intact" reservoir constantly dry.

To run wild with this metaphor a bit, I suppose there are different varieties of reservoir problems:
1) the "leaky reservoir" : good experiences are not internalized, noticed, or remembered
2) the "too small reservoir": only recent events (over days or weeks) determine the fullness of the reservoir
3) the "blocked reservoir" : there is an abundant inner supply of positivity, but symptoms persist, and the reservoir seems inaccessible

I suppose therapeutically, this reservoir notion could be worked on in several ways:
1) learning ways to "fill one's reservoir" on an ongoing basis -- so that one becomes less dependent on the immediate situation for well-being
2) "reservoir maintenance" : repairing leaks or blockages--there may be ways to consciously maintain, notice, hold onto, positive experience, instead of allowing it too "leak away" or be inaccessible.
3) discovering a reservoir that was always there, but that lay outside of awareness (here's a kind of psychoanalytic idea--though more about uncovering something positive rather than uncovering a hidden problem).

I intend this reservoir idea as a broad life metaphor, but there are direct analogies to be made between the "reservoir metaphor" and neurophysiology. For example, if neurotransmitter reservoirs within neurons are depleted (literally) by a drug such as reserpine, a depressed state will ensue (examples such as this are strong elements of support for neurotransmitter-based hypotheses--such as the serotonin hypothesis-- about depression). One of the problems about neuropharmacologic theory, though, is that it may focus excessively on quantities (such as "reservoir volume", or more literally, "serotonin function") while failing to attend to structure (structural change in the brain must be achieved through thoughts, actions, and relationships, not merely through changing "reservoir levels").

Friday, January 23, 2009

Desert Metaphor

A journey through life, especially if affected by mental illness, can be like a journey through a desert.

You may feel lost or starved. The view may be exactly the same, despite having invested days, weeks, or months, trying to forge ahead.

There may be life-threatening moments of intense thirst, and an uncertainty whether you will make it through the day.

The light of day may be intolerable and oppressive, and you may out of necessity have to work only at night, even though you may fear the darkness.

In psychotherapy, it has often been the common practice to examine the past, as part of a key to escaping the desert. In a desert, there may be some value to examining your past, but on the other hand this information may not be relevant to your immediate needs, and may be a distraction impeding your progress. Furthermore, in a desert, sometimes your "past" cannot truly be known, since the shifting sands cover up your path. The search for "past" can be a frustrating, fruitless diversion, punctuated by misleading mirages.

Cognitive-behavioural therapies, or "here and now" psychodynamic therapies, are more likely to help when lost in a desert. Some kind of desert guide may greatly ease the journey, even if the journey does not become any shorter (here I suggest the role of therapist as "desert guide" or "camel").

An immediate source of water and food helps a great deal too, and so does a good sun hat. The most basic needs have to be met first.

A psychodynamic style of therapy focusing extensively on the past is more likely to be helpful once you are already out of the desert, and are perhaps trying to make sense of the whole experience.

Thursday, January 22, 2009

Antisocial Personality

Many people use the term "antisocial" in daily language to describe a feeling of not wanting to socialize, or of reclusiveness.

In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.

I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.

For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.

A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.

However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".

The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.

There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.

And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.

Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.

Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.

Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.

Here's a reference:

Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.

The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".

In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.

So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.

Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.

There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).

Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).

In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.

The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.

I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.

Tuesday, January 13, 2009


I've been putting off publishing this post.

But to follow some of the behavioural advice about solving procrastination problems, I realize that I have to just publish what I've got, and maybe finish it or tune up the posting a little bit later.

Procrastination is often paralyzing. The motivational force to initiate an action is just not there, or there seems to be a lot of "friction" keeping things stalled. So, time passes, guilt about inaction increases, or denial is engaged in, as though the task to do doesn't even exist. UNTIL -- the day before something is due, or until some deadline approaches -- then there is a frantic pressure leading to a frenzied, exhausting all-nighter.

Some people actually produce good work this way -- or at least they claim they do -- but I think for most of us we produce less work, both in quantity and quality, and we condition ourselves to experience the process of work as negative, frenzied, stressful, or exhausting.

I'm pretty sure that if people who do interesting work despite procrastinating were to actually work on changing or improving their procrastination habit, they would end up doing even more interesting work. It may not necessarily be true that some kind of manic-depressive pattern is a key to creative inspiration.

Yet we may also condition ourselves to require high external pressure as a motivator.

This cycle needs to be broken, in order to solve the problem of procrastination.

Simple behavioural tactics include always doing a little bit of work every day -- especially the types of work that you are putting off. The key is consistency and daily regularity, rather than amount. If there is more continuity of effort, it makes the task much easier. Not only does more work get done, it also gets done more enjoyably. Once again, it is like learning a language or a musical instrument ( tasks which really cannot ever be procrastinated).

David Burns has a chapter on procrastination in The Feeling Good Handbook. Someone recently recommended to me a different resource--see what you think of this website:


In response to some of the comments, here are a few more points to add:
-different people may have different reasons for procrastinating, or different patterns of procrastination. It is important to look at, and address, the underlying reasons, whatever they may be. Part of a "cognitive therapy" or "psychodynamic" approach would certainly involve examining this closely.

-Other phenomena, such as anxiety, depression, ADHD, and OCD, may be strong contributing factors to a pattern of procrastination, and in fact may lead to procrastination being a more effective, tolerable, and comfortable strategy for completing tasks under these conditions. It is important to address these other issues. Medical and psychological strategies to treat anxiety, depression, OCD, etc. may be necessary in order for strategies addressing procrastination to be helpful.

-I do stand by the claim that daily work (as opposed to "last minute work") on anything leads to a deeper, more enjoyable, and more lasting effect on the brain and on learning, for the same reason that language learning requires daily work, and cannot be done on a last-minute basis. But I agree that there may be numerous reasons why this type of daily work could be difficult or not feasible for different individuals or circumstances.

-I suppose one exception to this would be if the "learning" has already been done, and if the individual's personal style is such that intensive bursts of activity are enjoyable. Some people may like to immerse themselves in one particular thing for days or weeks at a time (while procrastinating a whole bunch of other things, I guess), and this strategy may work very well for them. Some artists or authors like to work this way, for example. I don't think it would work well, though, unless the people were already skilled at the area in which they were immersing themselves.

-Another proviso about the "daily work" idea is that there needs to be some focus on joy in the activity itself. If the daily work is merely a burdensome, unrewarding chore, from beginning to end, then the mind gets consistently conditioned to hate the activity (this is one reason, for example, why many children learn to hate piano lessons or math -- they are made to practice or study joylessly and alone--though consistently-- by parents who may have well-meaning ideas about daily discipline, etc.). Finding ways to experience an activity with some element of joy is a particular therapeutic challenge -- conventional behaviourism neglects this. I think that more "Eastern" systems of thought and practice have a little more wisdom to offer in this area, with respect to finding ways to teach ourselves to experience, or rediscover, some joy and contentment in a seemingly or previously joyless moment or activity.

Thursday, January 8, 2009

Happiness and Economics

I just finished reading an excellent book called Happiness: Lessons from a New Science, by Richard Layard (Penguin, 2005).

His main points are in synchrony with ideas that I have alluded to in previous posts:

-Economic growth is a numerical measure which does not correlate consistently with well-being or health. Except for people who are living in poverty. $100 to relieve one person's poverty goes much, much, much farther to improve well-being (for both the individual and for the world) than $100 to increase a wealthy person's leisure budget.
-Despite large increases in wealth in many parts of the world, people are not any happier (in fact, they are often less so, particularly in the U.S.)
-Pursuit of wealth has an addictive quality: it produces short-term satisfaction, but the mind habituates to any short-term external satisfaction. The mind is more satisfied with stability, and is more averse to perceived loss than it is satisfied with material gain.
-If economic growth is optimized, it leads to "pollution" of various sorts. Literal, environmental pollution is one type (actually Layard could do well to include more ideas about environmental care in his thesis). Most economists do not measure this "pollution" in their calculations. But there is other "pollution" as well: a culture which values accumulation of financial wealth as the main priority may do so while "polluting" its social fabric. For example, optimal financial output may require longer workweeks and more worker mobility, which then becomes a social norm, leading to everyone spending less time with family & friends & culture, leading to declining morale and a declining sense of community, increased crime, etc. Once again, this type of social "pollution" from maximizing financial performance in society is often not included in economists' calculations.

The wisdom of his book lies in his attempt to combine the field of economics with psychology and the other social sciences, a combination which I think is badly needed. He encourages economists' calculations to be "weighted" by consideration of emotional well-being, not simply by optimization of simple financial measures.

Some of his specific ideas could be challenged (e.g. see the following paper: He advocates increased taxation as a deterrent to over-work, as a cost to pay for "pollution". I think the idea deserves attention, but it has certainly been challenged as a specific policy (the "cost" of feeling more burdened by the state may be a different psychological factor to include; furthermore, I think one of his stronger points is that motivations should be best drawn from inner sources, rather than from external incentives or disincentives).

However, the spirit of his ideas encourages us to do the following, as individuals, and as a society, for the sake of improving our lives & happiness:
1) avoid the "rat race" -- i.e. be wary of choosing a lifestyle in which you have to do more and more, to get more and more stuff, in the name of supposedly improving your life, when in fact you are sacrificing not only your own personal, family, social, and cultural life, but also participating in establishing a competitive social norm which others will want to follow, at their own expense, and at the expense of society itself. Let hard work be done for its intrinsic satisfaction, and as a satisfying way of life, rather than as a means to "get ahead" or to "get rich".
2) Pay close attention to nourishing aspects of personal culture which improve personal and collective happiness:
-be involved in helping others & be involved in your community
-avoid making choices just to keep up with someone else
-avoid criticizing or judging yourself in comparison to someone else; the modern world is set up to make you feel needlessly bad about yourself, or needlessly competitive to change something about yourself that needs affirmation rather than change
-educate oneself, and participate in the education of others, about emotional self-care
3) Watch less TV. The TV is a specific device which has clearly been shown to reduce happiness, through a similar process by which wealth itself can reduce happiness: it is an external source of pleasure, to which we become habituated, at the expense of relationships, community, physical fitness, and personal culture. Also it desensitizes us to violence, which is a further factor leading to increased aggression. Also it feeds, through advertising, the rat-race mentality of acquiring more and more stuff; much of this advertising is directed at children. He quotes an interesting study which supports his view: I might add the internet is another example of something similar.

Addendum: actually, as with many things, I think modern technology can have positive influences too. I remember many experiences of joy, humour, and togetherness watching movies or good TV series. Sometimes the TV can enhance education about the world, history, nature, current events, etc. And TV can introduce us to new aspects of personal culture, and therefore be a cultural enhancement. But I do think that TV can become an addictive and isolative habit; I guess the key is moderation, choosing wisely when and what you watch, and considering carefully why you're watching it.

I especially agree with Layard's ideas about encouraging children to learn from an early age about ways to manage and understand emotion, to practice compassion and empathy (yes, compassion and empathy can be "practiced" and "learned"), and to be involved in community-building. It often concerns me that many supposed community-building activities involving children (e.g. sports, academics, or even music lessons) end up being subverted into yet another rat-race or competition. Ideas from cognitive therapy could be introduced in elementary school, and I'm pretty sure that this could help prevent, or lessen the severity of, many cases of mood and anxiety disorder.

I also especially agree with certain other public policy points: for example, I think it is unconscionable that governments encourage gambling as a form of revenue. To encourage, and advertise, an addictive behaviour which takes individuals away from their families, loved ones, and communities, and leaves some in a miserable state of addiction, just because it is an efficient source of revenue, is extremely poor public policy. It is poor economic policy too, since more people spending more time gambling surely does not lead to increased economic success for individuals or communities, except for the people running the casinos.

I think his ideas about limiting commercial advertising directed at children warrants serious attention. Apparently Sweden has banned such advertising; the Scandinavian countries appear to be a good example to follow in terms of public policy which considers well-being above mere economic optimization.

Borderline Personality, addendum:

I continue to feel this whole subject--of borderline personality-- is a dicey one to wade into, but I didn't want to be avoiding it either.

Part of a problem I've observed is that many extremely important and valid concerns or complaints can be dismissively pathologized as part of a "personality disorder trait".

For example, negative experiences of physicians or the hospital system need not be considered part of an individual's "pathology".

In fact, I think it is more uncommon than common for anyone to have a smooth journey through any medical care system--it tends to be laden with frustration, despite hopefully encountering some good people along the way.

Negative experiences of individual caregivers or relationships within a system need not be dismissed as so-called "splitting" (a "borderline" phenomenon)--they may be accurate and insightful accounts of having encountered a negative relationship.

The experiences may be a product of having encountered poor medical care, a poor medical system, or an unhealthy set of social structures which provide inadequate help. Sometimes an individual's complaints about these negative experiences may actually be a sign of courage, a character strength, rather than of a "borderline trait".

I think a larger view of so-called "borderline phenomena" has to do with group dynamics, as opposed to individual dynamics. If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working. The relationship failure may be due to an inadequate structure, a lack of mutual understanding, communicative failure, a long history of relationship problems which biases the present point of view, tiredness or frustration on either side, or an insurmountable cultural gap. This reminds me of some of the conflicts between nations that go on today, in which each nation's "point of view" is understandable and valid, but the relationship fails, sometimes in a very destructive way, sometimes leading to an "arms race." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators. My point here is that sometimes it is not the individual who has a "borderline personality disorder", but the relationship, or the system, which is suffering from "borderline dynamics".

An author on the subject of borderline personality I consider important is David Dawson. Title: Relationship Management of the Borderline Patient, Brunner/Mazel, 1993

I do find him wise and frank. He challenges some of the the professionally self-indulgent dogmas about psychotherapy, psychiatric hospitalization, and psychiatric medication, dogmas which may not apply to every situation, dogmas which may well, in some cases, aggrandize the "healing power" of the system or the therapeutic process, dogmas which deserve a generous dose of humility in order to more soundly be helpful. He describes numerous dramatic "case vignettes", with much needed attention given to the consideration of process and relationship dynamics. Many of his ideas about the vignettes I disagree with, but the book could open a forum for debate and discussion.

But-- I find his style at times too cynical and lacking in gentle warmth, to affirm it strongly. In fact, Dawson's ideas I think at times have been misapplied in the medical system, used as part of a tactic to prematurely discharge some patients from hospital or from other follow-up care. Yet, I think Dawson's views are important to hear, at least as the starting point for a debate.

Wednesday, January 7, 2009

Borderline Personality

There are many patients I have seen who have had some mixture of the following symptoms or experiences:
1) sudden, intense shifts of mood, often towards extreme sadness, emptiness, or rage. Often times, these sudden shifts occur in the context of a relationship event (a disappointment with someone, a conflictual conversation, a breakup, etc.)
2) very chaotic interpersonal relationships -- lots of conflict, sometimes a lot of aggression, sometimes frequent break-ups, reconciliations, break-ups, reconciliations, etc. Sometimes this is a product of the person having chosen a partner with a chaotic relationship style, but sometimes this relationship chaos occurs even with a partner who is calm
3) prominent, longstanding thoughts about suicide, even when mood is better
4) frequent self-injurious behaviour (most frequently, cutting skin with a razor), which is often done to relieve extreme emotional tension. Sometimes self-injury or suicide attempts occur as a form of non-verbal interpersonal communication or protest.
5) prominent, longstanding self-hatred
6) symptoms which "seem psychotic", such as hallucinations, paranoia, or thought disorganization of various types, but which do not have the characteristic qualities or patterns found in psychotic illness such as schizophrenia
7) pronounced confusion about identity, often with respect to gender, sexuality, or "sense of self"
8) difficulty with relationship boundaries
9) a chaotic and often very negative set of experiences with doctors, the health care system, etc.
10) hospital stays in which symptoms got worse rather than better

I have seen many for whom these symptoms were their manifestation of depression, or part of a type of bipolar disorder, and for whom these issues improved following standard treatments for mood disorder.

For others, some of these symptoms are part of a post-traumatic syndrome.

I have seen many others for whom these symptoms seemed to be part of a developmental struggle, arising with adolescence or earlier, and resolving with time, support, work, development of purpose, meaning, community, autonomy, etc. Often a fairly short-term experience of therapy has helped.

For others, these symptoms become more lasting phenomena, and may in fact become more and more entrenched with time. It is as though the person has a chaotic relationship with time itself, which feeds the symptoms, rather than relieving them.

Some of the symptoms, such as self-injury, seem to have strong addictive components. Other types of addictive behaviours (such as substance abuse) are common in this population as well.

For many of my patients, there is so much overlap between "depression" and so-called "borderline personality traits" that I don't find that there is much point being concerned with "labeling" at all, since the same things help with both.

Here are some things that I have found to be helpful in all cases (in addition my standard advice about a healthy, happy lifestyle):

1) gentle, supportive, compassionate, friendly, consistent care in a setting with clear but non-rigid boundaries
2) treatment of specific symptoms pharmacologically (e.g. antidepressants may help with mood; anticonvulsants or antipsychotics may help with anxiety, irritability, insomnia, and lability; stimulants may help with inattention, hyperactivity, or distractability)
3) avoidance of harm (e.g. I would tend to avoid prescribing potentially addictive medications, or medications that are particularly dangerous in overdose; also some types of overly confrontational, reactive, over-medicalized, suggestive, dogmatic, or "digging into the past" styles of psychotherapy can probably be overtly harmful for some people, especially if the therapy style is engaged in without the patient's full understanding or consent).
4) gentle attention to the same kind of dynamics happening in the therapy as what happens in other relationships (e.g. intense conflicts, feelings of abandonment, "chaos"), and an attempt to gently work it out rather than let the symptoms threaten the relationship
5) cognitive-therapy techniques of various types can be particularly helpful; specifically Linehan's "Dialectical Behavioural Therapy" which is a type of cognitive therapy enriched by ideas from Buddhist mindfulness. Also Linehan's ideas emphasize the idea of "validation" which I consider extremely important -- symptoms need to be calmly understood, empathized with, rather than discounted or dismissed
6) long-term dynamically-oriented psychotherapy, 1-on-1 or group (or both). There is an expanding strong evidence base that this helps a lot
7) trying neither to over-react (e.g. push for an immediate hospital visit), nor to under-react (e.g. ignore or dismiss), regarding suicidal thoughts or self-injury; but to try to be understanding and helpful in any case
8) I do not tend to recommend hospitalization, especially through an emergency admission, as a cornerstone of therapy, except I do encourage people to use the emergency rooms if they cannot survive safely through the day and they do not feel they have other resources available. I believe it is much more therapeutic for people to choose themselves whether or not to use the emergency room.
9) a good day-program, if available, can be very helpful. These are harder to find nowadays

A few references:
(a Cochrane review of psychotherapy for borderline personality)
(a Cochrane review of medication for borderline personality; this shows, as I would expect, a modest and inconsistent evidence base, which I think supports the idea of being open-minded about using pharmacological therapies, but perhaps of having modest expectations of them, and being wary of relying too heavily on medication treatments alone)
(a randomized study showing broad, large effects from psychotherapy in patients having a borderline personality diagnosis, over a 1-year period)

(a study with an 8 year follow-up! --we need more such very long-term studies-- It shows that an intensive day program approach was very helpful)
(another longer-term study showing substantial benefits from psychotherapy)

It is important to note that many with so-called "borderline personality" may have depression or other problems at the same time, and each of these problems may improve with specific types of therapy. Many studies are not considering these "comorbid" conditions, and therefore underestimate the effectiveness of various types of therapy.

Here is a link to a dialectical-behavior therapy self-help site:

Personality Disorders

The area of personality disorders is a sensitive one. Many people find this type of diagnostic labeling pejorative, judgmental, or insulting. And there are examples I have seen where professionals have applied such labels to patients in a pejorative, judgmental, or insulting manner.

Some of the professional literature on this subject is almost impossibly pedantic or arcane.

Yet on the other hand, personality disorder categories do describe the experiences of life many people have been through, or are continuing to go through.

Some of my patients readily accept the idea of having a "personality disorder", and have worked earnestly and successfully with their symptoms, using this type of diagnostic framework.

I am cautious myself about using "personality disorder" terminology. Yet I acknowledge that sometimes understanding, and speaking frankly about, these issues, permits opportunities for things to get better more efficiently and quickly.

In general I would say that "personality disorders" could be understood as collections of chronic symptoms and behaviours which have had strong, recurrent, entrenched feedback cycles involving a person's experience of relationships with other people, with society, with work, and with lifestyle. The intersection of symptoms with these relationships tends to lead to negative results, then tends to perpetuate the pattern. And this dynamic persists irrespective of whether there are prominent mood or anxiety symptoms.

In chronic psychological conditions of any type, whether it be depression, anxiety, psychosis, etc., there are similar intersections between symptoms and relationships, but my sense of the dynamic in personality disorders is that the relationship and lifestyle disruption persists independent of other psychological symptoms.

In some cases, chronic primary symptoms such as anxiety, depression, irritability, or mood lability, could cause "personality disorders" to arise, particularly if such symptoms have been present since early childhood.

Another frequently-observed or theorized cause for "personality disorder" phenomena is childhood adversity or trauma. The adversities or traumas may differ, but in most cases recurrent or ongoing trauma is most strongly associated. Different types of adversity may affect people with different inherited temperaments in different ways -- the same type of trauma may severely affect one person, while causing few lasting symptoms in another.

It is clear that, just as with most any other set of psychiatric symptoms or diagnoses, there is a significant inherited predisposition to have a "personality disorder" diagnosis. Heritability estimates are typically in the 40-50% range. To some degree these types of findings have always seemed obvious to me, it confirms that most anything that happens in life is jointly a product of genes and environment, and the proportional split of causality is often about 50/50.

Advancing understanding of this issue has led to a conceptual shift: "personality disorders" need not be considered lifelong ailments or "defects of character". It is clear that all types of psychological symptoms may change or improve with time, under the right conditions.

There are numerous categories of "personality disorder" as described in the DSM-IV and other diagnostic schemes, and in future posts I would like to discuss each of them in turn. Also there are different theoretical schemes about what "personality" even means--and I think the best research in this area shows that personality itself is better-described using categories quite different from those in the DSM-IV. Yet, I find the DSM-IV categories do describe a common variety of problems and experiences which many of my patients have been through, and so I do think that they have relevance and validity.

Monday, January 5, 2009

Transcendental Meditation for ADHD

Today I encountered an interesting article in the journal
Current Issues in Education, Volume 10, No. 2, 2008

It is about teaching a meditation technique ("transcendental meditation") to children with ADHD, and measuring changes in their symptoms over time. The study shows a significant beneficial effect in numerous symptom clusters, including anxiety and mood.

Some of the authors appear to have good backgrounds in research and scholarship.

Looking up a different author, and checking out some of the other stuff on the internet about TM made me concerned about the level of religious dogma in this area, bolstered by numerous claims (many of which I think are overvalued) about "scientific evidence", also with many claims about TM being part of something morally advanced, yet I note various registered trademarks among the jargon used, together with an insistence that one has to learn the technique from a specially-trained instructor, and an insistence that one cannot learn the technique in other ways. One would think that a purely altruistic set of motives would lead to such ideas being shared more freely and humbly.

The study is substantially weakened by the fact that there is no "placebo control group", hence the findings likely exaggerate the specific benefit of TM (it may be possible, for example, that any other quiet technique taught to children for 10 minutes twice a day, might have led to symptom improvements).

But it is my hunch that meditative techniques can be helpful to improve contentment, and to reduce negative symptoms, for many people. Also, I do agree with the authors' point in this article, that there are different types of meditation, and that some types suit people better than others. Some of my patients have tried meditating, and found it unhelpful. It may be worthwhile in these cases to give a different style of meditating a try. TM apparently does not aim for "mental control"--and therefore it may be more suited for people whose minds and thoughts are hard to "control". "Control" as a meditative goal may just lead to frustration.

And I do--with some reservation--agree that having a meditation teacher or class may be necessary to learn the technique optimally, just like learning to swim or play the violin may require a teacher or class. Yet, I think it is fair to make use of other resources, including books and the internet. I am always wary of salesmanship or charlatanism in these areas, where people are charging a substantial fee while using various elements of persuasion to get you to sign up for something.

Another big area in meditation for treating psychiatric or medical problems is so-called "mindfulness-based meditation". There is an accumulating evidence base for this, and I encourage people to learn more about it. Interestingly, one of the pioneers in using these techniques in medicine first used it for successfully treating chronic physical pain.

I will be on the lookout for other pieces of objective evidence on this issue, as I find meditation interesting, probably beneficial, and at least harmless, provided the practice doesn't lead someone to be swept into some kind of cult-like subculture. I would agree with the statement that if everyone quietly meditated daily in some way, we would probably have a fair bit less violence and conflict in the world.