"The Power of Us" by Jay Van Bavel & Dominic Packer: a recommendation, review, and applications in psychiatry

 Jay Van Bavel and Dominic Packer are social psychologists whose recent book, The Power of Us, is a nice review of basic social psychology with a unique emphasis on the impact of identity and group affiliation on human behaviour and cognitive biases.  

This book would be an excellent accompaniment to The Righteous Mind, by Jonathan Haidt, and Blueprint, by Nicholas Christakis.   Haidt looks at individual differences in values as a factor affecting group behaviour.  For example, people who value loyalty and "purity" (as opposed to "compassion" or "fairness") as cardinal values may be more likely to have strong group adherence, and may be more accepting of hierarchical or paternalistic systems; such traits could lead in particular to involvement with conservative groups.   Haidt argues (and I strongly agree) that such values and traits have a strong hereditary basis (though are also partly influenced by environment & cultural milieu) and have evolved in humans due to selective advantages for those who have a strong inclination towards group affiliation.  But of course, too much loyalty can be a bad thing, if it causes people to adhere loyally to groups which are engaging in harmful behaviour--we see this problem in the news every day.    Christakis looks at group dynamics in an interesting mathematical way, with successful or unsuccessful group behaviour influenced by the structure of connectedness, which in turn is influenced by leadership styles, external factors,  and individual personality traits.  

The subject of group affiliation, identity, with associated biases, polarization, and conflict, is an incredibly important subject in the world today.  Group-based divisions arguably are a primary cause of political problems and war across the world, and lead to delays and inefficiencies in solving world problems such as poverty, environmental degradation, and war.  On the positive side, strong group allegiance has led to most of humanity's great achievements through history.  Most great accomplishments in the sciences, the arts, in politics, and in the law, involve large-scale collaboration.   

Group affiliation is a powerful source of identity for all of us.  If we have a strong attachment to a group, we are likely to favour ingroup members.   This is normal and ubiquitous,  but it can lead in an extreme case to hating or persecuting outgroup members.   To prevent this, it can be helpful to have a culture of interacting respectfully or collaboratively, or recreationally, with outgroup members (Jonathan Haidt made this point years ago, in The Righteous Mind).  It could be especially effective if any such recreational activity could blend members from different groups.  The authors cite some very successful examples of these ideas, such as having a soccer league in Iraq where each team was required to have players assigned equally from different conflicted religious groups.  The resulting games allowed each player, and each team, to like, respect, and enjoy outgroup members, since they became teammates,  leading to reduced conflict in their communities afterwards.  A famous example from classic social psychology research is the "Robbers Cave" experiment from the 1950s, in which antagonistic groups of teenage boys later worked together in friendship and harmony if they had to collaborate together to solve a problem external to them both.  

The chapter on "fostering dissent" is especially insightful.  The authors make the point that voicing a dissenting opinion within a group is socially costly.  Even if the dissent is about an important logical or moral issue, the risk of dissenting can be to make other group members angry, and therefore threaten one's position as a group member.  You risk being seen as disloyal or disrespectful.  They argue that you have to really care about your group to be willing to voice dissent.  I see this could often be true, but sometimes particular individuals are more oppositional or defiant, due to character traits, leading to frequent dissent even if they don't particularly care about their group status.  Another problem with dissent is that other group members may have quietly agreed with the dissenter's position, but it could be costly for them to endorse the dissent, since it could make them look bad or immoral for not having brought it up first.  So a default position in groups would be to maintain the status quo, and for dissent to be risky, even if the group is engaging in harmful behaviours or beliefs.   Unfortunately, this can cause harmful behaviour to be perpetuated in some groups, and for dissenters to be punished or ostracized.  Recent examples of this include U.S. politician Liz Cheney, who has spoken out against the deeply immoral behaviour in the leadership of her political party.  Unfortunately, she was defeated in the subsequent election.  While she should be seen as someone defending the honour, integrity, and values of her group, therefore protecting the group's long-term interests, she instead has been seen by her own ingroup members as disloyal, and punished for it.  I hope her own story is not over, and that her principled behaviour may prevail in the end.  

An approach to solving the dissent problem is to have a leadership structure or ethos in groups which encourages respectful disagreement, without fear of punishment or other consequences.  Also it is vitally important, as a persuasive factor, to frame dissent or challenge with the group's long-term well-being in mind--to remind others of the group's core values, of the group's long-term interests, with a dissenting view intended to be a service to the group rather than merely a criticism.  

On a larger scale, I think it is always helpful to expand the circle of our groups.  Instead of focusing on local or national or religious or political allegiances, why not focus on a shared humanity.  Some of the guiding insights of many of the world's religions, such as Christianity, were to expand a circle of love, respect, and inclusion to outgroup members, and not to shrink into insular, bitter enclaves judgmental of others outside of their own ranks.  

Psychiatric issues always exist in a social context.  Patients will always have group allegiances or identities.  These could involve religion, politics, gender, race, family, occupation, etc.  It is important to understand these group allegiances, empathize with them, and communicate therapeutic ideas with the group allegiances in mind.   Encouragement or advice for change carries a high risk of failing if it is expressed in such a way as to challenge a person's individual or group-based values.  A survey of group affiliation and identity factors should be an essential part of a psychiatric history, and an ongoing theme in a therapeutic dialogue.  

Compassion vs. Empathy: Reflections on Paul Bloom's Book

Paul Bloom, in his recent book called Against Empathy, challenges us to question the role of empathy as a vital ingredient of goodness or morality.  Bloom believes that kindness, guided by thoughtfulness, is the supreme guide to morality, while empathy is often morally neutral or even negative.

Bloom's definition of Empathy

By "empathy," Bloom is specifically referring to the phenomenon of experiencing and feeling what another person is experiencing and feeling.    Many of us define empathy more broadly, so as to imply kind consideration for others' distress, a willingness to help, and an intellectual understanding of another person's problems.  Even some of the researchers who study empathy are imprecise in their definition, leading them to include items about kindness or willingness to help on a symptom scale supposedly intended to measure empathy.

Bloom clearly is not talking about "understanding."   He affirms that it is clearly and obviously important to strive towards understanding of another person's problems or situation, in order to be able to best act morally and helpfully.    A variant of empathy, which we could call "cognitive empathy," refers to understanding, but not feeling, another person's emotional state.  Bloom affirms that this cognitive empathy is important and positive as a social skill, but is not necessarily a guarantee of moral behaviour.   With Bloom's specific, narrower definition of empathy (to feel what another person is feeling), he shows us the following:

Problems with Empathy

1) Empathy does not correlate with kindness.  Many people who behave cruelly have a lot of empathy for their victims.  In fact, sometimes the empathy for the victim causes a sadistic person to magnify their cruelty.  A good fictional example is the character of O'Brien (the "Big Brother" agent) from Orwell's 1984, whose emotional and cognitive empathy guided him to personalize and maximize his torment of the main character.

Conversely, some people who behave with the most astounding kindness and altruism are not guided or motivated by empathy at all.   People who perform daring rescues often do not empathize before they act.  Having an empathic reaction in an emergency could delay a life-saving action.

One example is described of a person who chose to give his kidney to a stranger for a transplant, guided by a cooly mathematical observation of the needlessness of having two kidneys for health, while many people would face death without a single kidney.    People, including young children, are usually motivated to do kind things not because of empathy, but because of a wish to be kind or helpful!

Empathy can actually deter people from behaving kindly, or from even being around suffering people, because the experience of feeling another's suffering is painful and aversive.  A caregiver who is highly, reflexively empathic is at greater risk of burnout.  Whole groups of people, such as those who identify as having autistic symptoms, may have much less "empathy" than average, but they are not at higher risk of causing anyone harm.   Violent offenders do not necessarily have "low empathy"-- the psychological factors associated with violent behaviour have much more to do with low self-control than low empathy.

2) Empathy as a moral guide can cause us to behave in a biased or unfair manner.  If we use only empathy to guide us to help a particular suffering person, it can guide us to help that person before helping someone else who needs the help more urgently.    Furthermore, we empathize more easily with people who are more similar to ourselves, and who live closer.  This may cause us to preferentially help others based on unjust factors (including age, race, ethnicity, etc.).   It is easier to empathize with a suffering animal we find "cute" compared to a suffering animal (who may be in even greater need) who is less photogenic.


Bloom rightly critiques the tendency for empathy to be admired as a type of stellar quality, for all of us to emulate in a quest to become better people, better therapists, or better societies.  He instead encourages us to strive towards kindness and understanding, with our actions guided by reason rather than the narrow, biased focus of emotional empathy alone.  This view is supported by those considered some of the world's greatest altruists, such as the Dalai Lama--in this tradition, it is calm compassion, free of anger, which is felt to be the best guide for moral action, rather than the emotion-swept milieu generated by empathy.


My Thoughts

I see Bloom's thesis as an extension of Kahneman's insights about psychological biases.  Our biases and emotional responses are an intrinsic part of being human, but they easily become experiences which fool us, and cause us to behave irrationally.

Empathy, in my opinion, is a quality similar to eyesight or one of the other senses:  it does not, in itself, have a moral quality.  It can have a narrow focus, which makes it prone to bias, and it can be easily fooled by illusions.  Having highly developed empathy does not make you more moral any more than does having sharp eyesight.  If you believe strongly that your sharp eyesight allows you to understand things better, you may be very prone to others taking advantage of your belief, and you may be very prone to being fooled by optical illusions.  This does not mean we should not cultivate our senses, including eyesight or empathy.  They are important talents and skills, and they deserve attention and practice.  It is just that we should not rely on them by themselves as moral guides.

Taming Empathy

I do believe that empathy is important, however.  It just needs to be "tamed."  I can think of many clinical situations in which an empathic moment--even to the point where I might shed a tear--has helped with my patient feeling a sense of connection and trust.   A therapist who shows no emotional response to a patient's suffering could be experienced as detached, aloof, and cold.  Also, many therapists have a reflexive suppression of their own affect, which is felt to be a part of professionalism, yet which causes an unnecessary and obstructive detachment.   A therapist's practice of allowing their own emotions to flow empathically, and to manifest in the session, can be an aspect of fostering connection and demonstrating sensitivity.   But if this empathy would lead to the therapist suffering with sadness or panic through the hour, at the same time as the patient, then this clearly would not  be helpful!  It would probably frighten or disturb the patient, and would also lead to burnout in the therapist.   A brief moment of deep empathy can be very therapeutic, but after that point, therapy moves away from pure empathy towards cognitive understanding and gentle problem-solving.

Empathy can also be a joy of life to experience, provided it is not understood to be a moral guide.   Empathy can and should be practiced and savoured, just as you would cultivate your other senses--but it should not be granted power as an arbiter of moral decisions.

Empathy for the Therapist! 

Bloom makes a nice point that in a good therapeutic environment, sometimes empathy is most beneficial in the opposite direction:  if the therapist is gently attuned and understanding, but calm and at peace, then the patient's empathy for the therapist may help the patient to attain calm and peacefulness in the midst of painful emotions.

Empathy could work this way in therapy as an example of social learning therapy combined with CBT:  if the patient would see the therapist briefly having a deep empathic moment of "co-suffering," but would then see the therapist gently step back, in a thoughtful, compassionate calm state, this could be an in-the-moment example for the patient to follow...in this way the therapist would truly be an emotional guide.  I think this effect should not be overstated, as the therapist's helping role may usually be much more modest and subtle.

The Importance of Listening and Showing Understanding

I believe it is very important to emphasize that we have been talking about Bloom's very focused definition of empathy.  I usually use the term empathy in a broader sense.    When people are meeting with a therapist or a friend, they often greatly desire to simply be with someone who will listen.   Many people do not desire to have advice or reassurance in response to what they are sharing, at least not right away.  And they may be frustrated if the other person starts to discuss their own similar problems.   It is often very appreciated if the listener at times reflects back what has been said, to convey respectful understanding, of both the situation and the emotions involved.  This reflection and demonstrated understanding is what I mean by empathy, most of the time.  A typical example could be saying something like, "you had an exhausting day..."  When giving this reflection, I would not normally feel exhausted myself!  Sometimes a more elaborate or detailed reflection could be good, but sometimes prolonging these responses for more than a brief sentence can interrupt the person's experience of being gently listened to.  

Audio and Video recordings of Positive Affirmations

In my last post, I was discussing a technique of practicing exposure to recordings of upsetting thoughts.

This same idea can be applied to positive thoughts too!

I encourage you to collect ideas, quotations, and encouragements.  Write them down, and then make an audio or video recording, using your own voice.

Choose a time when you are feeling calm and comfortable.  Make your recording a type of message to yourself, a message of support and encouragement.

Your encouragements could be quotations from a cognitive therapy exercise, in which you were reasoning or problem solving in response to negative thoughts.  Or they could be passages from a gratitude journal, in which you express thanks for any positives in your life.  Or they could be things you might say to someone else who has struggled or suffered in the same way that you did.  Or they could simply be simple, kind encouragements directed towards yourself.  For example, you could record something like "You are a beautiful person, full of kindness, love, and potential.  The world needs you. Take care of yourself...whatever hard times you are having now will pass..."   If you make a video, smile at yourself, and gaze at yourself with loving, compassionate eyes.

After you make your recording, it would be something to listen to or watch frequently.

Unlike the exposure therapy exercise, the goal here would not be to face a fear and strengthen yourself against it, but rather the goal would be to practice absorbing and accepting the positive messages.  If you listen to a piece of music frequently, the tune will eventually "play itself" in your mind, and your memory for this music will become more and more effortless.  Similarly, these positive recorded messages could become more naturally integrated into your memory.

I think that hearing your own voice, and seeing your own image, are more powerful influences on your mind and your thinking, compared to only working with your ideas using written text.  Hearing yourself speak is much more like experiencing your own thoughts, compared to reading your own written words.

Exposure Therapy for Worries, Intrusive Thoughts, Ruminations, and Obsessions

Worries, ruminations, intrusive thoughts, and obsessional thoughts can be a terrible source of suffering.  If they are mild or infrequent, they can be part of a healthy, balanced life.  But when they are occurring frequently, they interfere with all of our activities.  They make it hard to enjoy anything.  A beautiful walk in the forest is interrupted by upsetting thoughts about daily stresses, or about painful events that happened long ago.  Attempts to work or study are interrupted constantly, preventing you from getting things done, and certainly preventing you from enjoying what you are doing.  If the intrusive thoughts have to do with past traumatic events, it is as if these terrible events are happening to you all over again.

In this post, I am exploring a challenging approach to this.  But I know that in many cases upsetting thoughts cause extreme pain and suffering, and therefore any therapeutic approach must be considered with very great care.  The approach I am proposing may not be right for you, unless you feel very well-prepared for work that could be difficult.   With any therapeutic approach, you must feel entirely in control of the therapeutic process.  You must never be pushed into any sort of therapy, even by a well-meaning therapist whom you trust entirely.  Sometimes the framework of therapy implies that you should be doing certain types of work.  Just coming to a therapy appointment can implicitly push you into engaging with certain therapeutic tasks, such as sharing a painful story about your past.  

But I believe it is of the greatest importance to be guided entirely by your own will, with any therapeutic task.   

Upsetting thoughts are problems in which an event is happening outside of your own will.  Past traumatic events also have happened against your will.  So it would be wrong to engage in a therapeutic effort, unless you are very clearly in agreement with it, and you are engaging in each step with the full force of your will and consent.

I am also aware that many therapeutic ideas can seem too focused on some particular "technique."  Sometimes we can focus too much on "technique" in such a way that we are distracted from the larger picture.  In the big picture, I believe that healing forces include gentle self-care, empathy, healthy lifestyle, and loving relationships.  So, regardless of whatever "techniques" you try, be careful to remember that the "big picture" factors are the most important of all.

But let's get started on looking at some "techniques," with these limitations in mind:

What strategies or techniques can help to manage anxious thoughts, worries, or ruminations?


The Problem with Relaxation Techniques

Most people, including therapists, focus on techniques to help calm the mind.  These could include relaxation or meditation techniques.  Most of us would also encourage healthy distraction techniques, such as trying to read a book, listen to music, "breathe," go for a walk, talk to a friend, have a bath, etc.  Many medication treatments also focus on relaxation.  Benzodiazepines, including lorazepam (Ativan), clonazepam (Clonopin), alprazolam (Xanax), or diazepam (Valium), often literally calm the mind, slow down racing thoughts, and reduce the distress caused by rumination or worry.

But the problem with these approaches is that they are primarily avoidance-based, rather than strength-based.

Analogously, if you are very fearful about swimming, it will absolutely relieve your anxiety if you distract yourself, meditate, read a book, or take a sedative, whenever you are close to a swimming pool--but, of course, these techniques will not help you to cure your anxiety!  The only cure must involve deliberately approaching the water, and gradually facing your fear!

In many cases, relaxation therapy (especially if it is the only approach used) can make underlying anxiety worse, because it consolidates the notion that the anxiety is intolerable and must be avoided.

Exposure-Based Techniques

Over the years, I have become more and more a fan of behavioural therapy ideas, for approaching a wide variety of psychological symptoms.  I believe that this approach is strength-based, and is similar to having a physical fitness regime, or a structured program of learning a new skill (such as speaking a new language, playing a new sport, enjoying a new hobby, or playing a new musical instrument).

To treat a phobia about swimming, it is easy to prescribe a behavioural therapy program.  The first step might be to just watch people swim, while you sit in the bleachers.  The next step could be sitting at the side of the pool, with your feet in the water.  Eventually you might walk in the shallow end of the pool.  This could build up to putting your head under the water, learning to float, etc.  Eventually, with practice, you could be swimming laps in the deep end (maybe with the help of a swim teacher).

But how could we devise a plan to treat anxious thoughts or ruminations, using this type of approach?

An idea I have been working with is to encourage patients to make a detailed record of anxious thoughts or ruminations.  Try to "catch" the thoughts verbatim -- as though you are taking dictation, or using quotation marks.  Then make an audio or video recording, of yourself reading these thoughts aloud, in a way which mimics as closely as possible the way in which the thoughts occur in your mind.    The recording then becomes something to practice listening to...the task is to sit calmly with your thoughts.  If anxiety comes as you listen, let it come.  Consider it a type of "workout" to face a difficult task.

As with other types of workouts, it is important to plan the duration and intensity so that it is challenging but not overwhelming.  It can't be too easy -- otherwise there would be no training or strengthening effect.  But it can't be too hard -- otherwise you could injure yourself, or just have an unpleasant experience that would discourage you from working out again.

With exposure to recordings of anxiety thoughts, you can adjust the intensity in a number of ways (this is analogous to adjusting the weights in the gym).  Here are three ways to adjust the intensity or difficulty:
1) just turn the volume of the recording down.
2) listen to the recording for very short periods of time, and gradually increase the duration as tolerated.
3) listen to recordings of thoughts which are less upsetting.  As you feel able, you can introduce more difficult or challenging thoughts.  
   

There are various phenomena that can happen which reduce the effectiveness of this technique.  The mind has strong reflexes to manage anxiety using avoidance.  When dealing with worries or intrusive thoughts, it is very common to want to respond to these thoughts by trying to reason with them, reassure yourself, problem-solve, or distract yourself in various ways.  With this technique, it is important to simply let the thoughts come, let the ensuing anxiety happen, without trying trying to reassure, problem-solve, or distract.

I am not saying that problem-solving is unhealthy!  Of course, problem-solving and reassurance are very important!  But not if they occur during this type of exercise!  Analogously, if you are lifting weights in the gym, you could roll the weight upwards using a ramp, instead of lifting it directly!  This would be using clever problem-solving to bring the weight to a higher point!  But you would not get stronger if you used the ramp!  Or you could use a flotation device in the pool...this would be a good solution to help you float safely.  But it would not help you to swim better, or to master your anxiety of deep water!

Another type of technique used commonly for managing worrying and rumination is "thought stopping."  There has been some research supporting it.  This would appear to be an avoidant technique.  But according to one analysis, the reason that thought stopping can sometimes appear to work is because the exercise often first calls for people to deliberately induce anxious thoughts!  Only after a period of exposure to the anxious thoughts do people then use a thought-stopping technique.  At this point, often the thoughts which are "stopped" are not the anxious thoughts themselves, but rather the compulsive self-reassurances or problem-solving attempts.  Therefore the thought-stopping is actually favouring a better anxiety exposure exercise!

Summary of the Technique

1) make a detailed list of anxious thoughts, to replicate as closely as possible how they occur in your mind
2) make a recording, in which you read these thoughts out loud
3) listen to the recording, as a type of psychological "workout"
4) adjust the volume, duration, and content of the recordings, so that it is moderately difficult for you, but not overwhelming.  Aim for an experience of "mastery" just as you would when you are lifting weights successfully at the gym, or when you are doing some other type of exercise
5) While you are listening, you could attempt to do other tasks that you normally would like to do, such as studying.  But work hard not to engage in "avoidance" behaviours such as distraction, reassurance, or even relaxation techniques
6) You could aim for about 20 minutes at a time...but you might need to start with much shorter durations, such as a few seconds, if you are very sensitive.  Once again, it is like starting to do a new exercise such as running...you may need to begin with running just a few steps, and then building up to longer distances as you get stronger.
7) After each exercise, you could then do some relaxation or other pleasant activities...just like soaking in the hot tub after a workout at the pool or gym...
8) Pay attention to how you feel in the next few days.  Just like workouts at the gym, you might feel "sore" in some ways.  Sometimes you might have more upsetting thoughts or nightmares, and feel worse.  If this is the case, you may need to make the next "workout" easier.
9) You may need to have a guide (such as a trusted therapist) to help you with this.  The role of the therapist, with respect to this technique, would be like a "personal trainer" at the gym--the therapist would be there to support you, encourage you, and help you with any problems along the way.
10) Sometimes a particular technique, such as this one,  may not be right for you.  If this is the case for you, remind yourself that it is not a sign of "failure."  It is just a sign that a different strategy is needed for now.  You might come back to a technique like this at a later time, or you may find other techniques that suit you better.


Is there still a role for Relaxation Techniques? 

To carry the fitness analogy further, I think most of us like to relax during part of our physical workouts.  Before or after our exercise, we might like to stretch, warm up, cool down, or relax in a hot-tub or sauna.  This could add to the enjoyment of the workout, and possibly even reduce the chance of injuries.

With an exposure-based anxiety management technique, perhaps some relaxation-oriented ideas could be used before or afterwards, in the same way.  It could help make your work a little bit more enjoyable, part of a pleasant routine.  It would just be important that your relaxation technique does not cause you to indulge in some kind of compulsive pattern that could contradict the work you were doing.

How other techniques already use this idea

In mindfulness-style meditation, the strategy is not to "empty your mind" or to prevent anxious thoughts.  The goal in mindfulness is acceptance and practicing attention without excessive reaction to sensations, feelings, or thoughts.   Worries or intrusive thoughts are viewed as clouds drifting through the sky of your consciousness, rather than attackers which need to be confronted.  Therefore, a person practicing mindfulness is also practicing being with the upsetting thoughts, rather than avoiding them.

In EMDR, various upsetting thoughts or memories can be contemplated while doing a physical activity.  In this way, arguably, the eye movements have a catalytic role to allow exposure practice to occur in a framework which feels therapeutic and well-boundaried.  A weakness in this technique, and possibly a reason that EMDR may work better with some therapists or clients than others, is that the eye movement activity could in some cases be an excessive distraction, and therefore dilute the effectiveness of the other therapeutic work.  But I think that provided this potential problem could be addressed, EMDR techniques could help a client and therapist adjust the intensity of a therapeutic session, analogous to adjusting the difficulty of a physical workout.

In conventional CBT, the initial phase of paying attention to upsetting thoughts, and recording them, is already a type of "exposure."  The act of writing something down can often require a strong act of will, and carry powerful symbolic value.  But a problem with cognitive therapy can sometimes be that the thought records become distractions, foster rumination, or lead to excessive debate or intellectual argument about thoughts.  

In psychodynamic styles of therapy, the experience of freely discussing painful thoughts and memories also involves exposure to the strong emotions associated with them.  Sometimes, in this style, the therapist's quiet presence is not directly "reassuring."  Rather, the therapist has a quiet role of facilitating exploration without a need for direct reassurance or problem-solving.  But a problem with psychodynamic styles has to do with its passivity--there is a lot of focus on exploration and "interpretation" but often not enough focus on strength and practical, immediate, active mastery of symptoms.   The preoccupation, in psychodynamic therapies, of searching for remote causation of symptoms, can distract clients or patients from working on strategies to master their anxiety in the present moment.  

Limitations

For many people, intrusive thoughts are occurring so frequently and intensely that it is hard to recommend deliberate exposure to even more upsetting thoughts.  It would be like recommending a demanding physical workout to someone who is exhausted or injured from a grueling daily routine of hard labour.    In these situations, it may be important to look at other techniques, including more of a focus on relaxation, or on medication, to help reach a state of calm restfulness, before beginning an exposure-based strategy.

If there is a history of psychosis or mania, then there would have to be a lot of caution about using this type of technique.  But I would not rule it out entirely...there is more and more evidence about CBT-style ideas being useful in managing psychosis.

If negative thoughts are part of a volatile pattern leading to dangerous behaviours, including suicide attempts, self-injury, destructive bouts of anger, or severe dissociation, then very great care would have to be taken to make sure that this type of technique was used in an especially slow, cautious manner if at all.  There might have to be some preparatory steps to make sure that the situation was safe and stable enough to proceed.  This is again similar to recommending a physical exercise routine to someone:  it is important to make sure that a person does not have joint problems, heart disease, etc. which could make the exercise dangerous.

In some types of depression, a person can feel self-destructive.  With this technique, excessive exposure to the content of upsetting thoughts could be self-injurious.  Self-destructive behaviour would need to be addressed first, in order to allow a technique such as this one to be safe and helpful.  
One of the most important things, with any type of therapy, but especially with a process such as this, is to frequently emphasize that it is completely up to the client or patient to engage with the technique or not.  The therapist must never push this.  The client must feel completely free to stop the technique at any time, without any concern that the therapist would somehow be disappointed or disapproving.


The Role of Medication

A goal of medications is usually to reduce anxiety directly.  But I think it is important to think of effective medication as a "catalyst" rather than a direct "cure."   Medication may reduce the severity of the underlying problem, so that other types of therapeutic work could take place more effectively. The effect of medication could be analogous to reducing the weights in the gym, or to using a flotation device to help you practice kicking in the swimming pool.    Without medication, sometimes the symptoms could be so severe that it is much more difficult or painful to do the therapeutic work.  It would be like going to a gym where the only barbells available had 200 pounds or more on them!

Some medication can also theoretically improve sleep or restfulness, and therefore allow you to do better and more enjoyable therapeutic work the next day, when you will feel more rested.  In other cases, medication could help with energy, allowing you to become more actively involved in all therapeutic tasks.  

Another dynamic in PTSD can be that uncomfortable experience is too quickly assimilated--perhaps via the amygdala--into a strong, aversive "emotional memory."  Past trauma, in combination with inherited factors, can make this type of neural pathway hypersensitive.  Arguably, some medications, including beta-blockers and other adrenergic antagonists,  could reduce the intensity of this reflex.   This would be analogous to a person with arthritis using an anti-inflammatory medication before doing physical exercise--the medication would allow the exercise to occur more comfortably, and with a lower chance of injury.     But I have to admit that it can be hard to find medications that are consistently helpful for this type of problem...I do think it is good to have an open mind about trying different approaches.


Conclusion

Upsetting thoughts can be a difficult problem, but I encourage patient, gentle persistence in a search for relief.  Remember the big picture, of patient, gentle self-care, healthy lifestyle, and nurturing loving relationships.

I do invite you to consider the possibility of finding ways to approach upsetting thoughts in a way which seems paradoxical--by finding a way to face them directly, and to practice having the thoughts rather than practicing ways to get rid of them.  This practice is not meant to be masochistic, but rather is meant to build a strength inside of you, so that the bully-like emotional effect of upsetting thoughts is gradually weakened as your strength improves.

References

There are not enough research studies done regarding approaches to rumination, primary obsessions, and other intrusive thoughts...but a similar exposure-based idea is described by  Salkovskis & Westbrook (1989).  I will look for other articles to expand my list of references later.

Salkovskis, P. M., & Westbrook, D. (1989). Behaviour therapy and obsessional ruminations: can failure be turned into success?. Behaviour research and therapy, 27(2), 149-160.

Feeling Trapped in a Life You Don't Want: Hopelessness & Chronic Depression

I originally published this post in March, 2009.  I was just looking at it again today, while browsing through my blog...I thought I would re-publish this, and maybe work on adding to it.   I have been reviewing treatment guidelines for mental illness, and have been asked to help prepare some official guidelines for my workplace...while I find this task, of preparing "guidelines,"  meaningful or useful in some ways, with some worthwhile observations and tips to be discovered in the existing research, I finally find the task a great source of weariness and frustration.  This particular post really represents something that is much, much closer to the "core" of who I am, or who I want to be, as a psychiatrist.  And it reflects more deeply--than any "guideline" could-- my beliefs about caring for people who are suffering.   


This post is in response to a comment on my previous post "What to expect from an antidepressant".

What is the purpose of a life?

What needs to be present in a life to make it worthwhile?

If a life is like a work of art, a giant canvas that you have been working on for decades--what if you feel that the canvas has already been wrecked? The damage may have been caused by "bad genes" (e.g. an inherited tendency to be depressed, etc.), which in the canvas metaphor might mean the canvas itself is fragile, thin, easily damaged, doesn't hold pigment very well, etc.

Or the damage may have been caused by "bad environment" (e.g. a traumatic childhood, lack of support, lack of opportunity, natural disasters, war, poverty, etc.), which in the canvas metaphor might mean the canvas itself has been damaged by others, or by environmental adversity, causing it to be very difficult or painful to work with in the present.

Or the damage may have been caused by your own past efforts (e.g. a history of spending years trying to develop oneself-- in school, in relationships, in work, etc.--but where these efforts have ended in failure, pain, breakups, sorrow, regret, guilt, or a sense of having burned your bridges--and where the past failures obstruct future opportunities, e.g. via a poor academic transcript, work record, etc.). In the canvas metaphor this might mean there is a lot of paint on the canvas, but none of it is what you want, none of it is where you wanted it to be, none of it you actually like, it all looks like a collection of mistakes. If it was a literal canvas, you might feel like the best action would be to just throw the painting away, and either start fresh, or give up painting altogether. You might feel like you never wanted to paint in the first place, that the task was forced upon you by the fact of your birth, and by the social expectation that you are supposed to live out your life.

For many people who struggle with chronic depression, I think there is some combination of all these three possibilities: genes, external environment, and personal efforts which haven't worked out, all contributing to a state of hopelessness, tiredness, exhaustion. It can feel like a daily struggle just to make it through the day, a yearning for time to pass just for things to be over. Life can feel like a trap, a life sentence to a prison term, a forced existence that you never really wanted, or have long since stopped wanting.

The idea of a medication somehow "treating" this problem can seem absurd. Or the idea of so-called "cognitive therapy" changing this problem can seem insulting. It is like observing a painting you don't like in an art gallery, and then being told that you have to do some exercises to change your thinking, so that you will start to like it, then have it up on your living room wall for the next 60 years. In some ways this dynamic reminds me of salesmanship, in which case it can feel like the therapist, or even the whole external world, is trying to "sell you" the idea that your life is supposed to be worthwhile, when all you see is something you hate and want to get rid of.

I don't have easy answers to this problem.

But here are some of my beliefs about approaching it:


There are people who will care about you, and who will sit with you through your suffering. A role of a therapist in this type of situation, I think, is to sit quietly, to be gently and consistently present.

The world is full of possibility. No matter how bad conditions have been--internally or externally, past or present--growth and change are possible. The brain is a dynamic structure. It is as powerful and consistently active when alive as is the heart. But the brain reinforces its own pathways. If these pathways give rise to feelings of despair, hopelessness, and futility, then every moment of life can become experiences of despair, hopelessness, and futility. If these pathways of thought, emotion, and felt experience, have been trodden for decades, it can be hard to forge new pathways within the mind.

Immense, profound life change is possible, regardless of how severe problems have been, how long they have been present, or how much damage the problems have caused.

Such changes may require an enormous amount of energy and time, and may require a lot of external support.

There are many individual life stories of profound life change, stories of journeys through chronic hopelessness towards meaning, energy, and joy. Historically, some of these stories are of mythical proportion, and are present in literature and the other creative arts. Many religious stories contain themes of this sort.

Contemporary examples include stories of individuals overcoming lifelong addictions which had devastated their previous life histories (here I am not saying chronic depression is an addiction, but that addictions and depression can both be characterized by feeling very stuck in something bleak and hopeless). The lore in addiction treatment has wisdom to share about making radical life change--in "12 step" models, for example, individuals are called upon to admit "powerlessness" over their problem, and to make a set of statements of faith about a "Power greater than ourselves", etc. While I am wary of the potential for dogmatic religiosity in such statements, I also see that if dogma can be set aside, the "12 steps" can be seen as a sort of "leap of faith", a new contract with life, to live--and work-- with the help of a supportive community. It admits, powerfully, that one must reach out to connect with the possibility of change, it is almost impossible to do alone (the "higher power" idea can simply be an admission that one needs external help).

Psychiatric medications in chronic depression usually do not lead to "profound life change" (sometimes they do, but really this is in a small minority of cases). However, often they help a small to moderate amount. Either to relieve some suffering or pain, or to potentiate energy that might then help to effect a new course in living. I do not feel that any effective treatment leads a person to become resigned to an unpleasant status quo, and then to learn how to "accept a bad life". I feel that effective treatments allow unpleasant circumstances to feel more bearable, then to facilitate the hope and actions that are necessary to improve the unpleasant circumstances.

Cognitive therapy can help. The goal, however, in cognitive therapy, cannot be simple "salesmanship". I think the goal has to be building a satisfying life, where there are healthy, stable relationships: meaningful work, meaningful love relationships, and meaningful activities that bring joy or happiness.

With any type of process that causes deep changes in the brain, the pathway may require you to go right back to the simplest foundations.

I'm reading Norman Doidge's book about "neuroplasticity" right now (The Brain that Changes Itself), which incidentally I recommend highly. The evidence he presents is quite convincing, to some degree surprising, but on another level intuitively very obvious--the brain can change itself, sometimes very radically.

But if new paths are to be formed in one's "mental forest" one may need to start with tasks that seem extremely simple, even infantile, perhaps even "insulting" in their simplicity. Cognitive therapy can seem extremely trite, or even a ridiculous exercise in mental manipulation--an exercise to comform oneself to how society as a whole expects you to think or feel, trying to convince you to think good thoughts about a bad situation.

The thing is, though, these seemingly ridiculous tasks (such as cognitive therapy, etc.) can start new paths forming. In conjunction with this, new connections can begin with the external world, in the form of new friendships, new involvements in creative work, new involvements in education, etc.

There may well be burned bridges, but there is a vast energy available to build new bridges, if you so wish. And your past experiences may eventually become more useful to you than they are right now.

Depression can be extremely tenacious. It is so extremely tenacious that in some cases it is almost like a character that wants to perpetuate itself. The depression itself, so to speak, sets up arguments in one's mind about why this or that action (e.g. medication, therapy, life change of other sorts) cannot or should not happen. In the forest path metaphor, it is like the depression not only has become an extremely well-trodden pathway in a dense forest, but it has also put high fences around the pathway, and a deep moat full of crocodiles on the other side of the fence too.

Once again, I emphasize that I have no easy answers. As I look at the above post, I see that it is rambling. Parts of it probably sound preachy or trite. Probably annoying to look at if you are feeling trapped in a depressive state. I think I come off sounding like a salesman myself, trying to convince you to buy that painting you don't really like.

My intention, though, is to convey my belief that change is possible. There is proof that change is possible. I see this proof in my own clinical experience, as well as in the stories of others. Deep change in a chronically unhappy life is possible, but may require a great deal of external help, and may require a type of commitment to change that is extremely difficult or exhausting to initiate. And your depression won't want you to make any such commitment.

Seeing multiple therapists at the same time

It is usually taught, in "therapy school," that clients or patients should not be seeing more than one therapist at the same time.

Here are some of the reasons often given for this policy:
1) seeing more than one therapist could be an inefficient use of resources
2) the multiple therapists could be "working against each other" or perhaps confusing the client or patient
3) the multiple therapists could be part of a larger process of the client being engaged in unhelpfully complex relationship entanglements

There are many case studies describing situations in which multiple therapists appeared to bring about problems. 

But is there more substantial evidence, beyond case reports, about this?

To begin, why not consider other examples in life, where one might have "multiple caregivers":

1) Parents.  Many people have two parents.  While it is often the case that each parent provides different types of care to the child (e.g. one parent providing financial support, the other providing daily care in the home), it is more often the case, especially in the current generation, that parents share all elements of care.  This is not an "inefficient use of resources," and does not lead to a higher risk of the parents "working against each other," it is just better and more enjoyable parenting!

The therapist-client/patient relationship is not the same as a parent-child relationship, but there are some similarities in most cases.

2) Friends.  Many people have more than one friend.  The different friends a person may have do not necessarily provide different types of "friendship experience."  Some individual friends provide the exact same type of "care" as another.  You might have two different friends whom you like to have personal conversations with in the same kind of way, or two other different friends who both like to go hiking with you.  It often works well to have more than one friend, though of course there can be problems between them at times!

The therapist-client/patient relationship is not the same as a friendship, but there are some similarities in most cases.

3) Teachers.  Many people have more than one teacher.  For a given subject, there might be several different people sharing the task of teaching (for example, a professor, a TA, and a tutor).  While there could sometimes be differences or contradictions between the different teachers, it is generally considered beneficial to have more than one teacher!  In fact, being exposed to different teaching styles could improve learning.  Even if different teachers give contradictory advice, this could often enhance a learning process, as it exposes the student to multiple viewpoints, therefore stimulating a more open-minded analysis in the intelligent student.  It would be like reading two different newspapers, instead of just one, in order to better understand current events or politics. 

The therapist-client/patient relationship is not the same as a teacher-student relationship, but there are some similarities in most cases.


Are there ways in which multiple therapists are already accepted as a norm?

I believe there are.  In most health care systems, such as mental health teams, there are multiple people involved in an individual's care.  There may be a social worker, a nurse, a "case manager," a designated "psychotherapist," and a physician or psychiatrist. While each member of this team may have particular specified roles, it is often the case that each person of the team helps most through what I might call "common factors."  These "common factors" are akin to "Item 1 and Item 2" that I have described before (http://garthkroeker.blogspot.ca/2016/06/angry-birds-and-items-1-and-2.html).  Such factors are the foundation of all "psychotherapy."  Hence, in a stratified team setting, each member is already providing psychotherapeutic foundations.  It may often be the case that the client or patient finds some particular member of the team more beneficial than any of the others, not because of the caregiver's designated role, but because this team member is attending more to Item 1 and Item 2.

In other examples, it is very common for a therapist to recommend some other health care resource.  There might be regular psychotherapy sessions, but with referrals to a CBT group, a meditation group, a personal trainer, a yoga class, or a dietician.  While these referrals would overtly be to allow the client or patient to pursue some other type of care which is not taking place in the current psychotherapy frame, they also inevitably lead to a fundamental duplication, once again through Item 1 and Item 2.  Perhaps the yoga teacher or dietician might actually ask about the client's childhood, and offer some kind of empathic feedback!  Perhaps the personal trainer might recommend some behavioural therapy exercises alongside the workout routine!  This would not be unhelpful redundancy, but would rather be ways to potentially consolidate therapeutic ideas from fresh perspectives! 

Are there any neurotic or biased motivations among therapists, which lead to continuing aversion to the idea of multiple therapists?

One possible bias is simply the force of tradition.  It is a long-established belief that having multiple therapists is problematic.  I believe there are roots in the psychoanalytic tradition; here, the theory suggests that a strong "transference" must be formed with the therapist, in order for the therapy to work properly.  Having other therapists would somehow distort this transference process.

This reminds me of jealousy in a close personal relationship.  The assertion from the therapist is something like, "choose me, or choose the other therapist...you can't have both!"

The thing is, jealous behaviour does not actually improve the quality of a relationship; rather, it is a sign of insecurity.  Relationship quality is indeed important, but it must be built on a foundation of trust, kindness, and respect for freedom.


Here are some reasons to have a more relaxed attitude, professionally, about clients or patients having multiple therapists:

1) it is an issue of respecting the free choice of the client or patient
2) it may simply expand a circle of care, or a network of care, for vulnerable people who need or desire support
3) some therapists may have limited availability, or may frequently have absences, despite having a very good connection with a particular client or patient.  It can be good to have other therapists to be involved to cover for such absences.
3) potential problems or conflicts between different therapists can be resolved through dialogue or collaboration, not simply by forbidding the possibility of having multiple therapists
4) pushing different caregivers to have more restricted roles (e.g. for psychiatrists to only have brief medication management visits) causes impairment in morale and in clinical skills among such practitioners.  Psychiatrists who are only advising people about medication, while others do "psychotherapy,"  will become less and less attuned to Item 1 and Item 2, to the great detriment of themselves and their patients.  It will strengthen the stereotype of psychiatrist as detached, medication-prescribing, and superficial.

There are indeed cases in which having multiple therapists is clearly unhelpful for the client or patient, or for the therapist or system.  And, in these cases, as a professional decision, it may be beneficial to take steps to encourage the client to choose one or the other caregiver.  In other cases, it may be beneficial to step back from involvement in a person's care, to allow them to focus on just one strategy at a time.

But I think such decisions should be made on a case-by-case basis, and should not be made as part of a dogmatic policy. 

Parenting & Psychotherapy

There are many books out there about how to be a better parent.  The fact that this genre is popular is, in my opinion, a good sign of societal health:  perhaps part of parenting well is being interested in learning about ways to parent well!  It speaks to a cultural change as well, in which quality of parenting is considered important as a societal theme.

Demographics have changed over the centuries, in a way which bodes well for the earth's future:
 At this point, there is about 1.1% of population for each year of age, up to 1.6% per year for people in their 50's (the baby-boomers), then declining gradually for elderly.  In general, the population pyramid now looks more like a "solid bar" rather than a triangle, indicating that people of all ages are more equally represented in the population, rather than young children being most common.

This means that each family with children, on average, can invest more time, attention, and resources, with each individual child. 

What is the evidence about the merits of different styles of parenting?

Here we have the very surprising finding that differences in "shared family environment" have a much smaller impact on most phenomena, such as personality traits, intelligence, and mental illnesses, compared to differences "non-shared environment" (i.e. the environmental factors unique to the individual) and to differences in genetics.

 Yet, these findings refer to population averages. It is obvious that extremes of environmental experience will obviously influence outcomes much more.  An atmosphere of severe abuse and neglect is likely to have a damaging effect, while smaller differences in home environment within the "average" range in the society are much less likely to have significant effects.

People tend to focus excessively on the "smaller differences" side of things, with respect to parenting and home environment.  Provided that the home is secure, safe, relatively stable, with access to reasonable social and educational resources, it is probably true that variations within one or two standard deviations of the mean of parenting style are unlikely to make very much difference, in terms of subsequent illnesses, intellectual achievement, or overall well-being among children who grow up in such family environments.    The key thing is the avoidance of extreme negatives such as abuse or neglect.

Is there any other parenting variable that clearly matters?

I believe it is simply time, involvement, and availability.  Better parenting does not necessarily require parent education groups, expanded community resources and collaboration, better activity groups for the children, more efficient time-management strategies, etc.

Rather, better parenting simply involves being joyously, affectionately present for your children!

Presence and availability alone are not enough.  The availability has to be provided with a spirit of joy and delight.  Child-rearing cannot merely be a chore or a technical skill -- it must be nurtured as a joy of life.  Children who see that their parents actually enjoy parenting, enjoy laughing and playing and working together, are much better off than those whose parents spend equal amounts of time, but with a spirit of stress, negativity, or conflict.


I wish to make an analogy between parenting and psychotherapy.  I know it is an imperfect comparison, in many cases at least.  Some patients do not desire or need any such dynamic with a therapist, and it could be intrusive or presumptuous for the therapy relationship to have some kind of unwelcome "parental" quality.    For other patients, there is a more overt "parental" dynamic in therapy frames.  In any case, I think that there is a direct analogy between optimal "parenting strategy" and optimal "psychotherapeutic strategy."

Most of us, examining evidence of psychotherapy, emphasize technical differences in the therapy style or actions (e.g. using CBT vs. psychodynamic approaches).  Yet, evidence about relative advantages of one technique vs another is actually very minimal.

I do think there are technical elements which are important.   For example, I think principles of behavioural therapy must be called upon for management of any condition or problem -- it is like prescribing exercise to strengthen a muscle -- all the talking in the world cannot replace the need to actually practice something actively to become stronger or more skilled.   Similarly, a parent does need to literally teach a child to speak, to throw a ball, to ride a bike, to read, etc.  Time and togetherness alone are not usually enough to help a child acquire these skills.  

However, the biggest factor of all, in psychotherapy, is just like with parenting:   it is all about being available, and offering time and attention.  But just like with parenting, time and attention are not enough:  the time and attention must be provided with a spirit of joy, interest, and engagement, and with stable, healthy, safe boundaries. 

Nowadays, we have pressures upon medical and mental health care which seek to "optimize" care delivery.  Evidence is gathered about efficiency of care.  This tends to push medical and psychotherapeutic practice towards shorter visits, less frequent visits,  limited numbers of visits (for example, 6 month limits on courses of therapy), and indirect visits (e.g. through video links).    Most of the evidence supporting such methods is short-term. 

Imagine instructing a parent to become "more efficient,"  encouraging briefer interactions with children, less frequently, and for no more than 6 months at a time, particularly if it was found that the children's "symptom scores" had reached a particular threshold.

Optimal psychotherapeutic care requires time, patience, and availability.  In a setting of impoverished resources, there may be less time and availability to be shared.  But sometimes, such as in Canada, we do not actually have an impoverishment of resources.  It is "pseudo-impoverishment."  If it is difficult to access resources, the solution does not need to involve spartan rationing or obsessing about "efficiency."  It may mean that it is worth considering, for society as a whole, that it is good to invest more of our nation's vast wealth to offer personalized, patient, ongoing empathic care to those who desire or need it. 

The Business of Psychological Questionnaires

Questionnaires are certainly in vogue in mental health research.  Often they are referred to in technical-sounding jargon, for example it is common to call a questionnaire an "instrument"  or a "measurement tool."

There are good reasons to have well-standardized questionnaires.  In research, it is useful if people across the world are all using a similar type of questionnaire, so that comparisons can be made more easily and clearly.

In psychotherapy or other mental health practice, there is evidence that obtaining regular feedback from patients or clients can be valuable to improve the quality of the therapy, and to prevent mistakes.  One of the leaders in showing the importance of this is Michael Lambert, an esteemed psychologist and psychotherapy researcher from Brigham Young University.  In a nutshell, his research shows us that problems can occur in psychotherapy without the therapist realizing it:  the patient or client could be developing new symptoms, detaching or losing interest in the therapy, feeling upset or disappointed with the therapist, or even developing a life-threatening emergency, but the therapist may not know this, because it is not talked about or asked about in the session.  This could be because the patient is inhibited to share this information, but it could also be simply because the problem was never inquired about.  In therapy sessions, just like with any other interaction, one can follow a certain narrative pathway habitually, therefore missing things that could be quietly going wrong in the background.

So Lambert has developed a questionnaire called the OQ-45, which consists of 45 simple questions covering everything from mood, anxiety, relationship satisfaction, loneliness, drinking, family life, work life, cognition, and physical health.  The idea is for patients or clients to fill in this questionnaire frequently, maybe even before every therapy appointment, so that no potential evolving problem area would be "missed."   The questionnaire would only take a few minutes to fill out, and could be done in the waiting room before an appointment.    Samples of the OQ-45 can be found in an internet search.  


I believe that this type of questionnaire is useful.  Certainly we have to respect Lambert's many years of research, to acknowledge that feedback of this type can improve therapy.

But the therapeutic benefit of this is not due to some special property of the questionnaire itself!  And the therapeutic benefit does not require the sophisticated statistical analysis that is offered to purchasers of the questionnaire!  The benefit of this is simply to do a review of symptoms regularly with patients or clients.  

Questionnaires in psychology have become a business.  For hundreds of dollars, one can sign up to receive copies of a questionnaire, scoring manuals, or perhaps an on-line entry and scoring package, which may produce attractive graphs of results.

I believe that it is absurd--in most cases--to have to pay for something like this.  The therapeutic principle here is of simply keeping track of a wide range of symptoms or problems systematically.   The technology here is not a sophisticated x-ray machine or microscope -- rather, they are sets of simple questions such as "I'm a good person" or "My body hurts" (to be rated from 0-4).

I have jokingly thought of creating a questionnaire, to be marketed, with a full statistical analysis package and online access, called the "How Are You Doing" instrument (the HAY-D-1).  It would consist of a single question, "How are you doing?"  with the opportunity to choose from one of 5 responses.    Perhaps there could be a published article demonstrating its reliability, validity, and correlations with other established research instruments. 

Understandably, many researchers have worked long and hard to show useful results from their work.  And it could be very desirable for them to have a way to earn a financial reward from the fruits of their labor.  I suppose, in a free society, it is quite reasonable for people to attempt to sell such things, if people are willing to buy them.

But when there is this type of marketing and financial dealing going on, it can increase biases on the part of both the seller and the buyer.  The buyer, having paid good money for questionnaires or "instruments," is more likely to think highly of their acquisition, due to cognitive bias (think again of Daniel Kahneman's work showing such effects).  Perhaps therapists are more likely to rely on such purchased questionnaires rather than simply creating their own.

I think it could be useful, if questionnaires are to be used at all, to create custom symptom review questions.  There is also some evidence that questions about the therapeutic alliance could be pertinent to therapeutic progress; these are absent from many symptom review surveys, including the OQ-45.

A nice idea in CBT is to have the clients or patients be actively involved in assessing and planning their own progress, instead of having the therapist be the "assessor."  So, it could be a useful therapeutic exercise for clients or patients to design their own questionnaires, using their own language, and their own scale!  The therapist could encourage and suggest a wide range of categories of questions to be followed, covering areas of physical, social, occupational, cultural, and psychological health, as well as a category about the therapeutic alliance, but the questions themselves could be designed by the client or patient!    If statistical analysis was felt to be interesting or useful, we could easily design a simple app to create graphs, or use a spreadsheet -- we would not have to pay an extra fee for this!

So I support the idea of regularly conducting broad symptom reviews in psychotherapy, but I do not believe it is necessary to buy questionnaire packages.  It could be even better to design one's own package, or collaborate with a patient or client to design a custom, personalized survey.  

CBT as a mental workout strategy

Many studies have shown that CBT is effective for treating depression and anxiety disorders.  The studies are convincing, and the effect sizes have been large, usually comparable to medication treatments.

CBT studies are also usually well-designed.  The therapy itself is very clear.  While some complain that a "manualized" therapy is too mechanical or detached, it is true that a very standardized therapy approach allows a much more reliable scientific study.  A less structured therapeutic style would be expected to show much more variability between one therapist and the next, or between one patient and the next.  This fact does not mean that standardized, manualized therapies are superior to less structured types, but it does mean that the standardized varieties give more meaningful research results showing without any doubt whether a psychological therapy works or not.

I believe that CBT is a type of "fitness training" focusing on psychological symptoms and goals.  The CBT therapist is an educator and coach.  Actual CBT sessions are analogous to having a workout with a personal trainer.

Just as with the literal situation of seeing a personal trainer, perhaps two or three times a week for 6 weeks, one could have a lot of fitness gains from the sessions alone. 

But most fitness gains--especially for skill-related activities such as learning tennis, skiing, skating, dance, or bowling--happen as a result of the hours of dedicated, earnest daily practice.  These practice hours would take place between training sessions with the coach!

Similarly, there is some improvement in symptoms due to CBT sessions alone.  But most of the gains, in my opinion, will occur as a result of focused daily practice and homework between the sessions.

Most CBT research does not clearly indicate the number of hours of practice the patients have done, and do not have any measure of the quality of the practice done.  Just as with children doing homework activities, it matters how much time is spent, but it matters even more how good the quality is.  Was the work done in a sloppy, bored, rushed, haphazard manner, or was there evidence that the work was done with care, attention, organization, and devotion?

Similarly, very little behavioural therapy research has looked specifically at exactly how long an exposure task needs to be in order to produce an optimal effect.

In my own look at these topics, I have reached the following conclusions:

1) Daily homework of high quality is necessary for CBT to work best.  This is no different from getting good results in a university class, or following music lessons.

2) Exposure tasks (which I believe are an essential part of all CBT) need to last 20 minutes in order to be most effective.  Many clinics advise 45-90 minutes at a time.  The difficulty of the exposure task has to be adjusted so that it is moderately challenging (not too easy, and not overwhelming), with some feeling of mastery when it is over.  Just as with physical workouts, at least 3-5 exposure tasks per week should be a goal.

How long does it take for psychotherapy to work?

There are various research articles done in the past which describe rates of change in psychotherapy patients, some studies for example describing a plateau after about 25 sessions or so.  I find these studies very weak, because of the multitude of confounding factors:  severity and chronicity are obvious variables, also the type of follow-up assessments done.

In the CBT literature, a typical trial of therapy is perhaps 16-20 sessions.

In light of our evolving knowledge of neuroplasticity, and our breadth of understanding about education & learning, it seems to me that the most important variable of all is the amount of focused, deliberate practice time spent in a therapeutic activity.  Oddly, most psychotherapy studies--even CBT studies--do not look at how many hours of practice patients have done in-between therapy appointments.  This would be like looking at the progress of music students based on how many lessons they get, without taking into account how much they practice during the week. 

I have often compared psychological symptom change to the changes which occur, for example, with language learning or with learning a musical instrument.

So, I believe that a reasonable estimate of the amount of time required in psychotherapy depends on what one is trying to accomplish:

-Some types of therapeutic problems might be resolved with a few hours of work, or with a single feedback session with a therapist.  This would be akin to a musician with some kind of technical problem who needs just some clear instruction about a few techniques or exercises to practice.  Or it might be akin to a person who is already fluent in a foreign language, but needs a few tips from a local speaker about idioms, or perhaps some help with editing or grammar in a written text.

-Many more therapeutic problems could improve with perhaps 100 hours of work.  This would be like learning to swim or skate competently if you have never done these activities before.  Regular lessons ("therapy") would most likely speed up your rate of progress substantially.   But most of those 100 hours would be practice on your own, unless you're okay with the progress taking place over a year or more.   With the language analogy, think of how fluent you might become in a foreign language with 100 hours of focused, deliberate practice.  For most of us, this would lead to an ability to have a very simple conversational exchange, perhaps to get around in the most basic way in another country.  

-A much larger change is possible with 1000 hours of work:  with music, one could become quite fluent but probably not an expert.  With a foreign language, comfortable fluency would probably be possible, though probably still with an accent and a preference for the old language.
 
-With 5000-10000 hours of work (this is several hours per day over a decade or more) one could become an expert at a skill or a language in most cases.  

In psychotherapy, another confound though is whether the times in-between "practice sessions" lead to a regression of learning.  An educational analogy would be of practicing math exercises an hour per day with a good teacher, but then practicing another 8 hours a day with another teacher whose methods contradict the first.  Often times, learning will still take place with this paradigm, but it might be much less efficient.    Persistent mental habits, in the context of mental illnesses, can be akin to the "second teacher" in this metaphor, and unfortunately they do tend to plague people for many hours per day.

This reminds me of the evolving evidence about stroke rehabilitation & neuroplasticity:  substantial brain change can happen in as short a time as 16 days--but it requires very strict inhibition or constraint of the pathways which obstruct rehabilitation. (note: 16 days of continuous "immersion" = 16*24 = 384 hours!)  In stroke rehabilitation, the neuroplasticity effect is much more pronounced if the unaffected limb is restrained, compelling the brain to optimize improvement in function of the afflicted limb.  Here is a recent reference showing rapid brain changes following limb immobilization: http://www.ncbi.nlm.nih.gov/pubmed/22249495

In conclusion, I believe that it is important to have a clear idea about how much time and deliberate, focused effort are needed to change psychological symptoms or problems through therapeutic activities.  A little bit of meaningful change could happen with just a few hours of work.  In most cases, 100 hours is needed simply to get started with a new skill.  1000 hours is needed to become fluent.  And 5000-10000 hours is needed to master something.  These times would be much longer still if the periods between practice sessions are regressive.  In the case of addictions, eating disorders, self-harm,  or OCD, for example, relapses or even fantasies about relapse will substantially prolong the time it takes for any therapeutic effort to help.  Of course, it is the nature of these problems to have relapses, or fantasies about relapse--so one should let go of the temptation to feel guilty if there are relapses.   But if one is struggling with an addictive problem of this sort, it may help to remind oneself that the brain can change very substantially if one can hold onto to quite a strict behavioural pattern for the hundreds or thousands of hours which are needed.

As a visual reminder of this process, start with an empty transparent bottle, which can hold 250-500 mLof liquid (1-2 cups), and which can be tightly sealed with a small cap.  Add one drop of water every time you invest one hour of focused, deliberate therapeutic work.   The amount of time you need to spend in therapy depends on your goal.  If the goal is total mastery--then you must fill the entire bottle.  If simple competence in a new skill is an adequate goal, then you must fill just the cap of the bottle.  If there are activities in your day which contradict the therapeutic work, it would be like a little bit of water leaking out of your bottle.  So you must also attend to repairing any "leaks."  But every hour of your effort counts towards your growth.

A Learning Model of Psychological Change: the necessity of work & practice

It requires a great deal of work to bring about psychological change.

The brain is a dynamic organ, its development influenced by genetic predisposition combined with environmental experience.  Repeated environmental experience sculpts the brain, altering the strength of neuronal connections, neuronal activity, neurochemistry, and even neuronal growth or survival.

Various environmental adversities obviously predispose the brain to generate psychological symptoms, including specific incidents of trauma or neglect.

The manner in which adversity changes the brain is similar to the manner in which the brain changes in response to any other sort of experience:  sometimes there is sudden, intense change which can happen in an instant (e.g. a traumatic brain injury), but most often the brain changes gradually, after many repetitions of similar stimuli or similar inner processes.

Some environmental adversities are repetitive over months or years.  But often times the repetition which does further harm is generated by the brain itself:  in response to a problem, the brain's repetitious analysis and revisiting of the problem ends up causing consolidated change and ongoing symptoms. A great deal of the harm caused by specific instants of trauma is caused by the brain's reaction months or years after the trauma is over.  This reaction is akin to an autoimmune disease, in which the body's attempts to fight off disease end up causing inflammation, pain, and tissue damage. 

A symptom, such as anxiety or depressed mood, once generated from any cause, may lead to a cascade of brain changes which perpetuate and intensify the symptom.  The behavioural withdrawal which results from anxiety or depression changes the potential experiences the brain may incorporate in order to heal itself.  Even without overt behavioural withdrawal, an anxious or depressive state may cause the brain to perceive normal or pleasurable stimuli as dangerous, negative, boring, or unpleasant.   Each time this experience occurs, the brain changes further into a state of more deeply consolidated anxious or depressive disorder.  The theory of cognitive-behavioural therapy insightfully recognizes the role of thoughts as part of a cascade of phenomena perpetuating psychological illness.  Recurrent hostile, reflexively critical, cynical, pessimistic or negative thinking may at times have intellectual or philosophical validity; however, such thoughts, if highly recurrent, teach and sculpt the brain to make such a style of thinking an entrenched habit.  Such habits of thought are obvious causes for depression and diminished quality of life.    

My point here is to describe the brain as a "teachable" organ.  It is changed and sculpted by experience.  The source of this experience may be from the external environment or from the self-generated inner environment of the brain.   The degree to which the brain is sculpted by experience depends on the intensity of the experiences, multiplied by the time or frequency the experiences repeat themselves.

 In this regard, as I've stated before, the brain and its experiences are analogous to a growing garden, or a forest:  changes require time, care, knowledge about requirements, and energy.


Therapeutically, it is very clear to me that much work must be done in order to effect significant, lasting brain change. Likewise, a growing garden requires frequent care, particularly if there are adverse conditions caused from within (e.g. depleted soil, weeds) or from without (e.g. harsh weather, vandalism).  

The neurochemical environment can be an obstacle to brain change, in the same sense that abnormal soil chemistry may thwart the most earnest efforts of a gardener.  The "abnormal soil chemistry" may itself have been caused by an imbalanced garden ecology over many years, perhaps by genetic predispositions of the plants, and may conceivably be remediated and prevented in the long term by healthy gardening practices, yet an immediate external aid could be an immensely helpful catalyst to help these changes occur more easily and quickly.   Likewise, psychiatric medications can often be helpful catalysts for change.

But the key ingredient for brain change is experiential.  The type of experience capable of changing the brain substantially must be strong enough (i.e. it must employ a significant degree of the brain's capacity for attention, thought, feeling, and sensation, rather than simply being a passive or background activity), and must be frequent enough (i.e. it must occur regularly over a long period of time).

These requirements for experiential change are, as I've claimed before, similar to the requirements needed for learning a new language, or a musical instrument.

Without daily practice, therapy experiences which involve only one, or a few, appointments per week, are unlikely to cause significant psychological change, for the same reason that a language or music class once or twice a week will not lead to much language or music learning without doing daily homework.   The classes may be helpful or inspiring guides, but most of the change or learning will occur due to many hours of hard work, practicing, in-between classes.

Studies of different therapeutic strategies for treating psychological symptoms usually neglect to assess the most obvious and powerful source for change:  the amount and quality of the practice done.  It seems to me that most any style of therapy could work quite well (some slightly better than others, depending on the situation), provided that a great deal of disciplined work and practice takes place to learn new skills, and to effect change in the brain.

The analogy of musical practice leaps to mind again, in which quantity and repetition are important for learning, but also "quality."  To practice something passively, carelessly, or inattentively is often ineffectual, or sometimes even counterproductive, since one may be inculcating an unwanted habit.  Also, some types of practice may be excessively mechanical, or may be veering off a desired course too easily.

I am reminded of the "Suzuki" method of music education, which I think is wonderful, for the following reasons:
1) it encourages one to start young (i.e. at any age or level of ability)
2) it strongly encourages "playing by ear", listening frequently to recordings with strong attention to perceiving sound and tonal quality; this leads to a stronger and more rapidly developed appreciation for esthetics, as well as less dependency on external cues such as printed music.   The therapeutic analogy could be of  inviting frequent indirect involvement from a therapist or therapeutic system, rather than doing all "homework" completely on ones' own.
3) it strongly encourages group practice & performance, right from the beginning. This teaches not only solo musicianship, but also following and playing well with others, enjoying others, cooperation, being in a leadership role, having confidence with performance, and sharing one's gifts with others.   Also, practice is encouraged to be not just a solitary activity, but something which can be done with family or loved ones.  Therapeutically, I think it is strongly desirable to incorporate psychological work into group, family, and community settings.  
4) it emphasizes the importance of good posture.  Therapeutically, I think a fairly strict and disciplined framework to practice psychological techniques is healthy and reduces the likelihood of acquiring unhelpful habits.  On a literal level, I think a balanced exercise routine is psychologically healthy, including cardiovascular or strength training, sports, or a "postural" exercise such as yoga. 
5) it emphasizes the need for a lot of repetition.  Therapeutically, it may be necessary to practice techniques thousands of times, over a period of months or years, in order for them to become fluent.   Repetition should never be undertaken in a dull, mechanical way -- it needs to be infused with careful, reverent attention -- but it is absolutely needed in order to master anything. 

I challenge all those wishing to change longstanding psychological problems to frequently renew commitments to work hard, and to translate these commitments into a disciplined schedule of daily practice.  It may be that there are symptoms of  tiredness, amotivation, apathy, or a very negative or painful reaction to a broad variety of daily life experiences; these symptoms can prevent engagement with commitments, and can hinder the capacity to engage in disciplined work habits.  Also, the life stressors (work, money, relationship problems, etc) can take up so much time and energy that there is not much left to do regular psychological work.  Perhaps part of the therapeutic process at this stage is to problem-solve around ways to reduce stresses, reduce some of the symptoms, bolster energy, etc. as prerequisites to establishing a work plan.  Another view of this issue is that the "work" alluded to here could take place within any type of life stressor, it does not necessarily require a lot of extra time separate from other activities of daily living.