I invite the interested reader to have a look at an article in the Journal of the American Medical Association, 300(13), pp. 1551-1565 (as of today, it is the current issue).
http://jama.ama-assn.org/cgi/content/short/300/13/1551
It presents some compelling evidence that long-term psychotherapy is significantly effective in treating a wide variety of psychiatric illnesses, including those illnesses that are more complicated, perhaps not neatly fitting into a single diagnostic category. It specifically shows a superior benefit for "psychodynamic" psychotherapy. Psychodynamic therapies are more intensive, philosophically and intellectually challenging styles of psychotherapy, which also emphasize the importance of examining closely the patient-therapist relationship during the therapy sessions. Most psychotherapy research has looked at short-term therapy (typically lasting a few months), and the evidence base formed from this research has caused a standard of practice to evolve which supports short-term but not long-term therapy. This is very problematic, because such a standard of practice is literally "short-sighted": Many patients require, and benefit greatly from, longer courses of psychotherapy. I do understand that it is difficult to do long-term research studies for any type of treatment (it is much, much easier to do an 8-week study than a 5-year study!), so this paper is very important.
Interestingly, the study did not show a specific benefit from the therapist having more years of experience. But this is not a surprise to me. In my experience with teaching medical students & residents, and also encountering many different supervisors during my training (which is now a decade ago), I found that differences in each individual's style, personality, attitude, and comfort with patients, were far more significant factors which influenced their helpfulness as clinicians or therapists, rather than years of experience. I can think of examples on both sides: the passage of years may magnify authoritarian or arrogant tendencies, and reduce open-mindedness, in some psychiatrists, particularly if they are ascending some sort of professional hierarchy, if they are trying to earn the most possible money, or if they are not enjoying their work. Clearly, this is not beneficial to patients or students. On the other hand, I have encountered many psychiatrists whose talent and wisdom have grown and deepened over time; in these cases I think years of experience have allowed a gentle, compassionate, understanding calm with patients, with a continuing open-mindedness to learn and continue growing, personally and professionally, as therapists and teachers.
The study did not show evidence that a "manual" helped the therapy be more effective. Again, this is absolutely not a surprise. Imagine trying to have a conversation with someone who was basing their responses to you on what a "manual" advised! While the use of manuals has been a well-meaning device for helping therapists-in-training to learn, and for measuring the effectiveness of therapy techniques in research, such devices in many cases can obtund the type of creative, spontaneous, friendly, wise, and sometimes playful interactions that I believe are the foundations for good therapy. These qualities I think are harder for therapists to learn or to teach, though I think that a sort of apprenticeship model is most likely to work best. It is not a surprise to me that the best such apprenticeship models are themselves long-term ones (over years), as opposed to having a therapist-in-training constantly migrating every few months, to some new or different therapy style or supervisor. Mind you, I do think it is important for any therapist to learn every major type of therapy, from a variety of different mentors, and in my opinion it is then necessary for the budding therapist to form an individual style that suits them best. In this way they will be truest to themselves, and therefore be best able to help their patients.
Tuesday, September 30, 2008
Tuesday, September 9, 2008
Rates of Change - filling a milk jug
Some symptoms or problems can improve within a day.
Others could take a week or more.
In mood and anxiety disorders, and in other struggles towards life improvement, many significant changes or improvements can take several months.
With this kind of time scale, it can be hard to perceive any change happening in the present moment.
So, consider this analogy:
Let your symptoms or problems be represented by an empty 4-litre milk jug.
Let your efforts to improve your symptoms or problems be represented by a dropper, which will add individual drops of milk to the jug. Each major step towards substantive change is represented by a full jug. In many ongoing processes of life change--such as dealing with chronic depression--you may need to take repeated such steps, but I think each single step can be very important and significant.
A single drop is about 1/20th of one millilitre in volume. So, in order to fill the jug, you will need to add 80 000 drops.
In order to add 80 000 drops in about 2-3 months' time, you will need to add about 1200 drops per day, or 50 drops per hour, or about 1 drop per minute.
This is the rate to keep in mind with regards to substantive life change -- it is like adding 1 drop per minute in order to fill up a 4-litre milk jug. The moment-to-moment pace may seem slow, but it is not imperceptible, as long as you have a way to visualize it. Keep using your dropper. Be patient.
(To extend this analogy a bit further, I guess we should say that it is important to make sure your jug doesn't have any leaks -- many therapeutic efforts cannot catch up with what is lost from a leaky jug! Leaks may be caused by chronic stresses, addictions, unaddressed physical health problems, unhealthy relationships, etc. )
Others could take a week or more.
In mood and anxiety disorders, and in other struggles towards life improvement, many significant changes or improvements can take several months.
With this kind of time scale, it can be hard to perceive any change happening in the present moment.
So, consider this analogy:
Let your symptoms or problems be represented by an empty 4-litre milk jug.
Let your efforts to improve your symptoms or problems be represented by a dropper, which will add individual drops of milk to the jug. Each major step towards substantive change is represented by a full jug. In many ongoing processes of life change--such as dealing with chronic depression--you may need to take repeated such steps, but I think each single step can be very important and significant.
A single drop is about 1/20th of one millilitre in volume. So, in order to fill the jug, you will need to add 80 000 drops.
In order to add 80 000 drops in about 2-3 months' time, you will need to add about 1200 drops per day, or 50 drops per hour, or about 1 drop per minute.
This is the rate to keep in mind with regards to substantive life change -- it is like adding 1 drop per minute in order to fill up a 4-litre milk jug. The moment-to-moment pace may seem slow, but it is not imperceptible, as long as you have a way to visualize it. Keep using your dropper. Be patient.
(To extend this analogy a bit further, I guess we should say that it is important to make sure your jug doesn't have any leaks -- many therapeutic efforts cannot catch up with what is lost from a leaky jug! Leaks may be caused by chronic stresses, addictions, unaddressed physical health problems, unhealthy relationships, etc. )
Thursday, September 4, 2008
Managing Relationship Conflict
This is no easy subject. So much depends on the specifics of the situation and of the relationship. And perhaps different people deal with conflicts best in their own different ways.
But I think a few generalizations can be made:
1) Once anger has risen beyond a certain point -- and this point may vary, for different individuals, or for different situations -- there is no benefit to continued conversation. Anger is often a state of "outward flow", a state of action; an angry person may not be able or willing to listen or receive an "inward flow" of information or feedback. There needs to be a break, to cool down, after which if there are issues to discuss, both people will be able to hear each other better. Most issues of conflict are more fruitfully discussed when both parties are in a calm state.
2) If you are feeling unsafe, bullied, or subject to physical aggression, it is necessary to find a safe place as soon as possible. This may mean leaving physically. Or it may mean leaving the relationship. From the safe place, it will be necessary to carefully assess what to do next. It can be hard to think or plan clearly when you are in a dangerous position. You may need to seek external help, for shelter or safety.
2) Practicing empathy. While the capacity to empathize is to some degree an inborn, heritable trait, it is also a skill that can be practiced and improved. The simplest exercise is, in an argument, to simply state how you believe the other person is feeling, and why. We all have a powerful resistance to actually do this, even though most of us acknowledge that it's a good idea.
3) Apologizing. But only if you truly believe that you have been out of line.
4) Accepting apology. Which doesn't necessarily mean accepting a repetition of the status quo.
5) Be wary of the same old conflictual pattern happening over and over again.
6) If there is some positive territory, allowing some time and space for that. This could be shared interests, pleasures, activities, or mutual friends.
7) There are workbooks and other reading material which deal with relationships, managing or resolving conflict in marriages, etc. If this is a theme in your life, I strongly encourage you to acquaint yourself with this literature, and to work through a workbook or two (best if both you and your partner do it, of course). As with all self-help literature, you may find some of it preachy, trite, biased by the individual views of the author, etc. but I do think it is important to acquaint yourself with what is out there, some of it can be very helpful or at least an introduction to ideas that can help.
8) An external mediator, such as a therapist, can be helpful. It can often be important to find a mediator who does not have a specific individual alliance with either person in the conflict (i.e. the mediator should be neutral). And it can be important to find a mediator who is experienced working with relationship conflict. I believe it is important to consider that a mediator may help a relationship improve, but may also help an unhealthy or unsustainable relationship end more peacefully.
9) Maybe I should have "ranked" this item higher than (9) since it is very important: if there are untreated psychiatric symptoms in either individual member of a conflicted pair, then it can be very helpful to address and treat those symptoms. High levels of irritability can be treated with various types of psychotherapy, lifestyle change, and/or medication--with a reduction in an individual's irritability, that person may be able to negotiate conflict more peacefully and productively. In some depressive or anxious states, feedback which sounds critical in any way can lead to feelings which are so badly hurt that the conversation cannot continue. This emotional lability or hypersensitivity can also be treated through psychotherapy, lifestyle change, and/or medications.
But I think a few generalizations can be made:
1) Once anger has risen beyond a certain point -- and this point may vary, for different individuals, or for different situations -- there is no benefit to continued conversation. Anger is often a state of "outward flow", a state of action; an angry person may not be able or willing to listen or receive an "inward flow" of information or feedback. There needs to be a break, to cool down, after which if there are issues to discuss, both people will be able to hear each other better. Most issues of conflict are more fruitfully discussed when both parties are in a calm state.
2) If you are feeling unsafe, bullied, or subject to physical aggression, it is necessary to find a safe place as soon as possible. This may mean leaving physically. Or it may mean leaving the relationship. From the safe place, it will be necessary to carefully assess what to do next. It can be hard to think or plan clearly when you are in a dangerous position. You may need to seek external help, for shelter or safety.
2) Practicing empathy. While the capacity to empathize is to some degree an inborn, heritable trait, it is also a skill that can be practiced and improved. The simplest exercise is, in an argument, to simply state how you believe the other person is feeling, and why. We all have a powerful resistance to actually do this, even though most of us acknowledge that it's a good idea.
3) Apologizing. But only if you truly believe that you have been out of line.
4) Accepting apology. Which doesn't necessarily mean accepting a repetition of the status quo.
5) Be wary of the same old conflictual pattern happening over and over again.
6) If there is some positive territory, allowing some time and space for that. This could be shared interests, pleasures, activities, or mutual friends.
7) There are workbooks and other reading material which deal with relationships, managing or resolving conflict in marriages, etc. If this is a theme in your life, I strongly encourage you to acquaint yourself with this literature, and to work through a workbook or two (best if both you and your partner do it, of course). As with all self-help literature, you may find some of it preachy, trite, biased by the individual views of the author, etc. but I do think it is important to acquaint yourself with what is out there, some of it can be very helpful or at least an introduction to ideas that can help.
8) An external mediator, such as a therapist, can be helpful. It can often be important to find a mediator who does not have a specific individual alliance with either person in the conflict (i.e. the mediator should be neutral). And it can be important to find a mediator who is experienced working with relationship conflict. I believe it is important to consider that a mediator may help a relationship improve, but may also help an unhealthy or unsustainable relationship end more peacefully.
9) Maybe I should have "ranked" this item higher than (9) since it is very important: if there are untreated psychiatric symptoms in either individual member of a conflicted pair, then it can be very helpful to address and treat those symptoms. High levels of irritability can be treated with various types of psychotherapy, lifestyle change, and/or medication--with a reduction in an individual's irritability, that person may be able to negotiate conflict more peacefully and productively. In some depressive or anxious states, feedback which sounds critical in any way can lead to feelings which are so badly hurt that the conversation cannot continue. This emotional lability or hypersensitivity can also be treated through psychotherapy, lifestyle change, and/or medications.
Thursday, August 28, 2008
Scaled-up Structure of a Neuron
I'm always interested in analogies & thought experiments. One of them last year was to consider the following:
What would a brain cell (neuron) look like on a vastly expanded scale, where the body of the cell (cross-sectionally) would occupy an area about the size of a small urban residential lot (let's say about 10 x 40 metres, or 35 x 120 feet)?
Interestingly, it took a fair bit of effort to get an accurate picture of this (and even now, I'm sure I could get into a lot more detail). Advanced textbooks of neuroscience may be good at describing a lot of fine details, but they tend not to give the reader a good visual picture of what the brain -- or a neuron -- in action -- really looks like. In order to do this research, it involved digging at length into the neuroscience literature (full references are available to the interested reader).
Here are some of my findings:
A typical neuron cell body is about 20 microns in diameter (about 1/50 of a millimeter). If the cell body were made into a giant which occupied a whole city residential lot, we would be scaling upward by a factor of about 1.85 million.
At this scale, a single atom would be about 0.2 mm wide (well within visual resolution). At this scale, your head would be about 340 km in diameter. This is about the size of a U.S. state such as Ohio, Pennsylvania, or Louisiana; or almost as large as the Canadian provinces of New Brunswick and Nova Scotia combined.
Dendrites are arm-like extensions of a neuron's cell body. Dendrites can be up to 600 microns long, and on our scaled-up neuron, this makes the longest dendrites about 1 km long. Each neuron can have about 20 dendrites. Each dendrite in our model would be about 5 meters wide. In our model, dendrites are similar to the width of streets or alleys coming away from the yard (remember this is really in 3 dimensions), and each street or alley would extend to some outer reach of your local neighbourhood. Inside each dendrite are many mitochondria (the "power plants" of the cell), each of which about 4 x 1 meters in size (each about the size of a hippo).
There are fibers holding the whole cell together (and serving other functions), called neurofilaments and microtubules. They are typically about 10 mm in diameter in our model (like a medium-sized rope), and are spaced about 100 mm apart (so the inside of a neuron could get quite tangled up were it not for the fact that these "ropes" guide everything along smoothly, acting as miniature pulleys and motors).
A synapse is an area where two neurons communicate chemically. There are thousands of synapses on each neuron. In our model, each synapse area would be about 1 meter wide. The distance across the synapse (between neurons) in our model is about 180 mm (6 inches). Nerve cells release vesicles into the synapse containing neurotransmitters such as serotonin and norepinephrine. In our model each vesicle would be about the size of a small grapefruit. Each time the neuron is fully activated, about 300 of these grapefruit-sized vesicles would be released. Smaller activations of the neuron would cause only 5-10 vesicles to be released. After release, the vesicles are "recycled" within about a minute.
If there is a drug such as an antidepressant affecting the neuron, its size on our model would be something like a grain of sand. Concentrations of antidepressants in the brain are something like 1 in 6 million. This corresponds to one, or just a few, molecules of antidepressant -- each one the size of a 1 mm grain of sand -- in every cubic foot in our model. This shows us visually that just a tiny amount of something in the brain can have a powerful effect.
In the actual brain, neurons are "packed" with a density of about 100 000 per cubic millimeter. In our model this corresponds to neurons packed roughly equivalent to how the city lots are "packed" in a residential neighbourhood (but in 3 dimensions).
The brain's surface area, scaled up for our model, would occupy an area about the size of Washington state, or of southern British Columbia, all of which occupied by "houses" or "yards" corresponding to individual neurons (but in the real brain, there are 3 dimensions, of course). The "houses" would be locally connected through dendritic connections in areas corresponding to residential "neighbourhoods". And there would be many axonal connections linking these neighbourhoods to the far reaches of the brain's territory.
The total population of neurons in the brain is about 100 billion, which is 15 times the population of humans on the earth.
What would a brain cell (neuron) look like on a vastly expanded scale, where the body of the cell (cross-sectionally) would occupy an area about the size of a small urban residential lot (let's say about 10 x 40 metres, or 35 x 120 feet)?
Interestingly, it took a fair bit of effort to get an accurate picture of this (and even now, I'm sure I could get into a lot more detail). Advanced textbooks of neuroscience may be good at describing a lot of fine details, but they tend not to give the reader a good visual picture of what the brain -- or a neuron -- in action -- really looks like. In order to do this research, it involved digging at length into the neuroscience literature (full references are available to the interested reader).
Here are some of my findings:
A typical neuron cell body is about 20 microns in diameter (about 1/50 of a millimeter). If the cell body were made into a giant which occupied a whole city residential lot, we would be scaling upward by a factor of about 1.85 million.
At this scale, a single atom would be about 0.2 mm wide (well within visual resolution). At this scale, your head would be about 340 km in diameter. This is about the size of a U.S. state such as Ohio, Pennsylvania, or Louisiana; or almost as large as the Canadian provinces of New Brunswick and Nova Scotia combined.
Dendrites are arm-like extensions of a neuron's cell body. Dendrites can be up to 600 microns long, and on our scaled-up neuron, this makes the longest dendrites about 1 km long. Each neuron can have about 20 dendrites. Each dendrite in our model would be about 5 meters wide. In our model, dendrites are similar to the width of streets or alleys coming away from the yard (remember this is really in 3 dimensions), and each street or alley would extend to some outer reach of your local neighbourhood. Inside each dendrite are many mitochondria (the "power plants" of the cell), each of which about 4 x 1 meters in size (each about the size of a hippo).
There are fibers holding the whole cell together (and serving other functions), called neurofilaments and microtubules. They are typically about 10 mm in diameter in our model (like a medium-sized rope), and are spaced about 100 mm apart (so the inside of a neuron could get quite tangled up were it not for the fact that these "ropes" guide everything along smoothly, acting as miniature pulleys and motors).
A synapse is an area where two neurons communicate chemically. There are thousands of synapses on each neuron. In our model, each synapse area would be about 1 meter wide. The distance across the synapse (between neurons) in our model is about 180 mm (6 inches). Nerve cells release vesicles into the synapse containing neurotransmitters such as serotonin and norepinephrine. In our model each vesicle would be about the size of a small grapefruit. Each time the neuron is fully activated, about 300 of these grapefruit-sized vesicles would be released. Smaller activations of the neuron would cause only 5-10 vesicles to be released. After release, the vesicles are "recycled" within about a minute.
If there is a drug such as an antidepressant affecting the neuron, its size on our model would be something like a grain of sand. Concentrations of antidepressants in the brain are something like 1 in 6 million. This corresponds to one, or just a few, molecules of antidepressant -- each one the size of a 1 mm grain of sand -- in every cubic foot in our model. This shows us visually that just a tiny amount of something in the brain can have a powerful effect.
In the actual brain, neurons are "packed" with a density of about 100 000 per cubic millimeter. In our model this corresponds to neurons packed roughly equivalent to how the city lots are "packed" in a residential neighbourhood (but in 3 dimensions).
The brain's surface area, scaled up for our model, would occupy an area about the size of Washington state, or of southern British Columbia, all of which occupied by "houses" or "yards" corresponding to individual neurons (but in the real brain, there are 3 dimensions, of course). The "houses" would be locally connected through dendritic connections in areas corresponding to residential "neighbourhoods". And there would be many axonal connections linking these neighbourhoods to the far reaches of the brain's territory.
The total population of neurons in the brain is about 100 billion, which is 15 times the population of humans on the earth.
Thursday, August 21, 2008
Financial Metaphor
Managing your emotional life can be compared to managing finances.
"Investments" need to be made. Investments of emotion, attachment, time, energy. And money too.
It is much easier to "invest" when you have a bunch extra to work with. Wealthy people have an easier time putting money aside into new profitable ventures.
When you are using all your resources just to survive, it can be insulting and frustrating to be asked to "invest".
Sometimes, especially in depressive states, people are operating in a state of continuing, advancing debt. Emotional debt. Energy debt. Time debt. Relationship debt.
In addictive states, there is a neurophysiological debt that has to be "paid off" in order to get out of the addiction -- the price is in the form of acute and chronic withdrawal symptoms.
There are books out there about how to invest or manage money wisely.
I don't tend to like these books, in part because I think our culture has a very unhealthy preoccupation with financial wealth. Those who manage the economies of nations also perhaps consider financial wealth or growth a higher priority than a more basic good, such as "well being".
But I think that economists, marketers, and business managers can have excellent ideas, and I have to remind myself to keep an open mind.
How IS it possible to "invest" when you don't have very much?
Most financial advisors would say to automatically squirrel away a little bit every month, and stick it in an RRSP or something like that.
The key is -- consistency, regularity, and automaticity. A little bit each month--or every day--wisely invested, can add up.
In depression, such investments might take the form of "automatically" spending a little bit of energy or time exercising every day (even a minute or two). Or working on relationship-building. Or looking into a new activity. Or meditating.
If there is a state of "indebtedness" then making a plan to pay off the debt in an organized way, and to make a budget, etc. is necessary. But sometimes, external "debt relief" is needed. This may require reliance on external help for a time.
Another thing most financial advisors would say is that one should "diversify". Investing in only one thing makes you vulnerable to having a huge loss if the market changes suddenly. Investing in several different areas protects you, and insulates you, from environmental change. This could apply to relationships, activities, and therapeutic resources. Of course, if you "diversify" too much, it leaves your energies so diluted that it can be hard to appreciate or grow from your involvement in any one thing.
A final note I would make in this analogy is to observe that most financial advisors are actually salespeople, and not true unbiased advocates. While they may be sharing good advice with you, they will also profit from you investing with them. This automatically biases their advice. Perhaps not everyone is interested in building a big RRSP fund to pay for their retirement years; perhaps not everyone cares if they miss out on "market growth opportunities". It may be more important for many individuals to put more of their resources into the here and now.
So I encourage you to be well-informed about your "investments". Receive advice, but also research your choices independently, then decide.
Sometimes the best time for "investment" is when you are already feeling better, when there is an abundance of emotional resources again. Remember then, to put aside a little bit each day, this may protect you during a future drought or famine. Things like CBT, exercise, etc. sometimes work better when you are already feeling better, and you are using them preventatively. Even medications may sometimes work better as preventative agents than as acute treatments.
"Investments" need to be made. Investments of emotion, attachment, time, energy. And money too.
It is much easier to "invest" when you have a bunch extra to work with. Wealthy people have an easier time putting money aside into new profitable ventures.
When you are using all your resources just to survive, it can be insulting and frustrating to be asked to "invest".
Sometimes, especially in depressive states, people are operating in a state of continuing, advancing debt. Emotional debt. Energy debt. Time debt. Relationship debt.
In addictive states, there is a neurophysiological debt that has to be "paid off" in order to get out of the addiction -- the price is in the form of acute and chronic withdrawal symptoms.
There are books out there about how to invest or manage money wisely.
I don't tend to like these books, in part because I think our culture has a very unhealthy preoccupation with financial wealth. Those who manage the economies of nations also perhaps consider financial wealth or growth a higher priority than a more basic good, such as "well being".
But I think that economists, marketers, and business managers can have excellent ideas, and I have to remind myself to keep an open mind.
How IS it possible to "invest" when you don't have very much?
Most financial advisors would say to automatically squirrel away a little bit every month, and stick it in an RRSP or something like that.
The key is -- consistency, regularity, and automaticity. A little bit each month--or every day--wisely invested, can add up.
In depression, such investments might take the form of "automatically" spending a little bit of energy or time exercising every day (even a minute or two). Or working on relationship-building. Or looking into a new activity. Or meditating.
If there is a state of "indebtedness" then making a plan to pay off the debt in an organized way, and to make a budget, etc. is necessary. But sometimes, external "debt relief" is needed. This may require reliance on external help for a time.
Another thing most financial advisors would say is that one should "diversify". Investing in only one thing makes you vulnerable to having a huge loss if the market changes suddenly. Investing in several different areas protects you, and insulates you, from environmental change. This could apply to relationships, activities, and therapeutic resources. Of course, if you "diversify" too much, it leaves your energies so diluted that it can be hard to appreciate or grow from your involvement in any one thing.
A final note I would make in this analogy is to observe that most financial advisors are actually salespeople, and not true unbiased advocates. While they may be sharing good advice with you, they will also profit from you investing with them. This automatically biases their advice. Perhaps not everyone is interested in building a big RRSP fund to pay for their retirement years; perhaps not everyone cares if they miss out on "market growth opportunities". It may be more important for many individuals to put more of their resources into the here and now.
So I encourage you to be well-informed about your "investments". Receive advice, but also research your choices independently, then decide.
Sometimes the best time for "investment" is when you are already feeling better, when there is an abundance of emotional resources again. Remember then, to put aside a little bit each day, this may protect you during a future drought or famine. Things like CBT, exercise, etc. sometimes work better when you are already feeling better, and you are using them preventatively. Even medications may sometimes work better as preventative agents than as acute treatments.
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