Self-injurious behaviour is common. Cutting skin is probably the most common specific behaviour, but there are many other varieties of self-injury.
There are different reasons why it might arise, or factors that might be motivating the behaviour.
Quite often self-injury leads to a feeling of relief, of focus, of emotional intensity, in the midst of deep anger or sadness. Sometimes a long-suffering person may feel as though the capacity to feel has been lost--he or she may feel numb or empty--and self-injury gives rise to some type of feeling for a moment. Also, an act of self-injury may cause someone to feel "in control" during that moment, while they may feel "out of control" in other parts of life.
Another common motivation is self-hatred. Physical pain may be desired. The sequence of self-hatred, leading to self-injury, leading to a sense of relief, leading perhaps to guilt or worsened self-hatred afterwards, can become a powerfully reinforced, self-perpetuating behavioural pathway.
Another motivation is a wish to experiment with the idea of suicide, perhaps with the thinking that cutting skin deeply enough could cause death, but then discovering that the act of non-suicidal self-injury creates a feeling of focus, control, excitement, or relief.
Self-injury can be a very private act, but sometimes can be an overtly interpersonal act, a type of non-verbal communication. Such communication can sometimes become part of an interpersonal dynamic. This dynamic can sometimes (but not always) be part of a vicious cycle, making symptoms worse (David Dawson's ideas, as expressed in Relationship Management of the Borderline Patient, can sometimes apply here).
Self-injury can become part of a person's sense of identity or personal culture, particularly if it has arisen during adolescence or young adult life.
Regardless of the various motivations, I believe that self-injury is an addictive behaviour. Just like alcohol or opiates, it may create some form of relief in the moment, with consequences to pay afterwards. The person engaging in it may recognize that it isn't "healthy" but may continue, or may feel unable to stop.
In the treatment of any addictive behaviour, I believe there are a number of therapeutic principles which can help:
1) If there are underlying problems which are driving the behaviour, or triggering it, then these problems may be addressed with whatever help is available. For self-injury, these problems may include depression, loneliness, irritability, boredom, struggling with issues having to do with identity, meaning, personal culture, etc. Sometimes addressing these underlying problems satisfactorily will solve the problem of self-injury.
2) The self-injury itself could be understood as a psychological defence. If a defence is to be lowered or set aside, it has to be with the will, motivation, and consent of the individual. Without the defence, there may be periods of more intense discomfort ("withdrawal symptoms"), at least initially . I do not believe that a person should be urged or told to "stop cutting". I do believe that a gentle, frank discussion about addiction, triggers, abstinence, etc. could be introduced, with the patient's consent. Addiction treatment programs have a stronger sense of the dynamics here -- a person cannot and should not be forced or "contracted" to stop something. Such a dynamic is unlikely to help, certainly not for very long.
The will to change has to come from the person seeking help, particularly if a strong theme for the person is having self-control, autonomy, freedom--and particularly if the person's problems have in part been caused by past trauma, in which self-control, autonomy, and freedom were oppressed.
3) Alternative strategies to deal with emotional distress can be found and practiced. Common triggers could be identified (e.g. feeling frustrated, feeling bored, feeling lonely, craving sensation of some type), and plans could be formed to negotiate through these moments. A cognitive-behavioural model could be useful (e.g. using journaling), and meditative practices could be helpful (e.g. mindfulness exercises).
Sometimes "substitute" activities such as rubbing ointment on the skin, snapping an elastic band on the wrist, marking the skin with an erasable pen, etc. can be part of a transition away from more harmful self-injury behaviours.
4) If there is guilt or secrecy around the behaviours, it can help to have a forum--such as psychotherapy-- to talk openly about the issue, without the fear of the dialog leading to a highly charged or panicked emotional exchange. The power of guilt or the power of secrecy can be perpetuating factors. In addiction treatment models, it is acknowledged that a person may not have the power within themselves to stop -- help may be needed -- acknowledgment of this fact may break the cycle of guilt.
In practice, I find that self-injury can gradually settle down as other problems settle. In many cases it may--ironically-- settle best when it does not become a primary focus of therapeutic dialog. It may resurface from time to time under stress. If the problem is very intense and acute, people may have a hard time making it through the day or the week, and may feel that the existing help is not enough (e.g. the therapy may feel inadequate). But I think that sticking to a very stable, regular, open-ended therapeutic framework is important.
Tuesday, February 3, 2009
Modern Physics Metaphors
I hesitate to indulge in metaphors having to do with modern physics, for a couple of reasons:
1) while I love physics, from classical mechanics to quantum mechanics & relativity, I am of course am a mere amateur with respect to deep understanding and expertise.
2) many others have indulged in philosophizing on the nature of life using ideas from modern physics. Some such authors have quite inspired ideas, but others have gotten a bit carried away on the mystical side of things. I can imagine many physicists rolling their eyes at yet another amateur scientist philosophizing about quantum mechanics.
But--I just HAVE to indulge though--because modern physics is just too interesting and important! Also I feel that most physicists are so busy doing physics--much of which perhaps a daily grind through highly esoteric research--that they may not be applying their minds very often to considering the philosophical import of their work.
Another practical reason I have for dabbling in this area is that quantum mechanical phenomena are undoubtedly relevant in the workings of the brain. The behaviour of a neurotransmitter at a synapse, the motions and contortions of molecules within neurons, the energy sources which power these motions, the role and dynamics of electrical phenomena in neuronal stimulation--all of these phenomena require quantum-mechanical formulations to understand fully.
Relativistic phenomena, while immensely interesting, are perhaps less obviously relevant with respect to neurophysiology. Yet, who knows? Relativity is a ripe area to form metaphors, though.
Here are a few metaphors borrowed from quantum mechanical ideas:
1) "the energy of a ground state is non-zero": to some degree, a statement of hope--no matter how low things get, even in a "vacuum", the potential for energy is always present.
Perhaps, even in the freezing void of empty space (is your life like this?) , there is always the possibility for something new.
2) Positions and movements are best understand as probability distributions, rather than as precisely knowable entities. The probability distribution may be quite accurately knowable, but perhaps not more detail than that. This encourages the idea of letting go of the need to view nature in terms of absolutes.
It encourages the idea of possibility.
It discourages "black and white thinking" (though, ironically, a core feature of quantum mechanics is its description of energy states which occur as integers, and its description of energy which occurs as "quanta").
For some people it may be disconcerting to admit the probabilistic nature of phenomena (whether it be in the universe as a whole, or within the mind). But on the other hand, it may be a source of comfort, hope, connectedness, and possibility.
...there are many more such metaphors to build on, which could be applied to psychology. Feel free to correct or adapt mine...I may add to this post gradually.
1) while I love physics, from classical mechanics to quantum mechanics & relativity, I am of course am a mere amateur with respect to deep understanding and expertise.
2) many others have indulged in philosophizing on the nature of life using ideas from modern physics. Some such authors have quite inspired ideas, but others have gotten a bit carried away on the mystical side of things. I can imagine many physicists rolling their eyes at yet another amateur scientist philosophizing about quantum mechanics.
But--I just HAVE to indulge though--because modern physics is just too interesting and important! Also I feel that most physicists are so busy doing physics--much of which perhaps a daily grind through highly esoteric research--that they may not be applying their minds very often to considering the philosophical import of their work.
Another practical reason I have for dabbling in this area is that quantum mechanical phenomena are undoubtedly relevant in the workings of the brain. The behaviour of a neurotransmitter at a synapse, the motions and contortions of molecules within neurons, the energy sources which power these motions, the role and dynamics of electrical phenomena in neuronal stimulation--all of these phenomena require quantum-mechanical formulations to understand fully.
Relativistic phenomena, while immensely interesting, are perhaps less obviously relevant with respect to neurophysiology. Yet, who knows? Relativity is a ripe area to form metaphors, though.
Here are a few metaphors borrowed from quantum mechanical ideas:
1) "the energy of a ground state is non-zero": to some degree, a statement of hope--no matter how low things get, even in a "vacuum", the potential for energy is always present.
Perhaps, even in the freezing void of empty space (is your life like this?) , there is always the possibility for something new.
2) Positions and movements are best understand as probability distributions, rather than as precisely knowable entities. The probability distribution may be quite accurately knowable, but perhaps not more detail than that. This encourages the idea of letting go of the need to view nature in terms of absolutes.
It encourages the idea of possibility.
It discourages "black and white thinking" (though, ironically, a core feature of quantum mechanics is its description of energy states which occur as integers, and its description of energy which occurs as "quanta").
For some people it may be disconcerting to admit the probabilistic nature of phenomena (whether it be in the universe as a whole, or within the mind). But on the other hand, it may be a source of comfort, hope, connectedness, and possibility.
...there are many more such metaphors to build on, which could be applied to psychology. Feel free to correct or adapt mine...I may add to this post gradually.
Monday, February 2, 2009
Short Term Intensive Dynamic Psychotherapy
Here's yet another interesting therapy style.
A lot of these different styles influenced "my own" style with patients, which I consider to be a flexible and eclectic (and hopefully not too disorganized) mix, parts of which are more helpful in some situations than in others. I think that, in life generally, one must absorb those elements of wisdom or inspiration that resonate in a genuine way with one's nature. Many teachers or mentors may have wonderful kernels of wisdom to share, but perhaps many other aspects to leave aside or reject. I realize that, for my patients too, they may at times find parts of their therapy experience with me to be helpful, other parts less so, other parts not helpful at all.
Anyway, back to the title: "short term intensive dynamic psychotherapy" (STIDP). This style was developed by Habib Davanloo, a Montreal psychiatrist who wished to address the phenomenon of patients whose problems never seemed to change or get better, despite very lengthy courses of psychotherapy.
I consider Davanloo's ideas to be challenging, interesting, sometimes brilliant, often quite eccentric. His technique calls for the therapist to be much more active than in traditional psychodynamic therapy.
Here's my brief summary of what the technique is all about (this is very much my paraphrase, which reflects perhaps those elements of the technique, as I learned it, that have been salient to me over the years):
First of all, in order for the technique to be appropriate, it would be necessary for the patient to be quite stable with respect to symptoms of severe major mental illnesses. So, for example, it would be inappropriate to apply these ideas in situations where the patient is suffering from psychosis or mania.
The technique is based on understanding the dynamics of a patient's situation according to a sort of balance between anxiety, underlying emotion, and defences. In this balance, defences are either conscious or unconscious actions that a person takes in order to cope with anxiety. Both anxiety and defences suppress or distract awareness from underlying "emotion." Defences could include phenomena such as denial or repression, but also such immediate behavioural or conversational phenomena such as intellectualizing, ambivalence, compliance, defiance, passivity, engaging in small-talk, etc. (Here, defences need not be considered "bad" but merely as behavioural tactics that a person uses--often automatically-- to cope with emotion or anxiety). Anxiety could be manifest--again either consciously or unconsciously-- as muscular tension--visible during the therapy session--or through other pathways, including somatization (physical symptoms such as pain).
The technique aims to help a patient "experience underlying emotion" by helping the patient to become more consciously aware--in the moment--of anxiety and defences. With the patient's consent and will, sometimes these defences can be set aside quickly, leading to a strongly emotional experience. I do find it is true that people are often unaware of their defences, and can be unaware of the ways in which anxiety is being manifest.
Often the underlying emotion has to do with anger--the patient's defences being tactics to avoid experiencing or acknowledging anger--and the patient's anxiety being provoked by the magnitude of the underlying anger. If the "underlying anger" is "exerienced" (in a sort of cathartic way), it may be initially directed at the therapist, but upon subsequent dialog, it may be understood that this anger is "transferential", that it originated with an earlier developmental conflict, typically with a parent.
The therapist in this technique can be very active, leading to the patient perhaps feeling criticized or under very close scrutiny. For this reason, the technique only works if there is very clear informed consent, and a very clear and positive therapeutic alliance.
The technique may involve asking the patient to describe a recent problem or conflict in the week, with an emphasis on trying to understand the underlying emotion. The focus may shift to the "here and now" of the session, particularly if defences seem to be very active as the patient recounts the story. Later, the focus may shift again to an early childhood dynamic, perhaps with the idea that such childhood events form core conflicts which keep recurring transferentially.
Another component of the technique involves videotaping the sessions, in order to understand clearly what is helping, and what is not, with a view to considering that the moment-to-moment behaviour of therapist and patient is very significant.
The technique can be used to frame different sorts of problems, ranging from panic attacks, relationship difficulties, anger control problems, past trauma, at least some types of depression, and personality disorders. These different problems could be understood as leading to different forms or styles of defence and different manifestations of anxiety, both of which inhibiting a full expression or ability to experience emotion.
The theoretical lingo in this technique is, in my opinion--just like with so much other therapeutic theory--filled with a lot of overvalued Freudian-style language which is taken as literal truth. So we have dramatic descriptions of "breakthroughs", "unlocking the unconscious", etc. As with other phenomena of this sort, it is a ripe opportunity for some people to adopt the ideas with a sort of dogmatic, quasi-religious fervour; and the "guru effect" may be a factor as well. Yet, perhaps I shouldn't criticize the lingo too much -- it is a truly significant moment when a longstanding psychological truth is discovered, and a new way of experiencing an emotion is discovered -- and perhaps such an experience deserves an impressive-sounding label.
One thing I like about this technique, in a nutshell, is that it encourages the possibility that the therapist can sometimes bravely initiate a discussion about a patient's defences, leading rapidly to positive change. And this dialog may not need to wait for months or years, it could happen during the very first meeting, perhaps minutes after sitting down for the first time. And such a rapid pace could be an immense relief--though perhaps a surprise-- to the patient. In some therapy situations I find that there can be such timidity and passivity on the part of the therapist that very little happens -- not only can this be ineffective, I think it is downright boring sometimes, for patient and therapist!
In some ways it is like a stylistic mixture of cognitive-behavioural therapy and psychoanalytic therapy, but actually with a therapist who is more active than in either of these styles. In some variants of this style, the therapist might view cognitive-behavioural therapy as a sort of subset of the larger, more encompassing dynamic therapy, and might deliberately recommend CBT techniques as a sort of preparatory step.
The risks of the technique, in my opinion, lie in the dogmatism of its theory. Also, the style could be misapplied in such a way as to be offensive, argumentative, or dismissive. It may encourage some therapists to be excessively active, when the patient may need a quiet listener. I also believe it could be seen to aggrandize the role of therapist in a way I'm not particularly comfortable with.
There is a small but positive evidence base for the technique in the mainstream literature.
There is a significant case-series evidence base accumulated by practioners of the technique. Most case series are weak sources of evidence (because there is no control group, it is not prospective, etc.), but because the case series evidence in STIDP is also often accompanied by videotaped sessions demonstrating changes, I feel that this evidence base deserves stronger consideration.
Reference:
http://www.ncbi.nlm.nih.gov/pubmed/15583112
A lot of these different styles influenced "my own" style with patients, which I consider to be a flexible and eclectic (and hopefully not too disorganized) mix, parts of which are more helpful in some situations than in others. I think that, in life generally, one must absorb those elements of wisdom or inspiration that resonate in a genuine way with one's nature. Many teachers or mentors may have wonderful kernels of wisdom to share, but perhaps many other aspects to leave aside or reject. I realize that, for my patients too, they may at times find parts of their therapy experience with me to be helpful, other parts less so, other parts not helpful at all.
Anyway, back to the title: "short term intensive dynamic psychotherapy" (STIDP). This style was developed by Habib Davanloo, a Montreal psychiatrist who wished to address the phenomenon of patients whose problems never seemed to change or get better, despite very lengthy courses of psychotherapy.
I consider Davanloo's ideas to be challenging, interesting, sometimes brilliant, often quite eccentric. His technique calls for the therapist to be much more active than in traditional psychodynamic therapy.
Here's my brief summary of what the technique is all about (this is very much my paraphrase, which reflects perhaps those elements of the technique, as I learned it, that have been salient to me over the years):
First of all, in order for the technique to be appropriate, it would be necessary for the patient to be quite stable with respect to symptoms of severe major mental illnesses. So, for example, it would be inappropriate to apply these ideas in situations where the patient is suffering from psychosis or mania.
The technique is based on understanding the dynamics of a patient's situation according to a sort of balance between anxiety, underlying emotion, and defences. In this balance, defences are either conscious or unconscious actions that a person takes in order to cope with anxiety. Both anxiety and defences suppress or distract awareness from underlying "emotion." Defences could include phenomena such as denial or repression, but also such immediate behavioural or conversational phenomena such as intellectualizing, ambivalence, compliance, defiance, passivity, engaging in small-talk, etc. (Here, defences need not be considered "bad" but merely as behavioural tactics that a person uses--often automatically-- to cope with emotion or anxiety). Anxiety could be manifest--again either consciously or unconsciously-- as muscular tension--visible during the therapy session--or through other pathways, including somatization (physical symptoms such as pain).
The technique aims to help a patient "experience underlying emotion" by helping the patient to become more consciously aware--in the moment--of anxiety and defences. With the patient's consent and will, sometimes these defences can be set aside quickly, leading to a strongly emotional experience. I do find it is true that people are often unaware of their defences, and can be unaware of the ways in which anxiety is being manifest.
Often the underlying emotion has to do with anger--the patient's defences being tactics to avoid experiencing or acknowledging anger--and the patient's anxiety being provoked by the magnitude of the underlying anger. If the "underlying anger" is "exerienced" (in a sort of cathartic way), it may be initially directed at the therapist, but upon subsequent dialog, it may be understood that this anger is "transferential", that it originated with an earlier developmental conflict, typically with a parent.
The therapist in this technique can be very active, leading to the patient perhaps feeling criticized or under very close scrutiny. For this reason, the technique only works if there is very clear informed consent, and a very clear and positive therapeutic alliance.
The technique may involve asking the patient to describe a recent problem or conflict in the week, with an emphasis on trying to understand the underlying emotion. The focus may shift to the "here and now" of the session, particularly if defences seem to be very active as the patient recounts the story. Later, the focus may shift again to an early childhood dynamic, perhaps with the idea that such childhood events form core conflicts which keep recurring transferentially.
Another component of the technique involves videotaping the sessions, in order to understand clearly what is helping, and what is not, with a view to considering that the moment-to-moment behaviour of therapist and patient is very significant.
The technique can be used to frame different sorts of problems, ranging from panic attacks, relationship difficulties, anger control problems, past trauma, at least some types of depression, and personality disorders. These different problems could be understood as leading to different forms or styles of defence and different manifestations of anxiety, both of which inhibiting a full expression or ability to experience emotion.
The theoretical lingo in this technique is, in my opinion--just like with so much other therapeutic theory--filled with a lot of overvalued Freudian-style language which is taken as literal truth. So we have dramatic descriptions of "breakthroughs", "unlocking the unconscious", etc. As with other phenomena of this sort, it is a ripe opportunity for some people to adopt the ideas with a sort of dogmatic, quasi-religious fervour; and the "guru effect" may be a factor as well. Yet, perhaps I shouldn't criticize the lingo too much -- it is a truly significant moment when a longstanding psychological truth is discovered, and a new way of experiencing an emotion is discovered -- and perhaps such an experience deserves an impressive-sounding label.
One thing I like about this technique, in a nutshell, is that it encourages the possibility that the therapist can sometimes bravely initiate a discussion about a patient's defences, leading rapidly to positive change. And this dialog may not need to wait for months or years, it could happen during the very first meeting, perhaps minutes after sitting down for the first time. And such a rapid pace could be an immense relief--though perhaps a surprise-- to the patient. In some therapy situations I find that there can be such timidity and passivity on the part of the therapist that very little happens -- not only can this be ineffective, I think it is downright boring sometimes, for patient and therapist!
In some ways it is like a stylistic mixture of cognitive-behavioural therapy and psychoanalytic therapy, but actually with a therapist who is more active than in either of these styles. In some variants of this style, the therapist might view cognitive-behavioural therapy as a sort of subset of the larger, more encompassing dynamic therapy, and might deliberately recommend CBT techniques as a sort of preparatory step.
The risks of the technique, in my opinion, lie in the dogmatism of its theory. Also, the style could be misapplied in such a way as to be offensive, argumentative, or dismissive. It may encourage some therapists to be excessively active, when the patient may need a quiet listener. I also believe it could be seen to aggrandize the role of therapist in a way I'm not particularly comfortable with.
There is a small but positive evidence base for the technique in the mainstream literature.
There is a significant case-series evidence base accumulated by practioners of the technique. Most case series are weak sources of evidence (because there is no control group, it is not prospective, etc.), but because the case series evidence in STIDP is also often accompanied by videotaped sessions demonstrating changes, I feel that this evidence base deserves stronger consideration.
Reference:
http://www.ncbi.nlm.nih.gov/pubmed/15583112
Friday, January 30, 2009
Narrative Therapy & the "Guru Effect"
This is another interesting therapy style, pioneered by the Australian social worker Michael White (1948-2008).
Here is my condensed account of narrative therapy: the main idea that I appreciate in this style is the application of a "story metaphor" to a person's life and problems. The patient becomes an author. Problems in the person's life (such as depression or eating disorders) become characters, and each of these characters gets a name. These characters are understood to have voices in the narrative, and to influence the story. The ways in which the different characters exert influence upon the story are examined, by the patient and by others. The role of the character--its purpose in the plot, so to speak--is considered. The question is considered of whether the story requires the character in some way, whether the character needs to be present, or what the story would be like without the character at all. The next step is to creatively "re-author" the story, addressing the problems externally as characters to deal with. The motives could be considered about why the different characters are behaving as they do. Elements which empower or weaken the character are considered. Important messages the characters might have to communicate could be considered or validated. The different "antics" of the characters (problems) could be anticipated, "spoken back to", or thwarted, through a creative act of "re-authoring".
The idea is really quite similar to cognitive-behavioural therapy, but perhaps with a more imaginative infusion of literary theory.
I find much of the written theory about this style incredibly cumbersome and laden with unnecessary jargon. Also I think this style, like many others, tended to see the founder as a sort of guru. There is a phenomenon I call the "guru effect" in which people with complex problems report significant change when they encounter some wise, charismatic figure, often in a public setting (I guess we can see this on certain types of TV shows these days).
I don't mean to be too critical of the "guru effect" because I acknowledge that there are some people who can share their charisma and wisdom very effectively, in a way that can be dramatically helpful. The word "guru" itself, and its origins, ought to be treated with respect, and the existence of this phenomenon can be appreciated as a gift to the world.
However, the "guru effect" can sometimes lead to a lot of dogma and a type of religious fervour that can foster overvalued ideas about what it is that is actually helping. This is especially problematic, in my opinion, if the adherents to a particular style begin to reject or criticize other styles or ideas, in ways that are not founded upon good evidence.
In any case, I think there are some imaginative and helpful ideas in narrative therapy--I'm always on the lookout for variations of cognitive-behavioural therapy or other therapies that are a little bit more imaginative, creative, or even fun (therapy isn't always fun, but humour, enjoyment, creativity, and playfulness can be immensely important elements at times).
Here is my condensed account of narrative therapy: the main idea that I appreciate in this style is the application of a "story metaphor" to a person's life and problems. The patient becomes an author. Problems in the person's life (such as depression or eating disorders) become characters, and each of these characters gets a name. These characters are understood to have voices in the narrative, and to influence the story. The ways in which the different characters exert influence upon the story are examined, by the patient and by others. The role of the character--its purpose in the plot, so to speak--is considered. The question is considered of whether the story requires the character in some way, whether the character needs to be present, or what the story would be like without the character at all. The next step is to creatively "re-author" the story, addressing the problems externally as characters to deal with. The motives could be considered about why the different characters are behaving as they do. Elements which empower or weaken the character are considered. Important messages the characters might have to communicate could be considered or validated. The different "antics" of the characters (problems) could be anticipated, "spoken back to", or thwarted, through a creative act of "re-authoring".
The idea is really quite similar to cognitive-behavioural therapy, but perhaps with a more imaginative infusion of literary theory.
I find much of the written theory about this style incredibly cumbersome and laden with unnecessary jargon. Also I think this style, like many others, tended to see the founder as a sort of guru. There is a phenomenon I call the "guru effect" in which people with complex problems report significant change when they encounter some wise, charismatic figure, often in a public setting (I guess we can see this on certain types of TV shows these days).
I don't mean to be too critical of the "guru effect" because I acknowledge that there are some people who can share their charisma and wisdom very effectively, in a way that can be dramatically helpful. The word "guru" itself, and its origins, ought to be treated with respect, and the existence of this phenomenon can be appreciated as a gift to the world.
However, the "guru effect" can sometimes lead to a lot of dogma and a type of religious fervour that can foster overvalued ideas about what it is that is actually helping. This is especially problematic, in my opinion, if the adherents to a particular style begin to reject or criticize other styles or ideas, in ways that are not founded upon good evidence.
In any case, I think there are some imaginative and helpful ideas in narrative therapy--I'm always on the lookout for variations of cognitive-behavioural therapy or other therapies that are a little bit more imaginative, creative, or even fun (therapy isn't always fun, but humour, enjoyment, creativity, and playfulness can be immensely important elements at times).
Thursday, January 29, 2009
Anxiety Hierarchies
The idea of an "anxiety hierarchy" is simple and powerful.
It is an application of behavioural therapy, and is analogous to a well-designed educational or athletic training program.
In education--for example, learning to read, or learning arithmetic--a well-designed workbook would call for you to start with some exercises that you would find very easy. If the initial exercises are too hard, then it would be necessary to go to the previous workbook, and try something easier. If you can do the easier ones fluently, you can move on to the next page, and try some exercises that are just a little bit harder, and so on...the pace could be self-directed; some people might want to leap ahead quickly, others might want to linger on the easier pages, or practice doing them faster, etc.
In athletic training--for example, training for a marathon--one might have to start with just a few minutes of jogging, alternating with a few minutes of walking, a few times per week--once this feels comfortable, the intensity and duration could be increased.
An anxiety hierarchy is basically a "workout schedule" or "curriculum" for overcoming a phobia or an inhibition.
A prerequisite to engaging in this process is a clear wish to overcome the anxiety. It may well be possible to practice the skills necessary to become a skydiver, but unless you really want to skydive, you probably shouldn't do the training!
If the anxiety is social phobia, for example, the prerequisite for this approach is that you truly want to be able to interact socially with greater ease. If you have a phobia of bridges, you have to truly want to be able to cross bridges easily.
To do an anxiety hierarchy, it is necessary to consider tasks which involve your anxiety in some way, and rank them in difficulty, say from 1 to 100.
For social phobia, a rating of 100 might be warranted for the task of showing up for a group function, consisting of strangers, introducing yourself to everyone, striking up a conversation with the person who interests you most, and asking for that person's phone number. A rating of 50 might be for the task of asking a stranger in a crowded cafeteria for the time. A rating of 10 might be for reading a book in a crowded place, instead of at home. The details of how you do the ratings are up to you and how you feel.
It helps to think of as many tasks as you can along the "hierarchy", covering as many numbers as possible from 1 to 100.
The next step is--just like learning arithmetic or training for the marathon--to start with the easiest task, and practice it daily until you feel comfortable with it.
Then move on to the next harder step, and continue gradually working your way up the hierarchy. It is important to do the work every day, if possible; consistency and regularity are extremely important, just as in other learning tasks.
It is important to really take this seriously, and to put in your hours of work and practice. Just like marathon training or language learning, it won't happen unless you do it regularly, at a moderate level of difficulty, for solid blocks of time (e.g. one hour every day).
The pace of change may be quite similar to an educational or athletic task--after all, it is your brain that is changing, just the same way as your brain changes with learning anything else. Also your body learns to change--when you are more physically fit, the same athletic task can be done more efficiently, with less effort, and with less physiological stress. With anxiety tasks, your body will learn not to react with the same anxiety symptoms (e.g. racing heart, sweating, shortness of breath), as you train yourself.
It is an application of behavioural therapy, and is analogous to a well-designed educational or athletic training program.
In education--for example, learning to read, or learning arithmetic--a well-designed workbook would call for you to start with some exercises that you would find very easy. If the initial exercises are too hard, then it would be necessary to go to the previous workbook, and try something easier. If you can do the easier ones fluently, you can move on to the next page, and try some exercises that are just a little bit harder, and so on...the pace could be self-directed; some people might want to leap ahead quickly, others might want to linger on the easier pages, or practice doing them faster, etc.
In athletic training--for example, training for a marathon--one might have to start with just a few minutes of jogging, alternating with a few minutes of walking, a few times per week--once this feels comfortable, the intensity and duration could be increased.
An anxiety hierarchy is basically a "workout schedule" or "curriculum" for overcoming a phobia or an inhibition.
A prerequisite to engaging in this process is a clear wish to overcome the anxiety. It may well be possible to practice the skills necessary to become a skydiver, but unless you really want to skydive, you probably shouldn't do the training!
If the anxiety is social phobia, for example, the prerequisite for this approach is that you truly want to be able to interact socially with greater ease. If you have a phobia of bridges, you have to truly want to be able to cross bridges easily.
To do an anxiety hierarchy, it is necessary to consider tasks which involve your anxiety in some way, and rank them in difficulty, say from 1 to 100.
For social phobia, a rating of 100 might be warranted for the task of showing up for a group function, consisting of strangers, introducing yourself to everyone, striking up a conversation with the person who interests you most, and asking for that person's phone number. A rating of 50 might be for the task of asking a stranger in a crowded cafeteria for the time. A rating of 10 might be for reading a book in a crowded place, instead of at home. The details of how you do the ratings are up to you and how you feel.
It helps to think of as many tasks as you can along the "hierarchy", covering as many numbers as possible from 1 to 100.
The next step is--just like learning arithmetic or training for the marathon--to start with the easiest task, and practice it daily until you feel comfortable with it.
Then move on to the next harder step, and continue gradually working your way up the hierarchy. It is important to do the work every day, if possible; consistency and regularity are extremely important, just as in other learning tasks.
It is important to really take this seriously, and to put in your hours of work and practice. Just like marathon training or language learning, it won't happen unless you do it regularly, at a moderate level of difficulty, for solid blocks of time (e.g. one hour every day).
The pace of change may be quite similar to an educational or athletic task--after all, it is your brain that is changing, just the same way as your brain changes with learning anything else. Also your body learns to change--when you are more physically fit, the same athletic task can be done more efficiently, with less effort, and with less physiological stress. With anxiety tasks, your body will learn not to react with the same anxiety symptoms (e.g. racing heart, sweating, shortness of breath), as you train yourself.
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