Hallucinogenic drugs such as LSD, psilocybin, and ayahuasca have been used to treat depression and addictions, and to help with the psychological well-being of patients suffering advanced stages of cancer.
Terminally Ill Patients
Jan Hoffman's article, published on December 1, 2016 in The New York Times, describes some of the research supporting the use of psilocybin for treating psychological suffering in cancer patients.*
The most recent major study supporting this was published by Stephen Ross et al. in the December 2016 edition of The Journal of Psychopharmacology. In this study, 29 cancer patients suffering from anxiety and depressive symptoms were given either 0.3 mg/kg of psilocybin, or an active placebo of niacin. They received only one single dose! There were no serious side effects. The psilocybin doses led to large, sustained relief of anxiety and depression symptoms, following an immediate hallucinogenic, mystical effect which lasted about 6-7 hours. Response and remission rates for depression and anxiety symptom scores were significantly larger, compared to placebo, than what we would typically see for most other established therapeutic modalities, such as conventional psychotherapy or antidepressants. And these beneficial effects appeared to persist for up to 8 months.
In another study published in the same edition of this journal, by Griffiths et al., 51 anxious or depressed participants with life-threatening cancer received a low dose (~.01 mg/kg) and a high dose (~0.3 mg/kg) of psilocybin, 5 weeks apart. The authors found that the higher dose led to significant relief of anxiety and depression symptoms (final symptom scores were about 30% of the initial scores), which persisted over 6 months of follow-up. Interestingly, reports outside of the usual depressive symptom score domain also changed in a positive way; for example, there were substantial increases in "positive attitudes about life." A majority of subjects considered the experience with this therapy to have been very meaningful and significant. The amount of symptom improvement was correlated with the intensity of the experience on the dosage day. Once again, there were no severe side effect problems. Blood pressure increases of up to 20 mm Hg could be expected.
Treatment-Resistant Depression
Here is a reference to another study published in the prestigious journal Lancet Psychiatry by Carhart-Harris et al. in July 2016: **** This was an open-label study of 12 people with severe, treatment resistant depression. They received a first dose of 10 mg psilocybin, followed by a second dose of 25 mg one week later. They did not receive any further doses! They were followed after this for 3 months. Remarkably, there was a substantial reduction in depression severity scores which persisted at all follow-up points. 58% of the patients showed a response, and 42% of the patients showed full remission after 3 months.
Microdoses
Others have used so-called "microdoses" of hallucinogens on a more regular basis, typically about 10% of a typical recreational dose every 4 days (e.g. an LSD microdose would be about 10 micrograms). This is too low to produce a dramatic subjective hallucinogenic effect, but anecdotally can lead to a sustained relief of depression. Here is a reference to Alex Williams' January 7, 2017 article in The New York Times describing a case example of this practice: **
Addictions
Hallucinogens have also been used to treat addictions. Here is a reference to a study showing very good long-term abstinence rates (67% after 1 year) in smokers treated with 2-3 doses of psilocybin (0.3 - 0.4 mg/kg) in combination with CBT: ***
In another small study, two doses of psilocybin were given, 4 weeks apart (0.3 mg/kg, then 0.4 mg/kg) to patients with alcohol dependence. ***** The patients were followed for 36 weeks, and had a dramatic, sustained reduction in heavy drinking days (reduction from 40% to about 10-15%).
Conclusion
Hallucinogens remain illegal in most places. The quality and dose of hallucinogens available on the street might be very uncertain.
I have seen people whose experience with these agents appears to have helped them substantially.
But I have also seen people over the years who have used hallucinogens periodically, yet still suffer from a variety of psychological problems, including depression, anxiety, and addictions.
While the studies mentioned above have been very reassuring about toxicity risks and side effect problems, it would of course be very important to understand better any of the possible risks associated with this type of approach. Patients with bipolar or psychotic symptoms might be at particular risk of harm from hallucinogens, though I would be interested to see better evidence of such risks.
If hallucinogens do have a role in treating various types of psychological suffering, I think it is likely that they would have to be used with great care, probably in combination with a very safe, gentle, supportive milieu, and in combination with psychotherapy. Arguably, some aspects of the benefit might be due to a "catalytic" effect when used in a safe, therapeutic setting, or as an augmentation to psychotherapy.
I would be interested to see more carefully conducted, randomized controlled studies of hallucinogens, so we could understand this issue better. I think there is some urgency to get going with these studies, since the preliminary evidence seems so very promising. The most likely dosing schedule for hallucinogens would be very infrequent, which would cause such treatments to be economically very inexpensive. But as a result, we would not be seeing large-scale corporate funding for research into this! Also, parts of the research community may have quite orthodox beliefs about non-standard treatment regimes such as this, which might cause delays in setting up good studies quickly.
Tuesday, January 17, 2017
Tuesday, November 15, 2016
Healing Divisions: Empathy, Filter Bubbles, and Free Speech
There is a lot of conflict and division in the world. The recent U.S. election is just one of many examples of this.
What can be done to mend the conflicts?
I found a relevant TED talk a few days ago, featuring a social psychologist named Jonathan Haidt. He discusses the psychology of political difference, and also some ideas of what we can all do to help mend the divisions.
One of the simple challenges he poses to us all, is to practice empathy. It is easier to empathize with a person who has suffered in a way that we can understand or relate to. He points out that it may be much harder for any of us to empathize with someone whom we strongly disagree with. This lack of empathy with our intellectual or political opponents consolidates division, dislike, disrespect, and even hatred.
A very important obstacle to empathy in the modern world is a technical one: people who espouse a particular viewpoint may, through social media, or through other information sources, only expose themselves to those who already share the same views or opinions or backgrounds. Some services, such as Facebook, may deliberately filter information to be attuned to your interests and opinions. This "filter bubble" phenomenon leads to a reduction in empathy between opposing groups, and therefore magnifies division.
I encourage all of us to have a practice of learning why people feel or believe the way they do, even if they have very different opinions, feelings, or backgrounds. You may still strongly disagree at the end of this exploration, but at least there will hopefully be less enmity, and more understanding. You may discover that despite many differences, that there are unexpected areas of common ground. Such common ground can lead to peace instead of war.
A foundation required for this process to work is freedom of speech...I am very troubled by processes in which communication is suppressed. Even in the seemingly warm-hearted area of mental health care reform, I have seen processes of change in which dissenting voices were not welcome...the human tendency to suppress opposition in the name of efficiency or progress is universal. We must always take steps to protect our freedoms. This requires a certain bravery to express ourselves, even when your voice is a lone voice of dissent in a crowd...but it also requires a deliberate commitment to empathize, to strive to understand the feelings, thoughts, and motivations of those who disagree with you. Such empathy must be practiced as a basic discipline of life.
Another recommendation I have is to be aware of the "filter bubble"and to step out of it regularly. Read widely, from as many different sources as you can. This doesn't mean you need to agree with positions you find objectionable, but at the very least it does require you to be more aware of personal stories that you might not have been aware of before.
Addendum (in response to a message about this post): I am not meaning to suggest some form of passivity or tacit acceptance of situations which are alarming or wrong -- in fact, I strongly encourage using your voice! And there may often be a need for voices of protest or anger...but I also believe that strong leadership is needed to mend conflicts, which includes a voice that can speak to all. In large-scale human dynamics, people have a tendency to veer gradually towards extreme positions...for those who are drifting towards extremism of any kind, I think that an empathic voice can be much more effective to reverse an extremist trend, compared to an angry one. I think of some of the great voices in history, such as Martin Luther King's.
Addendum (in response to a message about this post): I am not meaning to suggest some form of passivity or tacit acceptance of situations which are alarming or wrong -- in fact, I strongly encourage using your voice! And there may often be a need for voices of protest or anger...but I also believe that strong leadership is needed to mend conflicts, which includes a voice that can speak to all. In large-scale human dynamics, people have a tendency to veer gradually towards extreme positions...for those who are drifting towards extremism of any kind, I think that an empathic voice can be much more effective to reverse an extremist trend, compared to an angry one. I think of some of the great voices in history, such as Martin Luther King's.
Monday, November 14, 2016
Grit in Psychological Health and Illness
I've recently finished reading a book called Grit, by Angela Duckworth. The author is a research psychologist who is part of the faculty at Harvard University. She also has a background and interest in childhood education, which is very relevant to her other work.
It is a good overview of the research that has been done about the factors that lead to success and achievement in various domains of life, such as in a profession, in athletics, and in the performing arts.
The author's thesis, in a nutshell, is that "grit", which she defines as perseverance over a long period of time, the practice of being undeterred by failures or disappointments, and the maintenance of long-term purposeful goals, is a much stronger factor leading to success, compared to hereditary factors or "talent."
While this may seem like an obvious truth, it is important to realize that the educational system, and the culture as a whole, tends to value the idea of "talent" more strongly than the idea of "persistent hard work." In one interesting study, an identical performance was judged more highly if the observers were told that the performer was "talented" compared to being told that the performer had "worked really hard."
How is this relevant to mental health?
Here are some of Duckworth's ideas, applied to mental health management:
1) if you are working on mental health, consider that it is necessary to work on this for years. Duckworth's research shows that successful endeavours in almost all spheres of life require a commitment of at least 2 years' time. During this time, it is necessary to have diligent, daily practice. This is not unlike the routines needed by a musician or athlete. This work needs to be guided by a long-term meaningful vision. The work may at times be difficult or even painful, and the work may be interrupted by periodic failures. The disappointing times must be accepted without allowing them to interrupt the work. In fact, it is necessary to learn from the disappointments rather than be derailed by them.
2) Duckworth ponders the unresolved question of whether the daily disciplined work needed for success must be "enjoyable." A lot of the work, in athletes for example, shows that the workouts needed for excellence are not, or cannot be, truly "enjoyable." The required work must challenge the status quo of your body's physiology and reflexes, and this is never easy to do. In this sense, a recipe for excellence is a tolerance for discomfort, which could be nurtured through practice. But I think this view could be reframed: the hard work needed may in the moment be uncomfortable, but provided there is an overarching sense of meaning and joy which guides the process, the periods of intense work would then fit into a paradigm of balanced health. I also believe that a good therapist, teacher, or coach, should always strive to make hard work as enjoyable as possible. Therapy itself may sometimes be quite joyful, and need not always be emotionally taxing.
3) In order to facilitate the years of work and discipline needed for growth and change, it is usually necessary to be part of a culture or community of change. Athletes are usually part of a team, whose members motivate each other. Musicians and academics hopefully are part of communities whose actions challenge and maintain growth and practice. It can make a huge difference to have a dedicated teacher or coach who believes in you, who sees your potential, and who challenges you to work hard. In mental health, I think a good therapist can have a "coach-like" or "teacher-like" role in this way. I think a good therapist should strive to be inspiring, motivating, but also challenging.
4) As Duckworth shows, it is necessary to have a sense of purpose in order to be able to commit to years of hard work. In depression, it is often the case that a sense of purpose is weakened or lost. It is of the utmost importance in therapy to address the issue of meaning. Without meaning, the hard work required for change could feel like a terribly draining, pointless chore. But how can we recapture meaning which has been lost? Maybe sometimes it is not so easy, but we can start by at least addressing it in conversation, and exploring possibilities. Often, in depression, meaning can be rekindled through behavioural exploration, in conjunction with relief of symptoms. In other cases, meaning can be recaptured even when other symptoms are at their worst.
5) One of the connotations of this type of work is that short-term models of mental health care are unlikely to lead to mental health "excellence," unless they serve merely as preliminary introductions to new ways of being. Just like in a successful classroom, sports team, or company, the atmosphere of change must allow for a sustained, long-term commitment. But it is an important critique of some longer-term therapy, that it can become too passive, just like the situation in which a teacher or coach becomes resigned to a class or a team which is not thriving. A good therapist, just like a good teacher or coach, must always strive for growth and change, while also helping the process to be as joyful and meaningful as possible.
It is a good overview of the research that has been done about the factors that lead to success and achievement in various domains of life, such as in a profession, in athletics, and in the performing arts.
The author's thesis, in a nutshell, is that "grit", which she defines as perseverance over a long period of time, the practice of being undeterred by failures or disappointments, and the maintenance of long-term purposeful goals, is a much stronger factor leading to success, compared to hereditary factors or "talent."
While this may seem like an obvious truth, it is important to realize that the educational system, and the culture as a whole, tends to value the idea of "talent" more strongly than the idea of "persistent hard work." In one interesting study, an identical performance was judged more highly if the observers were told that the performer was "talented" compared to being told that the performer had "worked really hard."
How is this relevant to mental health?
Here are some of Duckworth's ideas, applied to mental health management:
1) if you are working on mental health, consider that it is necessary to work on this for years. Duckworth's research shows that successful endeavours in almost all spheres of life require a commitment of at least 2 years' time. During this time, it is necessary to have diligent, daily practice. This is not unlike the routines needed by a musician or athlete. This work needs to be guided by a long-term meaningful vision. The work may at times be difficult or even painful, and the work may be interrupted by periodic failures. The disappointing times must be accepted without allowing them to interrupt the work. In fact, it is necessary to learn from the disappointments rather than be derailed by them.
2) Duckworth ponders the unresolved question of whether the daily disciplined work needed for success must be "enjoyable." A lot of the work, in athletes for example, shows that the workouts needed for excellence are not, or cannot be, truly "enjoyable." The required work must challenge the status quo of your body's physiology and reflexes, and this is never easy to do. In this sense, a recipe for excellence is a tolerance for discomfort, which could be nurtured through practice. But I think this view could be reframed: the hard work needed may in the moment be uncomfortable, but provided there is an overarching sense of meaning and joy which guides the process, the periods of intense work would then fit into a paradigm of balanced health. I also believe that a good therapist, teacher, or coach, should always strive to make hard work as enjoyable as possible. Therapy itself may sometimes be quite joyful, and need not always be emotionally taxing.
3) In order to facilitate the years of work and discipline needed for growth and change, it is usually necessary to be part of a culture or community of change. Athletes are usually part of a team, whose members motivate each other. Musicians and academics hopefully are part of communities whose actions challenge and maintain growth and practice. It can make a huge difference to have a dedicated teacher or coach who believes in you, who sees your potential, and who challenges you to work hard. In mental health, I think a good therapist can have a "coach-like" or "teacher-like" role in this way. I think a good therapist should strive to be inspiring, motivating, but also challenging.
4) As Duckworth shows, it is necessary to have a sense of purpose in order to be able to commit to years of hard work. In depression, it is often the case that a sense of purpose is weakened or lost. It is of the utmost importance in therapy to address the issue of meaning. Without meaning, the hard work required for change could feel like a terribly draining, pointless chore. But how can we recapture meaning which has been lost? Maybe sometimes it is not so easy, but we can start by at least addressing it in conversation, and exploring possibilities. Often, in depression, meaning can be rekindled through behavioural exploration, in conjunction with relief of symptoms. In other cases, meaning can be recaptured even when other symptoms are at their worst.
5) One of the connotations of this type of work is that short-term models of mental health care are unlikely to lead to mental health "excellence," unless they serve merely as preliminary introductions to new ways of being. Just like in a successful classroom, sports team, or company, the atmosphere of change must allow for a sustained, long-term commitment. But it is an important critique of some longer-term therapy, that it can become too passive, just like the situation in which a teacher or coach becomes resigned to a class or a team which is not thriving. A good therapist, just like a good teacher or coach, must always strive for growth and change, while also helping the process to be as joyful and meaningful as possible.
Monday, October 31, 2016
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.
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.
Sunday, October 30, 2016
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.
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.
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