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Tuesday 31 May 2011

The Down Side of Positive Affirmations

One of the problems with cognitive therapy is the set of preconceptions that people have about it. I often get partway through my brief explanation of the idea (which boils down to “We react to what we think is going on, not what’s really going on”) and then I’m stopped by the client, or dinner companion, or trainee. “You mean like the power of positive thinking.”

Actually, no. Positive thinking can get us into as much trouble as negative thinking. Both depart from reality, and reacting based on an incorrect fantasy about reality can lead to all kinds of problems. Indebtedness, lack of preparation, bankruptcy, academic failure, war (“We’ll invade their country and they’ll welcome us with open arms…”), you name it.

One of my least favourite forms of self-boosterism is the concept of the positive affirmation. This is the idea that we can boost our mood, self-esteem, and performance by reciting happy thoughts to ourselves.

If the happy thoughts happen to be true, I have no problem with them. But most of the affirmations I hear are happy lies:

I have all the resources I need to accomplish all of my goals.
I can achieve anything I set my mind to.
I’m perfect, just as I am.
Everyone loves me.

No, we don’t have what it takes to accomplish all of our goals, and we cannot and will not achieve everything we would like. We’d like to be Olympic sprinters, but we didn’t start before age 30, so it’s not going to happen. Period.

No, not everyone loves us. And if most of them do, on occasion, feel a faint flush of appreciation for us, it is as nothing compared to the constant devotion that our needy egos would demand of them.

Positive affirmations can actually help us to feel better – temporarily. But eventually, reality will hit us between the eyes and we’ll realize we were kidding ourselves.  Our original negative thoughts will seem to be confirmed, and will gain even more heft than they had before.

I’d prefer to jettison positive affirmations entirely, in favour of affirmations of reality.

“I would like to have gone to the Olympics, but instead I had a social life when I was a teenager.”  
“I have the resources to achieve many of my goals – if I make them priorities in my life.”  
“I am imperfect and always will be, but so will everyone else so I can relax.”  
“I’d love to be universally admired, but I’ve proven that I can survive having at least some people dislike me.”

Telling ourselves the truth is a great strategy. The truth acknowledges reality and its survivability. The truth includes positive factors that we often ignore, choosing instead to focus on our shortcomings. Our typical negative thoughts have a trump card: We have rehearsed them so long they have become instinctive. The truth has a trump card of its own: Reality will confirm it over time.

Tuesday 24 May 2011

Soundproofing Office Space: Drywall and Insulation

Most offices are designed to provide visual privacy, but they’re not soundproofed.  No one cares if someone in the next office hears about their auto insurance.  And dentists seem to take delight in having minimal privacy from the sound of drilling and gasping in the next booth.

Result:  When you rent an office suite for a psychotherapy practice it probably won’t be very sound-dampened.  I discuss this issue in Private Practice Made Simple (New Harbinger Publications, 2011), but let’s consider a few of the measures that can help.

One of the issues is drywall.  Most office suites use drywall over wood or steel studs, with minimal (i.e., usually zero) insulation.  Sound hits the drywall in your neighbour’s office, passes through it like a hot knife through butter, leaps the air gap or vibrates through the studs, waltzes past the second sheet of drywall on on your side, and is clearly audible to you and your visitors.

How can you deal with this?  At Changeways Clinic we recently moved into a new office suite with just this problem.  We took several measures, but let’s focus on the walls for the moment.

We removed the drywall on one side of each wall between the therapy offices.  We stuffed the space between studs with a dense insulation product called SafeNSound, which has better sound dampening qualities than standard pink insulation.  Then we replaced the drywall on the one side with QuietRock, a dense (and heavy!) drywall alternative that sharply reduces sound transfer.

Does that solve the problem?  Well, no.  There are other ways that sound can get from office to office – past continuous window frames, over the tops of walls that only go to the dropped ceiling, through hollow doors, through electrical sockets, and along common heating units that run from one office to the next.  I’ll talk about these in other posts.

But yes, QuietRock is a great product and does reduce sound transfer through the walls themselves.  If one sheet isn’t enough, you can remove the regular drywall on both sides and replace them both, or you can double-sheet the one wall you have removed.  Some dealer websites provide a demo video that you can watch.  Here are two:

Note:  No, I haven’t got any kickbacks for mentioning this product, though I will certainly cash any cheques that the manufacturers see fit to send my way.  Nevertheless, QuietRock has worked reasonably well for us.  Of course, if the sound isn’t coming through your drywall but is finding another way from one room to the other, the drywall barrier won’t do much.

More on soundproofing here!

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Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple.  It contains information on starting a practice, creating a space, designing a website, getting referrals, managing finances, avoiding burnout, and much more.

The book is available at bookstores, from the Changeways Clinic website, and through Amazon here.

Vancouver Workshop November 29 2013

Click here for information and registration for the one-day workshop Private Practice Made Simple being held in Vancouver Canada Friday November 29. 

Tuesday 17 May 2011

Psychology and Long Term Disability

Mental health providers sometimes feel like the poor siblings of physical health practitioners.  We don’t stitch people up, we don’t perform heart transplants, we don’t cure cancer.  Many of the conditions we see are not life-threatening, and some of them improve with the simple passage of time.

So how important are we, really?

This is a complicated question that merits consideration from many angles.  Here let’s just focus on one:  Long term disability (LTD) figures.

In Canada, the “big three” disability insurance providers are SunLife, GreatWest Life, and Manulife Financial.  To this we could add the Canada Pension Plan, which provides Disability Benefits to individuals with severe and prolonged conditions.  There are many more minor players in the field as well.

LTD usually kicks in once a person has exhausted their store of sick days and, in many cases, after a period when the person is covered by Short Term Disability benefits.  LTD premiums represent a major expense for employers, and large numbers of people are on LTD at any given time.

Insurers are in the business of collecting premiums and saving money by offering benefits only to those who really need them, and only for as long as they are needed.  A worker on LTD may cost the insurer several thousand dollars per month.

One way of reducing payouts is to provide the disabled person with extra treatment so that they will get better, be more likely to return to work, and return a month or more sooner than they would have otherwise.  So insurers gamble on this and free up funds on a case by case basis for physiotherapy, psychological care, and other kinds of help.  This pays off frequently enough that it’s worth doing.

But what are the main causes of LTD claims?  Many people guess that things like cancer would be a major source.  But Manulife Financial reports that malignancies only account for about 3% of cases.

The number one category in their report, at 23%, is musculoskeletal concerns – a grab bag of disorders including back pain and other problems.  An additional 5% involves chronic pain, fatigue, and fibromyalgia.  Mental health providers are major resources for this group.  We help people cope with long term pain conditions, making lifestyle adjustments and training clients in a variety of management strategies.

The number two category, at 22% just a single percentage point behind the leader, are the mental and nervous disorders (plus an additional 9% for diseases of the nervous system – likely a category more neurological than psychological).  Mental health practitioners are again involved in helping people to overcome the variety of psychological difficulties to which people fall prey.

The summary report, if you are interested, can be found here:

Other studies, which divide up causes differently, have found that major depression alone is the single largest or second largest cause of LTD.

And what are the costs?  Depending on the length of time a person is off work, the insurer can pay out many thousands of dollars.  In their report Manulife provides examples of various professionals, the nature of the disability, and the amount paid out in each case, ranging up to $973,000.

If these are the costs just for the LTD insurer, consider the costs to the short term disability supplier, the company providing sick time benefits, the workers who are on the job but functioning at an impaired level, the governmental employment insurance and pension costs, the medical system costs, and others.

So mental health care is not an also-ran after all.  It represents a treatment resource for a hugely expensive societal problem.  If we provide efficient and evidence-based interventions that actually produce positive change, we can bring about major improvements in the lives of our clients – and huge savings for funders.

We are used to thinking in terms of benefit to our clients.  This is the main reason most of us went into the field.  But it may not be the main reason that people employ us or refer people to us.  Suffering is costly.  If we take our work seriously, we are not an expense.  We are a money saver.

Sunday 15 May 2011

PsychSalon Talks - Letting Go: The Essential Life Skill

Tuesday May 24, 7 pm, at UBC Robson Square, Room C400

Which is more important: Grasping or releasing? Life is a dance between the two, but popular culture - and popular therapies - often emphasize attainment rather than acceptance, striving rather than giving up. An enormous amount of human distress arises from the inability to release and accept. In this edition of our monthly PsychologySalon series at UBC Robson Square, Vancouver, we consider the value of giving up.

We'll talk about the range of life problems caused by not letting go, and the variety of life situations where letting go is essential and adaptive. Along the way we’ll touch on grief, aging, codependency, relationships, addictions, and obsessions. We’ll also discuss some of the strategies involved in relaxing, opening our grasping hands, and allowing reality to be reality, whether we like it or not.

For more information about PsychologySalon talks, visit us here.  You can buy tickets online or at the door.  $15.

Tuesday 10 May 2011

The Time Horizon

In a hockey game, it’s important to know where to look.  If you focus on the end of your stick, or on your sweetheart in the stands, you won’t score many goals.  

Similarly, in much of life it matters a great deal where you place your attention.  In my clinical practice, many of the problems people have are influenced by the time horizon they use.  If it matches the needs of the situation they tend to do better than if there is a mismatch.

Imagine a physician completing her residency and studying for final examinations four weeks away.  If she focuses relentlessly on her future after the examination – the consequences of failure, whether she really wants to practice in the area she has chosen – this will impair her ability to prepare during these few weeks remaining.  

At this point she has invested years of her life in the field she has chosen.  This is not the time to begin trying to decide whether she really wants to be a surgeon.  The impulse to abandon ship is likely to be so contaminated by her desire to avoid the stress of the exam that it cannot be trusted.  Once the examination is over, she can make the decision whether to practice as a surgeon or not:  passing the exam does not commit her to any course of action.  Much of the work of therapy, then, is to decatastrophize failure (her life will not be destroyed no matter what happens) and then to pull in the time horizon to the task of the moment:  her preparations.

Sometimes clients have a time horizon that is too close.  People who are extremely anxious sometimes try to cope by refusing to think about the future, doing everything they can simply to get through the day.  When they allow thoughts of the future to come up, they worry about bad outcomes – failure, bankruptcy, illness, loss, death.  

The task of therapy is often to help the person remain in the mindful present for much of the time, but to begin contemplating where they would like to be in a month, in a year, in five years.  Then we can work backward from this vision to identify the steps they may need to take in order to make that future a reality.

Here’s an example.  Many young people suffer from a crisis of confidence about their abilities.  After graduating from high school, they continue to live with their parents and find it too stressful to think of furthering their education or finding employment or even meeting new friends.  Their time horizon creeps inward.  

They might ask themselves “What do I feel like doing today?”   The answer is easy.  If the mission is to feel as relaxed and happy as possible today, the best thing to do is to stay at home, perhaps watch television, and avoid the potential humiliations of the outside world.   And indeed, if this was their last day on earth, these might be reasonable options.  But it isn’t.

If a confidante can help them to relax enough to lower their defenses against the fearful future, they can readily see that continuing to choose comfort in the short run makes them more uncomfortable in the long run.  By extending the time horizon for short periods we can explore a vision of a future that might be more fulfilling.  Then we can map our way back to find the first few steps of the path.

Individuals who experience chronic pain can be similar.  If the question is “How can I best control my pain right now?” the answer is usually quite easy.  Take pain medication, avoid movement, and perhaps have another hot bath.  All of these are entirely reasonable and appropriate things to do, but for most pain conditions they tend not to help the person become more mobile.  

Instead, we need to ask “How can I best reduce my pain two months from now?”  The answers will be quite different.  Gradual increases in activity, scheduled (rather than as-needed) medication, and mobility exercises will typically increase short term discomfort but produce greater benefits in the long run.  Our goal should not be to disregard short-term pain relief, nor to challenge ourselves to the point that discomfort is intolerable, but to supplement the present-oriented coping strategies with strategies for the future as well.  

In short, if we are feeling stuck or uncomfortable in our lives, the time horizon we are using is one place to look.  Sometimes we cast our eyes too far ahead, and need to focus on the here and now.  Sometimes we need to supplement a focus on the present with a careful consideration of the future.  When in doubt, shift the horizon and see what happens.

For more information on setting effective goals, consider visiting my vlog on YouTube called How to be Miserable.

Tuesday 3 May 2011

Emotions in Three Times

Think of something you might do.  Anything at all.  Go to a movie, poke yourself in the eye, gamble at the casino, whatever.

We can imagine how we would feel during three periods relative to that event:

  • Beforehand
  • During the event
  • Afterward

Now take all the spectra of emotional experience and reduce them to a single dimension:  Pleasant or unpleasant.  And classify how you would feel in each of the three periods relative to different things you might do.

We can all think of situations where all three would be positive.  Having a great meal with a good friend:  We look forward to it, we enjoy it while it’s happening, and we’re glad we did it.  Positive, positive, positive.  We have no difficulty getting ourselves to do these things.

How about hitting your thumb with a hammer?  We wouldn’t look forward to it, it would hurt to do it, and we’d regret it afterward.  Negative, negative, negative.  And in fact we don’t generally do things like this on purpose.  They’re easy to discard as options for a Saturday afternoon.

But there are many behaviours that switch from positive to negative.  Think of addictive behaviours (and substitute your favourite addiction for the examples here):  drinking, gambling, obsessive games of computer solitaire, TV-watching, endless internet surfing, staying at home in bed.

During the anticipatory period we feel the attraction of the behaviour.  “I’ll just turn on the TV for a little bit.”  “Just one little drink.”  Positive.

While we’re doing it, we might enjoy the experience or we might feel more neutral.  “This is okay, but a bit boring.  Why am I doing this?”  Positive, negative, or neutral.

Afterward, we experience regret.  “There’s another evening wasted.”  “This hangover is awful.”  Negative.

Then there are behaviours that switch from negative to positive.  These might (or might not) include completing the tax form, going to the gym, getting out of bed, calling up friends to organize an activity, working on a renovation project, or phoning your aunt.

During the anticipatory period, you don’t really want to do them.  “I’d rather just lie here a little longer.”  “I hate the thought of reviewing my receipts.”  There is a sense of repulsion from the task.  Negative.

During the task you may like it or not, but it usually isn’t as repulsive as the anticipatory period.  “Actually, learning to ski isn’t that bad.”  “Ok, I’m actually getting some of this blog written.”  Positive, neutral, or a little negative.

Afterward, there is a sense of satisfaction.  “That was actually great.”  “I’m glad that’s done with.”  “I feel better having gone to the gym.”  Positive.

Um, okay; so what?  The question, of course, if how to govern our decisions in situations where the emotional reactions shift from positive to negative, or from negative to positive.

The answer?  If we decide based on how we will feel afterward, we’ll generally be happier.  Our taxes will be done, we’ll be more fit, we will have organized social events with our friends, we will complete projects, we will eat right.

If we act based on our anticipatory emotions, our temptations if you will, we will find that we get little done and spend our lives in unsatisfying activity.  We’ll drink too much, exercise too little, and get nothing done.

In my own life, some of my best experiences have involved hiking in the coastal mountains of British Columbia.  But when the alarm clock goes off at 6 a.m. on a Saturday, do I really want to go?  Never.  I’m much more tempted to roll over and go back to sleep.  “Why did I say I’d do this?  I must be crazy.”  If I obeyed my temptation I would miss out on hiking, on skiing, on mornings generally, on the satisfaction of getting my taxes out the door, on being even moderately fit, and on virtually everything I now feel satisfied to have done.

During my clients’ depressions, the situation gets worse.  Anticipatory enjoyment vanishes altogether, and the temptations to avoid, neglect, or put off become much more powerful.  Their enjoyment during events, and their satisfaction afterward, are also muted.  Only with time, practice, and repetition does the old enjoyment return, and the anticipation (“Maybe it would be fun to meet up with Carol”) tends to take even longer.

My usual recommendation:  Base your decisions mostly on how you will feel to have done something – or how your old self would have felt to have done it.  Occasionally, base your actions on how you will feel simply to do something – how you will feel during.  But, as much as you can, ignore temptation altogether.  It’s a lousy guide.

Is this simply a soulless injunction to be responsible, to ignore our feelings and obey the demands and expectations of others?  To be responsible little soldiers and deny ourselves any pleasures?

Absolutely not.  During and After last longer than Before.  This is a recipe for enjoying life more, not less.  It’s how to be a successful hedonist – and without fouling up your life.