The Placebo Phenomenon

A quick link for Christmas Day, reviewing a researcher's work on the placebo effect:

http://harvardmagazine.com/2013/01/the-placebo-phenomenon

Happy holidays, everyone.

Time for a short break.  I will be taking some time away from the blog (and, hopefully, the computer) over the holidays.  My next post will be Tuesday January 8.

Tragedy and Mental Health

In the wake of disasters such as Newtown, Columbine, Polytechnique Montreal, the Portland Mall, and others, the sequence of events has become depressingly predictable.

At the first reports of the events, the news trucks are scrambled as fast as the SWAT teams. Live feeds come in from the site, with excited reporters darting around for scraps of information. If the event is sufficiently “significant” - by which is meant a high enough death toll, the coverage goes into overdrive.

Driving around town doing errands this past Friday, a Canadian station punctuated one of its hourly news broadcasts with the dry observation that a US network had suspended all of its afternoon programming to focus exclusively on the event, just as it might do with the Superbowl.

In the course of the coverage we are treated to reporters scrounging for survivors and, in this case, worried parents, so that we can hear every detail of what they saw. If they saw nothing, they are asked how they feel, and this is reported as breaking news. The father of the shooter in this instance apparently found out from a reporter coming to his home for a reaction shot, and his response was duly recorded in story after story.

The script in these events calls for the shooter or shooters to be identified and then turned into celebrities. Their names and photographs are repeated over and over again until everyone on the street remembers them. In the Newtown tragedy a scrap of blurry archival video showing the boy from the rear was played repeatedly. Or so I’m told. If they were bullied or otherwise felt wronged, their grievances are aired publicly for the entire world to hear. Osama bin Laden himself couldn't get his point of view so widely disseminated.

The possibility that the quest for fame and media coverage may be among the causal factors in these incidents is studiously avoided – although that too would be dissected by the media if they could find their way around the irony.

Next in the sequence is the enlisting of mental health professionals to offer their opinions about an individual they have never met and about whom they know nothing. They pick their way gingerly around the issue, carefully avoiding direct statements that may later be refuted. These are typically given no more than five minutes on screen, as the appearance is an exercise in saying nothing.

The focus then widens. The possibility that the widespread availability of guns may be a problem is briefly considered. As one currently-viral facebook post puts it, “One failed attempt at a shoe bomb and we all take our shoes off at the airport. Thirty-one school shootings since Columbine and no change in our regulation of guns.”

Not entirely true, of course, at least in Canada. Our government has taken decisive action – responding to a badly-implemented gun registration law by cancelling the program altogether and shredding the information they spent millions to collect.

Politics is the art of the possible – you have to respond to moments of opportunity when they arise. So maybe it is not surprising that various groups seize upon tragedies like this to push their agendas.

One of the scripts, which scarcely needs dusting off as it is brought out so regularly, is the need for increased funding for mental health services. Given what I’m about to say, let me be clear: I do think that mental health services are poorly funded in most countries, and what funds are available are even more poorly managed. Let’s take that as a given.

The assumption, however, is that increased mental health funding will result in lower rates of school shootings and other mass killings. With better funding would come better screening of the population. Individuals at risk of perpetrating events such as these would be identified. Treatment would ensue, and tragic outcomes would be averted. The rate of mass killings would decline.

All of this is possible. But I am not aware of any evidence that any of these assumptions is true. If you survey mental health clinicians, many believe these ideas, and they may well be right. Certainly there is little reluctance for anyone to express these beliefs in the media.

What we seldom hear is the converse opinion, which is also held by many people.

Imagine a world in which the funding for mental health programs is doubled or trebled.  My own belief is that this would not have any significant impact on the incidence of mass killings.

That may not be a popular idea, and so I suppose I should have strong evidence to back it up. I don’t. In the absence of clear evidence, it is merely an opinion – just as the belief that an army of clinicians could reduce mass killing is an opinion.

I’m not alone in holding this idea, and others have doubtless thought it through better than I have. But here’s my reasoning, such as it is:

With better funding would come better screening of the population. Cadres of new clinicians would have to go looking for clients, and we would institute mass screening of students, disaffected employees, and other citizens. This seems both unlikely and undesirable. I strongly doubt that improved mental health funding would result in more community screening, and if it did there would be an outcry.

Individuals at risk of perpetrating events such as these would be identified. The common refrain after events like these is “he was such a nice, quiet boy; I would never have imagined him doing something like this.” This from friends, family, and neighbours. Later it often emerges that there were signs from facebook postings or other online activity. Mental health workers have no magical ability to divine dangerousness, and have access to considerably less information about the people they see than the person’s own family. We might be able to identify people at somewhat higher risk of perpetrating mass murder by looking at specific variables – like the fact that someone happens to be male – but the resulting number of false positives would make this pointless.

Treatment would ensue. Mental health treatment is almost always voluntary. Most perpetrators do not seem to have seen themselves as mentally ill and so would probably not seek out or cooperate with treatment. The very hostility of their acts suggests a belief that the problem lies outside themselves and that they are justified in their rage. As well, the perpetrators usually seem to be middle-class individuals who would already have access to the mental health system if they chose to seek it out (there may be data on this point, and perhaps data that contradict this observation, but mass shooting does not usually seem to be a crime of the impoverished).

Tragic outcomes would be averted. If treatment was provided, the risk of offending would be eliminated, or at least much lowered. This might be true, though there is scant evidence in support. One argument against is the number of instances in which perpetrators (such as the accused in the Aurora theater shooting) were already in some form of treatment. There is a problem with this, obviously: deeply troubled young men are more likely to be in treatment anyway, and perhaps treatment reduces their likelihood of offending without, unfortunately, eliminating it. But we would still need evidence to claim decisively that mental health services reduce risk at all.

So if we can’t troll through the population, if we can’t really identify risk very well, and we can’t control risk should it be found, it’s hard to see how increased mental health funding will eliminate school shootings.

A colleague of mine once observed that mental health clinicians are the ones who chase after the horse after the barn door has been left open. By this reasoning, we would be no more likely to reduce the incidence of shootings than by increasing the number of emergency trauma surgeons.

Why bother making this point? In times of tragedy, it’s always tempting to go for the easy answers. Let’s just increase mental health funding. And mental health clinicians, all too aware of the gaps in service, are reluctant to contradict anything that might result in a more comprehensive and well-funded system.

But this particular problem may not be caused by the lack of mental health care – not much, at any rate. The real culprits almost certainly lie elsewhere: the availability of guns, the aggrandizement of violence in media and its actual practice in the artificial world of video games, a cultural sense of entitlement and rage. And an obsession with celebrity causing some to seek it in the only way a young, talentless male can manage: by destroying the lives of others. A method that is based not on distortion but on an accurate perception of the consequences of amassing a high body count.

Inevitably, I can be criticized on the same grounds as anyone else who spouts off, sans information, in a public forum. What makes me think I know any more than anyone else? I don't. This is just one more of an avalanche of blog posts by people far removed from the circumstances. The irony isn't lost on me. But frustration makes me point, as others are doing now, at one of the many likely culprits. So let's lighten it up with a quiz question.

Quick, name these celebrities:

• The perpetrator of the Newtown tragedy.
• The Aurora theater killer.
• The Columbine boys.
• The Norwegian extremist who killed teens at an island campout.
• The Montreal Polytechnique shooter.

I won’t reveal the answers, because they have been elevated to the public consciousness more than enough.

But if you came up with any of their names, try Part 2: Name one, just one, of their victims.

Profession: Iatrogenic Fear of Emotion

Some fear is normal.

One of my interests in recent years has been the negative impacts of the mental health system. Although mental health services are intended to contribute toward mental health, unexamined assumptions often seem to result in unintended harm. A friend and colleague of mine once remarked that he felt the majority of his time was spent trying to undo the damage of previous mental health care.

In my last post I touched on one aspect of this issue – the belief amongst practitioners that having the best of intentions for our clients will contribute to better outcome.

It certainly does help to hold the best interests of our clients uppermost in mind. But we can’t use our intentions as a substitute for knowledge, training, an assessment of what the client really wants to achieve, or good old uncomfortable self-doubt. We should always be questioning what we are doing, rather than resting easy in the confidence that our good intentions will inevitably lead in a positive direction.

I remember a student at one point debating the relative merits of psychotherapy and pharmacotherapy and remarking “well, at least we don’t do any harm.” The assumption was that at worst psychotherapy will be ineffective, a null outcome, and holds the potential for significant gain. It took some effort to convince him that in fact psychotherapy, practiced incompetently, can be extremely damaging – I gave him some of the examples mentioned last week.

Treating Emotions by Making Them Scary

Clients often come to therapy because they are experiencing troubling emotional states: anxiety, depression, anger, guilt, shame, or what have you. They don’t like the discomfort (or the horror) and this is absolutely understandable.

In therapy we work with the person to develop strategies that will enable them to reduce the magnitude of these difficult emotions.  By gently venturing into the situations that frighten us, for example, we can reduce our fear in the long run. By pushing past the inertia that depression brings and reclaiming our lives, we can reduce depressive despair. And eventually what was a disabling state becomes a manageable and even helpful guide.

But there can be an unintentional message of therapy for difficult emotional states: “These are dangerous feelings and you are quite right to be frightened of them – we need to do all we can to stamp them out.”

On one level, this makes sense. Example: depression, left unchecked, may lead to job loss, relationship breakdown, and suicidality.

What is the impact, though, of labeling an emotional state as a threat – or as a disease? This removes any of the existing signal value the emotion may have. It no longer means “Hmm, working 16 hours a day at a job I hate may not be sustainable” and becomes “I’m mentally ill.” 

Further, by frantically steering the client away from the emotion, we emphasize that it is something to be feared. If fear is already the problem then we have just added to it.

An extreme example of this comes from recent announcements about the upcoming revision to the diagnostic manual used by most of North America, the DSM. DSM5 will remove an exclusion to depression diagnosis for individuals who are recently bereaved.

It’s easy to see the reasoning for this. Bereavement is an extreme emotional state that can be temporarily disabling in intensity. There is no requirement that the origin of a state be mysterious in order to be classed as a disorder. For example, we can diagnose caffeine intoxication even though it’s obvious why a person is experiencing it: they just drank a gallon of coffee. A bereaved person recently lost someone profoundly important to them, and as a result they are now experiencing symptoms very similar to clinical depression. No surprise.

But this makes normal grief a mental disorder. Rather than being a difficult, challenging, but normal-range life experience, grief becomes a mental illness.  And paradoxically, the failure to experience any grief when a person close to us dies is a non-disorder. The abnormal is normal, and the normal has been classed as abnormal – and therefore subject to intervention.

Do We Create the Problems We Treat?

The concern is that by labeling an increasing number of normal human experiences as mental disorders, or by declaring them treatable, we are narrowing the range of human emotion that our society deems acceptable.  The former highway of feeling that we may have been permitted begins to resemble a narrow sidewalk, or a tightrope.  Anyone outside these shrinking limits becomes disordered and in need of a pill or a Viennese couch.

I now frequently see people who have become discouraged during a difficult part of their lives. They have been told that the discouragement or lethargy they experience is a disorder, a disease of the mind. In some cases, they have been informed that they have a brain disease that will need medical treatment for the rest of their lives. Apart from being simply incorrect, this well-intentioned diagnosis can be profoundly damaging.

The mental health industry’s claim to ever-greater tracts of normal emotional territory seems likely to have effects beyond the consulting room. The taint leaks into the surrounding culture. When we leap forward and lecture on the emotional damage caused by natural disasters and improper diet, when we help create magazine quizzes (“Could YOU have social phobia?”), when we participate in the proliferation of diagnostic categories, we may be damaging the society we live in.

Although well-intentioned, our efforts may create more misery than they relieve.

Process: The Fallacy of Good Intentions

A few weeks ago I presented a workshop on some of the technical skills involved in conducting effective psychotherapy. One of the participants, a student in a training program, commented “I guess the most important thing is that your heart is in the right place.”

Nice idea, bad results.

I cautioned her that having a desire to help on the one hand, and actually helping on the other, are two separate things. But I realized afterwards that I was holding back in an effort to play nice. The truth is, I think that a belief in the power of good intentions is one of the most damaging elements of our field.

Going beyond what the student said, or perhaps intended, the idea seems to be that if one has a pure heart and wishes for the best interests of a client, then one will naturally choose actions and strategies that will lead in that direction. At minimum, the clinician will do no harm.

The type of therapy I do often involves working with a person to discover their underlying assumptions (about themselves, others, the world) for problematic ideas that might be leading them astray. The same idea can be applied to governments, cultures, and professions, including the profession of psychotherapy.

The belief in the benevolence of good intentions is a good example. It distorts by encouraging us to believe in what we are doing, and to lower our guard against potential harm. It relaxes the need for research evidence. After all, if our intent is positive, then we should at least do some good, shouldn’t we?

The field of mental health has unquestionably damaged a great many people over its history. The examples we hear about most are those in which the practitioner used the client for his or her own ends: sexual gratification, financial gain, a sense of power, or what have you.

But imagine that we could take all of the negative impacts that we have had and sort them into two categories: the product of bad intentions, and the product of good intentions. I believe that the damages caused by good intentions would easily dwarf those caused by evil or self-involved clinicians. Entire areas of practice would fall into the nice-try-bad-outcome category. Some examples:

• The widespread use of lobotomy in past decades. It was believed that simply inserting a metal paddle into the prefrontal cortex and destroying it would result in better mental health. “I know it’s part of the brain, but we don’t really need it.” Egas Moniz was awarded the Nobel Prize for medicine in 1949 for this effort.

• The near-universal implementation of critical incident stress debriefing, which appears to increase rather than decrease the likelihood of lasting post-traumatic effects. I took this training myself and felt a vague regret at never having the chance to use it - until I saw the data coming out on the effects.

• The practice of putting individuals suffering subclinical depression on antidepressant medication, despite the absence of research evidence supporting the efficacy of these medications for this level of symptomatology (a recent study in British Columbia revealed that 20% of women were written a prescription for an antidepressant in one year alone).

• The practice of so-called “reparative therapy” to turn gay men and lesbians into heterosexuals. This never seemed to work, damaged the lives of those so treated, and resulted in the leaders of the exgay organizations regularly coming out and denouncing their former efforts. (This practice was no more “effective,” it seems, than the former strategies of psychiatric hospitalization, electroconvulsive therapy, or, yes, lobotomy.) Yes, I know: This is more the bad-goal-worse-outcome sort of practice, but the practitioners' belief in the goals of their work helps it to fit.

• The therapeutic fad of the 1980s and 1990s of taking vague symptoms of distress as indicators that clients had been abused by satanic cults. At its height, practitioners claimed (sans evidence) that thousands of people were being killed each year in these rituals. They weren’t, but thousands upon thousands of clients were being damaged by well-intentioned but gullible practitioners who jumped on the bandwagon.

It would be easy to go on. In every case, the intention was benevolent – cure people, prevent dysfunction, control illness, or secure a better seat in heaven. The means were promoted by well-intentioned people who genuinely believed that they were doing something positive. The results were disastrous. One can only wonder whether if the people involved believed just a little less in themselves and in the power of their good intentions, perhaps fewer people’s lives would have been ruined.

I’d like to see the belief in good intentions dragged out into the open – preferably in training programs – and subjected to the critical scrutiny it deserves. Like other distorted beliefs – and like vampires – the strong light of day might cause it to wither away.

And good riddance.

The Cost of Wilderness Rescue - And Wilderness Fear

Equipped, but not overly so.

On Sunday I went on the year's inaugural snowshoe in the mountains north of Vancouver.

Winter is now upon us, and with it all of winter’s traditions.

• Someone will go hiking just before a blizzard hits, and will be found next spring. 

• Young (and almost invariably male) skiers will sneak into the backcountry and need to be rescued. 

• Snowmobilers will attempt highmarking and predictably trigger avalanches from which they will need to be dug out.

And down in the cities, people will snort at their foolishness and repeat the refrain that those who go out of safe boundaries ill-equipped should be billed the cost of their rescue.

I will be one of the ones rolling my eyes at some of the stories (“Safety equipment? Umm, we had a cell phone…”), sorely tempted to join the chorus. Bill them! Leave them! Serves them right! Give them a Darwin Award!

Hopefully I will hold back.

Canada is a more urbanized country even than the USA. Increasingly, Canadians live within their cities and seldom venture out. Those who do are often regarded strangely. “Bit of a loner. Likes the bush.” And those who go out there, beyond the television screens and the cell reception, seem to be doing something both pointless and foolish. If something goes wrong, well, why is that my problem?

But we seldom hear calls for a cessation of funding to rescue people from other mishaps – many of which are caused by our own actions.

Snowshoeing, downtown Vancouver in background.

• The person caught in a motor vehicle accident while driving to the supermarket 4 blocks from home.

• The person who suffers a heart attack after eating at fast food restaurants daily for many years.

• The person who dutifully works 16 hours a day at their desk job, striving to pay off the mortgage on the family home, and lapses finally into depression.

• The person who remains safely ensconced at home, watching others live fictionalized lives on television, and trips on an unpopped kernel of corn.

Stand at the entrance to an Emergency Room at any major hospital and interview each person who arrives. We can find a way to blame almost anyone for their misfortune. “Well if you knew she had strep throat, why did you kiss her?”

So why the smirks and calls for repayment from those who run into trouble in the backcountry? Perhaps it is because the social norms are changing. Wilderness travel, backpacking, backcountry skiing are becoming marginalized rather than valued. It’s easy to criticize those other people, not like me, who get into trouble doing things I would never do.

We have begun to fear our country. Once a much-loved asset, the wilderness is now a threat.  It’s a dangerous place that only a few outdoor-expedition geniuses are qualified to handle.

But perhaps the greatest threat to Canada – and the world – is the assault on our natural environment. How can we expect people to care for something they have never seen, something they fear, something that seems to want to kill them? For people to appreciate what we have, they must see it and walk through it. Then they might be more inclined to think before destroying it.

We are in no danger of bankrupting ourselves looking for young people who venture beyond their abilities. We are in much greater danger of irrevocably damaging our environment – and our physical and mental health – by ignoring the consequences of our lifestyles on the world and on ourselves.

Sure we need better training. We need to remind people that the mountains are not equipped with safety rails nor are they designed by Disney. We should be encouraging more wilderness education as a standard part of our school system.

But we don’t need to encourage even more fear of the natural world than our urban dwellers already have.

Practice: Marketing your business

How do therapists get clients? There are thousands of therapists out there. How do they decide on you?

Here's an article on the subject from the New York Times:

http://www.nytimes.com/2012/11/25/magazine/psychotherapys-image-problem-pushes-some-therapists-to-become-brands.html?pagewanted=1&_r=2&smid=go-share&

Resources: The Core Program in PDF

Sometimes the mind-numbingly obvious escapes us. Or at least it does me.

For years we have been selling Changeways Clinic therapy protocols from our website at www.changeways.com in hard copy format. This necessitates printing the manuals, creating the enclosed CD-ROMs with the reproduction masters for clients, then sitting and listening to CBC while stuffing the insert sleeves with the disks.

But, frustratingly, Paypal in Canada (unlike the US) only allows you to define one shipping rate for a product, so we can't use it to sell copies to folks from the UK, Australia, and elsewhere. They've had to use our print-copy order form and fax it to us. And the shipping to locations overseas is exorbitant.

And how do we produce the hard copies? By uploading the pdf files to our local printer.

"So," anyone with two neurons that still fire would ask, "Why not make the electronic pdfs available for purchase via email?" No shipping cost, no inventory to keep, and near-instant delivery of the product.

Well, don't ask me why this was never done before. My only defence is that other projects have sometimes gotten in the way of sensible and convenient upgrades to our website.

At any rate, we now have the Core Program protocol for the group treatment of depression available in pdf format. As a matter of fact, we have it in three formats:

• USLetter, Imperial Spelling. Canada uses the same standard paper size as the USA, so our original manuals are all USLetter, but in the Imperial Spelling (or at least the Mid-Atlantic version used in Canada) that our American cousins find so quaint. Behaviour, centre, colour, etc.

• USLetter, US Spelling. We get a lot of orders from the USA, so we went thru the documents at nite at our center (okay, only "center" is actually correct) and altered the spelling to standard US.

• A4 Paper, Imperial Spelling. Most of the world uses the A4 paper format, taller and narrower than USLetter, so we reformatted our Imperial version for A4. Imperial purists in the UK may object that we don't go all the way (our program is still a program, not a programme), but we're mostly there.

All versions are the same price and are emailed out the moment our Workshops and Products Coordinator comes to the office, which means within a max of 2 business days.

For $55.00 Canadian, the purchaser gets the full pdf of:

Core Program Participant Manual for clients, 94 pages
Core Program Clinician's Guide providing therapists with instruction on how to run the program, 220 pages.

And:

Quick Reference. Large font note-form reminder pages to help therapists keep themselves on track during each session. 42 pages.
Goal Setting Form for Clients.
Goal Setting Form for Clinicians.
Group Attendance Form.
Thought Challenging Form, Portrait Style.
Thought Challenging Form, Landscape Style.
Participant Feedback Form.
Therapist Feedback Form.
Clinician's Guide Feedback Form.

And:

Permission to reproduce all materials designed for clients, for as many of the purchaser's own clients as they wish. The Clinician's Guide can also be reproduced for other clinicians working from the same agency at the same address.

For $20, purchasers can also get a copy of an audio MP3 with eight hours of lecture content to supplement the Participant Manual. These talks can be reproduced for the purchaser's own clients as a way of supplementing the group, bringing clients up to speed when they miss a session, and as an instructional aid when using the materials with clients on an individual basis.

Umm, fine, but what is the Core Program?


The Changeways Core Program is a group therapy protocol for the treatment of depression. In a practical and psychoeducational format, it assists clients in the development of self-care and depression management skills. It is the most widely used depression group protocol in Canada.

The delivery format is flexible, but it is most frequently used as a once-per-week eight-to-ten session closed-ended outpatient group. Some private practitioners and inpatient hospital settings have adapted it as an open-ended format.

What does the Core Program cover?

The emphasis is on providing specific, research-based strategies for dealing with life problems. Behavioural activation is a core of the program. Clients are invited to set and review personal goals in every session of the group, "stirring in" other concepts and strategies as they are presented. The contents include:

• Identifying problems and transforming them into goals for change.
• Behavioural activation strategies:  Breaking goals down into manageable steps.
• Learning about stress.
• The signs, symptoms, and causes of depression.
• The effects of diet, exercise, sleep habits, caffeine, and drugs and alcohol.
• The importance of building recreation into one's daily life.
• Strategies for developing a more satisfying social life.
• An introduction to assertiveness skills.
• Identifying negative and self-defeating thought patterns.
• Learning to think in a more balanced and realistic manner.
• Preventing mood problems from becoming unmanageable.

Get the workshop PLUS the manuals!

We offer a 12-hour online workshop on the Core Program for mental health professionals. Just visit psychologysalon.teachable.com for a listing of all of our courses. You can also view the course preview below. 

Social Anxiety: Find the Landmine!

Especially during exposure exercises.

Almost everyone has social anxiety. Take us to a formal reception where we don’t know anyone, and watch the heart rate rise. Put us on a stage with a set of notes and a hostile audience and see what happens.

Like most fears, social anxiety exists on a continuum. Beyond a certain point the fear becomes disabling – preventing the person from reaching his or her deeply-held goals and wishes.

The treatment for just about any unhelpful fear is the same: approach the feared situation, tolerate the anxiety, and stay there long enough for the anxiety to fade (in a process we officiously call habituation), replaced (usually) by boredom.

To this we usually add an examination of the belief system. This can be complicated, but usually boils down to “What is it that you imagine happening, how likely is that, really, and how bad would it be if it did?” From there the thing can become enormously complicated, but that’s the nub.

Effective treatment depends on our ability to identify the real fear. If we believe that our agoraphobic client who avoids shopping malls fears shopping, then we might create an exposure task involving a browse through the Amazon website. And we would almost certainly get nowhere, because agoraphobia is not at all a phobia of the agora, nor is it a fear of shopping. It is usually a fear of specific internal bodily sensations developing in situations from which it might be difficult to escape.

One problem is that the person himself or herself often isn’t too clear about what they fear. Ask a socially anxious client what they are afraid of, and you will often hear “job interviews, public speaking, social events.” If you ask what it is about these situations that seems fearful, you can hit a wall. “I just don’t like them; never have.”

Left unexplored, this would pull therapists to suggest exposure tasks like attending small social events and working upward. And this might be helpful. But often we will get no improvement, and clients will report a feeling of relief when the tasks are over that does not translate into a reduced anticipatory fear. They feel like they have traversed a minefield without being blown up, but this does not reduce the fear of minefields in the least.

Why not? Because the client was never afraid of minefields. They were afraid of mines.

We have to figure out the nature of the landmines that the client fears within social situations. And they often have difficulty telling us.

That’s an awfully long leadup to a tiresomely obvious tip, I’m realizing. My own anxiety about appearing foolish in this forum is waking up and looking furtively around. Which, of course, makes posting it a perfect exposure exercise.

See enough people with serious social anxiety, and you know darned well what they’re afraid of. But things go better if you get it from them, and every so often you are surprised. A simple question will usually crack open the cognitive shell:

“Imagine we were to make you utterly invisible, then send you to a party – exactly the type that you say you are most afraid of. No one can see you. How would you feel?”

The usual answer is that the person would feel much better, plagued only by a residual anxiety that the invisibility spell might wear off. This tells the therapist – and the self-surprised client – that they aren’t afraid of parties after all. They are afraid of something that might happen at parties – something that depends on them being visible to others.

“I’m afraid of doing something stupid – like dropping food on the floor or having my fly down, or not being able to think of anything to say.”

But none of this is true either.

“Have any of those things ever happened when you were alone? How did you feel?”

“Oh, fine.”

“So it depends on you doing something that seems foolish to you, and them seeing it. What would happen if they did?”

And here we get the reality. Our socially anxious person isn’t afraid of social situations at all, nor of being awkward. They’re afraid of other people seeing and possibly negatively evaluating their performance. Consequently, simply exposing the client to a social situation is unlikely to produce impressive results – unless we expose them to what they really fear: making errors visibly in front of others and risking – or, even better – receiving negative evaluations.

The further down the anxiety chain that we can structure our exposure exercises, the better. Not just going to the party, but doing something awkward. Not just doing something awkward, but doing it so someone notices. Not just having them notice, but letting them develop a negative evaluation of us. And surviving that.

It’s not always possible to go all the way. Most of us are unwilling to do things that will make our bosses even more convinced that we are idiots, no matter how therapeutic the task might be. But usually we can come up with something that gets us far enough to dissolve some of the irrational fear. Look as though you are about to hand the boss a report, then confess an error – “Oh, I haven’t included the appendix at the end – I’ll add that and get this to you later.”

Most effective social anxiety exposure work involves making at least some deliberate errors while entering moderately feared situations. Deliberateness, of course, is critical. “I seem to make errors constantly and the fear never gets any better.” It is the voluntary performance of social errors that helps. Stumble on the way into the cinema. Spill your coffee at Starbucks. Mis-button your coat before going into a store. Make your hand shake as you hand over money. Confess your anxiety before commencing your talk.

Know the true nature of the landmine you fear. Then jump on it.

PsychologySalon Talks for 2013 at VPL

We have now confirmed the 2013 schedule for PsychologySalon talks for the public at Vancouver Public Library.

All talks start at 7 pm and are held in the Alice MacKay Room of the Main Downtown Branch of the Library (below concourse level).

Tuesday March 26 - Out of the Blue: The Nature and Treatment of Major Depression. With Dr Randy Paterson.

Tuesday May 28 - Superhero Psychology 101: Understanding the Appeal.  With Dr Lindsey Thomas.

Tuesday September 24 - The Vision Project: Setting - and Reaching - Your Life Goals.  With Dr Randy Paterson.

Tuesday November 26 - How to be Miserable: 12 Brilliantly Effective Strategies.  With Dr Randy Paterson.

Mark your calendar!  Hope you can make it.

Reviews: Why "The Secret" Gives Me Hives

Wish hard enough and the trees will plant themselves.

One of the advantages of writing a blog is that it gives you an outlet for the occasional spleen-venting.  One of my pet peeves of the past few years has been the popularity (now waning, thankfully) of The Secret, a set of ideas presented in a DVD and book by Rhonda Byrne, formerly an Australian reality television show producer.  If what follows seems a bit, well, cranky:  that’s an accurate impression of how I sometimes feel.

What is The Secret?

First, The (supposed) Secret is no secret.  It’s based on the idea that when you concentrate on something happening in the near future, you influence the actual probability of that event happening. Adherents also call this the “Law of Attraction” – which actually isn’t a law, just an odd idea.

So if you concentrate with all your heart on that BMW you might just get it, whereas if you expect things to go badly, they will. And this is independently of the influence of your thoughts over your behaviour – so it’s not just that if you want to be wealthy you’ll work hard and define your goals. The universe will respond to your desires and give you what you anticipate. Apparently.

The actual exercises invoked to shift the universe one’s way vary from proponent to proponent.  Reading them, it’s hard to escape the sense (despite denials) that the core idea in each case is “wishing will make it so.”

The fact that it isn’t a secret actually isn’t a big deal for me.  It’s not uncommon to say that the secret of investing is to buy undervalued stocks and sell overvalued ones, that the secret of goal setting is to identify distant goals then focus on the immediate steps toward them, that the secret to a long relationship is to overcome the natural temptation to guess what your partner is thinking and instead communicate. None of these ideas is guarded with lock and key; they are available to anyone. So if something that has sold millions of copies cannot reasonably be called a “secret,” who cares?

So what’s my problem?

Well, where do I start? I imagine it's obvious that I don't actually believe this idea. It doesn't fit my experience, it doesn't appear to fit the lives of my clients or friends, and it doesn't make logical sense when you follow it through to its conclusions. But fine: Lots of people believe things that I don't, and I don't blog about them.

Partly, The Secret doesn’t seem to have worked well for its developers. Look up the Wikipedia article on the subject, then the Wikis on the various people connected with the film. The few years since it was produced have not been kind to many of these people.

To be sure, informing people that “wishing will make it so” is an excellent way to make money, and the books and DVD have been estimated to have pulled in many millions.  But it would appear that the developers of the film and related products did not take care to envision future harmony amongst themselves.

It’s also not Eastern wisdom, despite frequent claims to the contrary. Anytime someone wants to get bogus credibility for an idea, they say it’s from an Eastern wisdom tradition. This is as silly as saying that it is from Northern or Southern wisdom, but in any case the Secret is a purely Western-based idea.

And: The Secret is portrayed as a selfish, consumeristic self-enrichment tool.  The film portrays case after case of people wishing for wealth, jewelry, clothes, cars – and never anything for the broader world. No one seems to hope for anything good to happen to anyone else, and it doesn’t seem to enter anyone’s head to envision a world without AIDS, global warming, hunger, or the American Republican party.

And then there’s OCD

I treat people who suffer from obsessive compulsive disorder. Many people with OCD have spontaneous intrusive unpleasant thoughts, like throwing the baby off the balcony, fondling the rear of the person ahead of them in line, a relative’s plane crashing in flames, or hepatitis germs spreading on the kitchen counter and infecting everyone in the house.

These thoughts are typically produced by the person’s attempt to suppress them: they try not to think of pink elephants and as a result are obsessed with pink elephants. And they often worry: What if my having the thought means it will come true, or somehow makes it come true?

The Secret is like pouring gasoline on this cognitive fire: If you envision your mother developing cancer, you might bring it about. This makes it more important for them to suppress such thoughts, which makes them all the more insistent. Not true and not helpful. Thanks, Rhonda.

And quantum nonsense

Adherents of the Law of Attraction also make frequent reference to the idea of “Quantum Healing.” There truly is something remarkable about this term, as uttering it serves as an off-switch for critical thought within much of our culture.

Richard Feinman famously said that if you think you understand quantum theory, you don’t understand quantum theory. Legions of nonphysicists nevertheless claim not only that they understand the theory, but also that they are able to make use of it (without the benefit of the physicists’ expensive colliders and other equipment) to change people’s lives.

The fact that quantum theory has little to do with self-improvement is no great impediment. Because so few people know anything significant about quantum theory, using the word “quantum” effectively shuts off debate and increases receptivity to whatever is said next. “Ah, this person has studied quantum mechanics, which is way beyond me; they must know what they’re talking about.”

Then there’s blaming the victim

I see other people whose lives have not gone well.  In fact, I have made it my life’s work to deal with negative outcomes.

In the negative, The Secret seems both false and unhelpful.

Worry does not appear to increase the likelihood of negative events happening – at least not directly.  A standard therapeutic exercise is to have a person list all of their worries over the past year or more. When they’ve finished the therapist then asks them to place a check mark beside everything that actually happened.

The point is to realize just how much of our time is spent envisioning negative futures that never arise. In fact, people often realize that the truly awful things that have happened to them are things that they never anticipated. We all have negative thoughts constantly that can surely make us miserable, but that do not produce reality in themselves.

I seem to have spent a great deal of my own life anticipating and envisioning possible catastrophes around every corner, but the disasters I envision never seem to come true. The stressful events that have happened have almost invariably been things I had never considered possible.

In the positive sense, The Secret also seems false and unhelpful.

Unrealistic positivity is as much a problem as negativity. Bankruptcy, excessive debt, and foreign wars are often the product of positive thinking. George W. Bush appears to have been a great positive thinker: we don’t need the help of other nations, we can cut taxes and increase expenditures and it will all work out, we can invade a country and expect to be greeted with open arms, the levees will hold even if we don’t fund their maintenance. The result was a profound weakening, possibly now irreversible, of the most powerful nation on earth. Mr Romney seems cuts from similar delusional cloth: We can spend more on the military, cut the taxes of the very rich, and the budget will be balanced.

At the level of the individual, positive envisioning can be destructive as well. “This time he won’t hit me.” “I can do the same thing as all those other times, but the result will now be better.” “Even though this person closely resembles my previous abusive partners, they’ll be different.” “This business idea is sure to make me a fortune.” “I won’t get addicted.” “I won’t get caught.” “I can still drive with four beers, and the traffic is light anyway.”

And inappropriate absolution.

The Secret absolves us of responsibility for one another.

The bad things that have happened to sub-Saharan Africa are not the product of colonialism, bad governance, western weapon sales, or misfortune; it is the result of the populations of these nations calling negativity upon themselves. The people who died in the Holocaust? They inadvertently brought it on themselves. The hungry, the poor, the ill? Not our problem, not our responsibility.

Is there any reality in The Secret?

Actually, I think there is. Envisioning what you want might help in two ways. First, the universe might magically rearrange itself to give it to you. I don’t believe that this happens, for reasons expressed above, but people can judge this one for themselves.

Second, clearly envisioning our goals may influence our behaviour in subtle ways to help us to achieve them. It is something of a cliché to say it, but we are unlikely to arrive at our destination unless we know where we hope to go.

Some of this is obvious. Knowing that I want to become fluent in French may encourage me to sign up for courses, spend time with French-speaking friends, and visit French-speaking countries – all of which may help transport me to my goal.

But there are subtle effects as well. Simply writing down one’s goals seems to make their achievement more likely. For many years I have made it a habit to sit down on my birthday and write down some goals for the year ahead. Often I have set the page aside and haven’t looked at it again for quite some time, only to discover it and realize that I have achieved much of which I had hoped to do. Look:  the hall closet really is cleaner, the bathtub has now been replaced, there is a new computer system for the clinic assistant.

“Aha” the proponents of the Secret will cry. “You’re criticizing the very principle that you are using!” I doubt it. I think that the act of formulating a direction, a trajectory, in my mind results in a fairly natural (as opposed to supernatural) selection of activities likely to take me in that direction. When I look at the goals I have actually achieved, it seldom seems like the universe has simply tossed a bone my way. I published a book because I wrote a proposal and sent it to a publisher. I got more fit because I made exercise a priority. I increased the number of trees in the orchard because I called the nursery and ordered some seedlings.

Things happened which were outside my control, surely. The nursery had the trees I wanted; the publisher liked my book idea. But I don’t need to invoke secret machinations of the universe to explain these events. Coincidences occur, people’s goals mesh, and some things work out. Many (actually most) of the things I envision (other books, other directions for the orchard, other lecture invitations) don’t materialize. With clients I often suggest one of my own life principles: Most things don’t work. That’s why we have to try a lot of things.

What we don’t need to do is sit on the couch, dreaming and waiting for the doorbell to ring.

Resources: Breathing Made Easy

Sometimes the most basic skills are the most useful as well.

One of the most common reasons that people seek help from therapists is that they experience unnecessary activation of the body’s stress response.

The stress response evolved in primitive environments where the best strategies to deal with perceived threats were to fight or run away. We developed the capacity to reprioritize the functioning of our bodies to give us more strength and speed.

Unfortunately, no benefit comes without its price. The stress response may make us faster sprinters, but it also disrupts digestion, impairs certain aspects of immune function, runs the risk of damaging the circulatory system, makes us less creative and socially fluent, and tempts us with hostile or fearful impulses that may not be helpful in the modern situations we face.

I’ve been training people in relaxation strategies for over 25 years. The research is clear that such strategies, practiced regularly, can be tremendously helpful. One of the most helpful techniques is diaphragmatic breathing. Here’s why:

• It’s readily learned (though it does take some practice).
• People gradually get faster and more effective at bringing their stress activation downward.
• It can be used on the spot in stress-triggering situations – no need to go out and find a yoga class or play your relaxation tape.
• It can be paired with other exercises to help overcome specific fears and triggers (like social anxieties, specific phobias, agoraphobia, and the memory triggers of PTSD).

I’m always tempted to race over diaphragmatic breathing training with clients, given that I know it so well and that I’m usually trying to cover a lot of ground in a session. But when I don’t take the time to introduce it slowly, it never works as well.

An Online Course

For years I’ve wanted to have a way of teaching clients diaphragmatic breathing that didn’t occupy quite so much of our limited clinical time together. I’ve also been convinced that most people, in therapy or not, can benefit from learning a good breathing exercise.

For the past few months, I’ve been working intermittently on this problem. Yesterday the result went live on the internet.

It’s a course on the education website udemy.com entitled Breathing Made Easy. It’s a series of 12 short talks that lead viewers through a training process culminating in four-stage breathing – an exercise that separates diaphragmatic from intercostal breathing and helps people slow and deepen their breathing, using bodily changes as cues to vary their pace.

There are also recommendations on cue-controlled relaxation: recognizing internal symptoms and external stressors and shifting them from signals to tense up to signals to breathe and relax. The intent is to help users develop a kind of homeostatic mechanism in which anxiety is welcomed (it isn’t dangerous, after all), permitted, and used as a cue to shift into deeper breathing.

The whole program takes about 90 minutes, and provides people with three dowloadable worksheets they can print and use to help them learn and apply the exercise. It may also be useful for clinicians wanting some tips on how to train their own clients in diaphragmatic breathing.

Offer for Readers

To introduce the program, I’ve created a Coupon Code that readers of psychologysalon.com can use to access the program for $8, which is almost 50% off the regular price of $15 (itself not a bad deal, I suspect). To access the program, simply go to

www.udemy.com/breathing-made-easy

and enter the redemption code “psychsalon” (all small letters, no quotation marks) where requested. Also feel free to pass the code along to friends, family members, colleagues, and clients.

Replies: The Goal of Therapy

Reader Sophia M has commented on the September 25 post on The Marshmallow Test. For our discussion, see that post.  In the course of our exchange she wrote this:

"There is the idea that the aim of psychotherapy is to help people overcome their neurotic unhappiness and to become ordinarily unhappy. How do you view that?"

I like the idea of turning the blog into as much of an exchange as possible, so I said I'd make my reply a new post. All readers: Take this as an encouragement to write questions, raise issues, and comment freely as part of this site.

Origins

A therapeutic pessimist?

The idea Sophia mentions comes from Freud, who once wrote "much has been gained if we succeed in turning your hysterical misery into common unhappiness." The remark has significant resonance and has lived on as one of his most oft-repeated quotes.

This remark is sometimes taken as an indicator of Freud's own pessimism about the utility of therapy. He seems to set the bar rather low in terms of his goals for psychoanalysis, perhaps sensing the weakness of his methods.

But I think this would be an attempt to take Freud out of context and use his words against him. Much of his work can be criticized for various reasons, but I think here he was trying to say something reasonable. And it may be even more relevant today.

The Function of Emotions

The emotions we experience seem to function as a kind of behavioural guidance system. They tell us what to do next. Fear tells us to get the heck out of here, anger tells us to attack, and happiness tells us to "do more of whatever you just did." Many of the impulses we get from our emotions are not very helpful, presumably because we live in a very different environment than the one in which they evolved.

From this we can see the shallowness of the idea that we should be happy 24 hours a day. First, we are simply not wired to experience unrelenting happiness. Second, the guidance function of emotion would be lost if we only experienced one thing. No one would buy a navigational system that could only say, over and over, "go left, go left, go left, go left."

The problem we see in our culture (and in therapists' consulting rooms) is that people often seem to be extremely prone to certain painful emotions and seldom get to experience the positive ones. The terms "hysterical" and "neurotic" have become pejorative since Freud's day, but essentially just mean (when applied to misery) unhappiness that proceeds not from the essential nature of our circumstances, but from our own minds.

For example, on any given day we might be perfectly safe and most of our needs might be satisfied, but we can still be horribly unhappy because a tendency of the mind causes us to focus only on the misery of an unhappy past, or the prospect of losing everything in an unhappy future. Or we might focus on certain elements of the present (a friend is displeased with me at the moment) and ignore the rest of the picture (I am employed, I have other friends who care for me, and I'm tasting a lovely bagel).

It is usually this misery that we are trying to work with in therapy.

Ordinary Unhappiness

Life is difficult, and it can be a bit odd to respond to all losses, illnesses, and tragedies with complete equanimity or manic cheerfulness. Recently there has been a controversy about a proposal for normal grief to be diagnosable as a depressive disorder in the upcoming DSM5 psychiatric guide (I wrote about it here). If one's beloved spouse dies, surely it would be more abnormal to be unaffected than to experience grief.

Life has routine disappointments, ranging from "this bagel's not as good as the last one" to "my child has been diagnosed with a life-threatening illness." We don't need to maximize our misery in response to these situations, but it is normal to feel disappointment, fear, sadness, grief, guilt, shame, and anxiety at least some of the time. I think this is what Freud was mainly talking about when he used the phrase "common unhappiness." Not a disorder, therefore not to be treated. Therapists can still have a role, but more one of a midwife to misery rather than a surgeon trying to excise it.

The field of Acceptance and Commitment Therapy (ACT) and a growing number of other clinicians have pointed out that the field of mental health may have inadvertently perpetuated the idea that uncomfortable emotions are bad or pathological. This removes their signal value - from "Ah, whenever I go into work I feel down - perhaps I need to think about a job change" to "Ah, whenever I go into work I feel down - clearly I have a biochemical imbalance that needs treatment." It is as though we have made a perfectly normal aspect of being human - say, having opposable thumbs - and redefined it as being a disorder. "Those aren't thumbs, they're tumours!"

I think Freud was also a bit of a pessimist about how happy most people could be, and if you look at the time he was practicing, this is not a big surprise. World War I, the Depression, the gathering clouds of World War II (he died in 1939) - cheerfulness would be a chore. Our own day seems much more comfortable, but perhaps this is only because we cannot see the future.

I think that therapy should most often focus on "unnecessarily and unhelpfully severe unhappiness" (to use a term that gets away from Freud's "hysterical misery").

But I also see room for Positive Psychology and its emphasis on optimal functioning and improvements in happiness and life satisfaction. Positive Psychology has a fair share of detractors ("Feel happy all day long and to hell with creating a better world") but any field can be dismissed if few enough brain cells and words are used ("Evolutionists are saying I'm descended from a monkey!").

The evidence suggests that indeed we can improve our life satisfaction, and that doing so is likely to make us more energetic and more capable of making a positive impact on the world. There are risks, certainly. We can become so focused on our own daily enjoyment that we ignore the contributions we can make to others. The whole exercise can become yet another element of our cultural narcissism. But depressive lethargy seldom promotes action or positive change; enthusiasm and realistic goals do a better job.

So: Can we get rid of everyday unhappiness? No, nor should we. It's useful and, coupled with careful thought, can help guide our lives. But we can work on the mix of happiness and unhappiness to become more capable of dealing with life's challenges.

Private Practice: The Work Journal

Moleskine - A good option.

Opening or operating a private therapy practice? You’re going to make mistakes. Lots of them. Plus, you’re going to have to do a lot of things that come up only occasionally – the instances being just far enough apart to allow you to forget all about how you did them last time. Things like:'

• Buying a web address.
• Setting up your wireless network.
• Rebooting a crashed computer from your spare boot disk.
• Dealing with a major unpaid bill.
• Reviewing your lease renewal.

One strategy is to keep your clinic manual up to date, and to create a new page for each task. The manual, after all, isn’t just for your assistant.  It’s for the future you.

Another is to have the private practice version of the lab journal.  Open it up, write the date, and make a diary entry on significant events in the adventures of a clinic manager. Avoid entering the names or identifying information of clients, because once the book is full you’ll want to label it with the dates (“Jan ’10 – Jun ’11”) and put it on a shelf for future references, rather than locking it away in a file cabinet.

“Wait, wait, wait,” you say. Wouldn’t the clinic guide idea make more sense? Entries by topic rather than by date, and all that? Every time you want to consult your past wisdom you’ll have to hunt for the right entry.

True. But if this system works for you, you’ll actually use it. And for almost everything you want to find, you’ll be able to track it down – particularly if you enter a title beside each date (“March 21 ’11:  Setting up credit card system”). If you perfectionistically insist on a topic-wise system that feels too cumbersome to use, you won’t keep it up for long anyway.

As well, you can feel free to use your work journal for items that wouldn’t make sense to put into the clinic manual. Prices of suites in nearby buildings. Work goals for the coming year. Problems for which you have not yet found a solution.

The work journal can be a bound collector of many of the random notes that otherwise will go astray and necessitate a file-by-file hunt through the clinic. “Where did I put my list of options for last year’s air-con system?”  You may have to do some page flipping, but you won’t have to tear the place apart.

*   *   *

Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple, available at bookstores and through Amazon here.

Cognitive Therapy: Do we ever REALLY get rid of our negative thinking?

Cognitive therapy targets our automatic, rapid-fire appraisals of situations, many of which operate outside awareness. Something happens, and we feel a reaction. A person in the bank lineup ahead of us reaches into his pocket, and we feel fear.

Here comes that "I'm going to drown!" thought again.

We may or may not be aware of thinking anything in particular about the event. But if we did not have any intervening thoughts (“Maybe he’s going for a gun”) it is difficult to explain the emotional reaction, or the fact that different observers have differing reactions.

We often discover that we distort reality a fair bit, based in large part on our past experiences. Our first partner was abusive, so we automatically view partners with deep suspicion. We were fired from an early job, and since then we have tended to overanalyze negative feedback for signs that we are about to be fired.

Much of cognitive work entails contemplating the situation and our reaction to it, and becoming aware of the process of appraisal that took place between the two. Then we can evaluate our reasoning and see whether there are any flaws in it, or whether we may have accurately assessed a part of the situation (“He really does hate me …”) but have missed other valuable information (“On the other hand, most people seem to like me”). We strive for a slow-fire reappraisal that is more fair, balanced, and useful than our automatic thinking.

But why bother?

The assumption is that by doing this we can achieve personal change. One change, obviously, is that we can finally stop torturing ourselves with these reconsidered situations. By discovering the truth about that breakup a year ago we can more readily set it aside and move on.

But we also want to appraise new situations with greater accuracy. We’d like to finally be able to go into our annual work evaluation without a sense of fatalistic dread. We’d like to go into the bank and not hit the dirt every time someone takes out their wallet.

By rethinking past events and rehearsing our more realistic thoughts when we find ourselves in new situations, we can weaken the old ideas. And, sure enough, some old catastrophic appraisals eventually vanish. We become able to fly without having any thoughts that the plane will crash. We can give a talk without worrying that someone will stand and call us incompetent frauds.

But does this always happen? Is this the only goal of cognitive work? What if we don’t reach it?

Our negative thinking frequently doesn’t evaporate as readily as we might like. The truth is, even with effective, competent, and diligent cognitive therapy, the negative thinking often continues to at least some degree. In fact, this is probably the most common outcome. We still think “I’m going to fail!” every time we go into an exam, “S/He’s abandoning me!” every time our spouse has an evening out with his or her buddies, “I’ll be fired!” when we discover a spelling mistake in an email we sent to the boss.

So was the cognitive work a waste of time? Not at all.

The other, less discussed outcome of cognitive work is a decreased identification with our negative thoughts. Initially we might think “They all hate me” when we go to social events. Over time, we recognize that thoughts like this come from experiences in our awkward adolescence, not our adult life, and that mostly people seem to quite like us.

The thoughts don’t entirely go away, but by knowing where they come from, or simply that they are usually “neural misfires”, we learn not to place too much trust in them. We drive to the party knowing that our brain will probably spout “They hate me” at some point, but we simply don’t care that much. It’s something the brain does, it doesn’t mean it's true. Likewise, though, we can’t assume that everyone loves us. We might acknowledge that we are not the greatest judge of what others think of us; our past has produced a systematic bias to anticipate rejection.

When describing this process of “disconnection,” I often use an example with which many can identify. You go the Customs desk and the thought occurs to you that you are smuggling something and are about to be caught, and you become anxious – even though you aren’t smuggling so much as a breath mint.

Over time you learn that this is simply something your brain does when you approach Customs desks, and you learn to ignore it. “Yup, I’ve got heroin, like always” you say to yourself, and roll your eyes. It no longer alarms you because you know it’s going to happen, and you know it’s a misfire. In effect, through awareness and mindfulness of our thoughts we install a buffer between our distortions and our reactions.

Both outcomes – cognitive change and this disconnection effect – occur in cognitive therapy, and both are valuable outcomes. The latter effect is as important as the former, and is at least as common if not more so.

Rather than remaking our craziness, then, the goal is often simply to recognize it, welcome it, allow it to speak, and be amused and interested by it. Self-knowledge rather than personal renovation.

Goal Setting: Temptation Versus Aspiration

How do we decide what to do next?

Up or down?

When I have a break in my schedule, I often find myself asking, in effect, “What do I feel like doing?” In other words, I instinctively check my emotional motives. “What seems appealing right now?” 

We live in a culture that encourages this. “Follow your passion.” “If it feels good, do it.”

The problem is that on a lazy afternoon what many people feel like doing is switching on the television, aimlessly surfing the net, or reading the news. And this is just fine, especially if afterwards we think “That was great. I feel relaxed and refreshed now.”

The problem is, we often don’t. What feels appealing in the moment isn’t necessarily the thing that will be most enjoyable to be doing, or most satisfying to have done. Immediate appeal is often governed more by our laziness, our cognitive fuzziness, our indecisiveness, or our fear of failure than by our passions.

When we experience unpleasant emotional states the situation becomes worse. The emotions, taken together, are a behavioural guidance system, prompting us toward activities that, in the primitive environments in which they evolved, would be a good idea. If you’re afraid of it, run the other way. If you’re angry, attack. If you’re depressed, withdraw to recover.

In a modern environment, these emotional prompts – we might call them temptations – often point in the wrong direction.

Let’s take depression as an example. When depressed, many people feel an instinctive urge to stay home, preferably in bed, accomplishing little and avoiding social contact. But if they give in to these temptations, they tend only to feel worse. And if we take a nondepressed person and make them behave in this way, their mood seems to drop.

Whether we are depressed or not, many of us notice that our temptations are poor guides. The upcoming exam makes me anxious, so I’ll do anything to avoid studying. The work project feels overwhelming, so I’ll dither around on trivia. Cleaning the house seems dull, so I’ll watch just one more YouTube cat video.

But what’s the alternative? Some people imagine that the only other possibility is to guide one’s behaviour based on the expectations of others. I’ll have to “behave responsibly” or “conform.” And sure enough, sometimes we have to do this. The government declares that our taxes are due on a certain date, so we’d best get them done.

A more valuable alternative to temptation is aspiration. What would we like our ideal self to be doing?
If I was the person I strive to be, what would I do next? This is somewhat akin to the idea of “What would (insert religious figure here) do?” but is just a bit more differentiated: “What would a slightly more inspiring or effective version of ME do?” Perhaps Moses would ascend a mountain looking for tablets, but an ideal version of me would clean out that bathroom cabinet.

One of the most difficult aspects of overcoming depression is learning to over-ride the temptations that it whispers in your ear. “Just lie here another few minutes, close those curtains, unplug that phone, cancel that social event, switch on that TV.” The whispering can get so loud that it’s difficult to think of alternatives. “If I didn’t do that, I can’t think of anything else I feel like doing – and I don’t know what I should do apart from that.”

The strategy, and it always feels quite artificial to use it, is to imagine a nondepressed and somewhat more energetic version of yourself and ask what they would be doing. This usually points the way forward. Sometimes they would be doing something that is obviously out of reach. “They’d be training for the marathon.” But if they were starting from our present position, maybe they’d get dressed and walk to the store.

If we’re not depressed, it’s slightly easier. I’d be writing my next blog post. I’d be starting a load of laundry. I’d be replying to my friend’s email.

Once we know the answer, however, the temptation is to run a check for emotional appeal. “Hmm. Laundry. Nope, doesn’t seem like fun.” The right course won’t usually feel instinctively right or appealing. It doesn’t become tempting just by thinking of it. We’ll have to tolerate the flat, colourless drudgery of putting things in the washing machine. And gradually our emotions will begin to shift to a more active, satisfying state. We'll have less in our in-basket, a longer list of accomplishments, and our leisure time in the hammock will be spent relaxing rather than cringing at the things we are avoiding.

Online Course

Want more behavioral strategies for working with inertia and low mood? PsychologySalon has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.

Resources: The Marshmallow Test

Sometimes a web video can be a great prescription for clients, and can illustrate a principle that would otherwise remain vague and overly intellectual.

The adult marshmallow?

In the 1960’s Walter Mischel, a psychologist at Stanford, conducted his famous marshmallow study on the ability to delay gratification. Children were brought into a room, given a marshmallow on a plate, and told that they were free to eat it or wait until the experimenter returned, at which point they would be given two. Predictably, some children held out and others didn’t.

Test subjects were followed up years later. Successful delayers were found to be rated by parents as more competent, to have higher SAT scores, and to meet other markers of life success more often than nondelayers. Some evidence has linked delayers to having greater activity in the prefrontal cortex, an area of the brain associated with the inhibition of emotional impulse (to grossly oversimplify, the part of the brain responsible for “I want to but I won’t”).

The question, of course, is whether the test simply reveals an inborn trait or capacity, or whether the ability to delay gratification can be trained. The evidence here is scantier, but it seems likely that children can be taught to over-ride at least some of their temptations. Providing children with regular chores, for example, seems to give children useful practice at inhibition (“I really want to play, but I’ll make my bed first and then go”).

Inhibition has a bad name lately. We’re supposed to “go with the flow” (presumably, the flow of other’s example, or of our own temptations) or “follow our passion” (only do it if you really want to). It’s widely believed in our culture that success at difficult tasks is a product of innate passion and talent rather than self-discipline.

Yet even in creative fields such as art, writing, and composing, discipline appears to be as important as ability. Indeed, if the 10,000 Hour Rule (a rule-of-thumb principle which states that expertise in most fields is accrued by extended practice, not primarily by talent) is correct, then discipline may be more important than native ability.

The route out of many psychological difficulties similarly involves the capacity to over-ride impulses. Most anxiety-related conditions bring with them an intense desire to avoid. Treatment (particularly exposure-based therapies) typically involves recognizing the desire to avoid but over-riding and approaching instead. Depression brings a desire for withdrawal and isolation; recovery generally involves pushing oneself outward bit by bit. Virtually all addiction problems involve giving in to gradually accumulating desire; recovery is to a great extent about learning to over-ride. Parenting, coping with long-term relationships, achieving life goals, getting through school: at some level almost every concern involves coping with and often resisting momentary temptation.

How can we introduce a discussion of this idea with clients? Ideally we would want to do so in a fun and preferably entertaining way that makes the issue a humanity-wide one (“we all find this difficult”) rather than an individualistic (“I’m just bad and undisciplined”) manner.

One way is to discuss the Marshmallow Test in session, then to invite clients to go and view some videos of the test on YouTube. Here’s a reasonable one that gives some of the background theory as well:

http://www.youtube.com/watch?v=6EjJsPylEOY

Here’s a parody that transposes adult actors for children, suggesting that as adults the principle also applies:

http://www.youtube.com/watch?v=jQvBrEEYS20

Or just suggest your client do a search on The Marshmallow Test. They'll find it.

Problem: I don’t like marshmallows.

Neither do I. You could fill my office with them and there’d be the same number an hour later. But imagine that we update the test with something else:

• Chocolate covered almonds.
• Google News.
• Beer.
• Chips.
• Cigarettes.
• Inappropriate sex partners.
• Internet pornography.
• Online gambling.

You’ll know your client well enough to come up with something they might find difficult to resist.

Then what?

Clients often feel quite judgmental of themselves for having difficulties, and may exhibit a knee-jerk tendency to do so in response to learning of the Marshmallow Test. “Look, I don’t have the self-control that that four-year-old has!”

This, of course, is not our point. None of us has perfect self-control, and accumulated habits have greater degrees of temptation associated with them, often overwhelming our abilities to inhibit impulses. Gaining control will involve developing the habit and “exercising the muscle” of self-control in a particular area where we have difficulty.

So the next thing to do is to self-disclose. What’s a variation on the Marshmallow Test that you would fail, and what did you do about it?

Once upon a time, one of mine was computer solitaire. I’d have a few moments and think I’d pass them with a game, then an hour later I’d “wake up” having played perhaps a dozen. In this case my solution was stimulus control: I reduced the availability of the game by deleting it from my computer.

That may not sound much like learning to resist eating marshmallows – it’s more like solving the problem by not having any marshmallows around. Good. It’s often useful to reveal our own frailties. (Eventually, by the way, I stopped deleting it from new computers and, despite this, no longer play any computer games. Except on iPad. Damn you, Angry Birds.)

Then invite the client to contemplate whether they have any “marshmallows” in their own life. Frame it as a Marshmallow Test. “So if I gave you a bottle of Jack Daniels and told you that if you brought it back next week with the seal unbroken I’d give you a second bottle, that might be difficult?”

At this point we can begin working on strategy – even making reference to the ones the children use in the videos. Getting involved in something else, looking away, staring at the marshmallow to build resolve – whatever might be helpful in dealing with the current concern.

Online Course

Want some more behavioral strategies for working with inertia, self-discipline, and low mood? PsychologySalon has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For this and other courses, visit psychologysalon.teachable.com. 

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. 

Resources: The Core Program for Depression in Arabic

A few weeks ago I posted the announcement that the Changeways Core Program was available in Farsi. Today I'm happy to add that we are also making it available in Arabic.  

Like the Farsi edition, this one is being made available free of charge to appropriate healthcare professionals.

Please forgive the repetition, but I'd like to reprise much of what I said for the Farsi launch:

Background

Changeways Clinic began its life at UBC Hospital in Vancouver as a post-hospitalization group therapy program for clients suffering from major depression. We developed The Core Program, a cognitive behavioural therapy protocol for running these groups. This includes a manual for clients and another for therapists running the program.

This program was remarkably successful, and we have updated the program repeatedly to incorporate client and clinician feedback and new research. (We call the current version the "3rd Edition" but the first few versions weren't numbered - it's probably actually the 6th Edition.) The program is in use across Canada, and has been implemented in the USA, the United Kingdom, Hong Kong, and Australia as well.

The problem, of course, is that not everyone is able to read the English language manual. Canada is a land of newcomers, and some would benefit more from having the materials in their own language. But  translations are notoriously expensive, and so we have been restricted in our ability to provide multilingual editions.

The Arabic Project

Sharareh Haji Ghorbankhani and Hevin Kurdi worked together to create the translation.  Sharareh  has offered the program in the Greater Vancouver area in English and has also worked with the Arabic speaking population. The translation is an immense project, running to 74 pages.  

The manual is not simply a word for word translation, but also a cultural translation, expressing the concepts in a way that is designed to be most accessible to Arabic-speaking populations. 

Distribution

The original intent was to create an edition to accompany groups based on the program that were being offered for the Arabic-speaking community in Vancouver.

Like Goli Shifteh, who worked on the Farsi manual, Sharareh soon saw that the resource could be used for Arabic-speaking populations anywhere in the world. Consequently, it would be nice to make it more widely available. The question is how.

The decision we arrived at is to make the Arabic Participant Manual available free of charge to universities, physicians, and mental health professionals in a pdf format. This is also what we decided for the Farsi edition.

One option was to simply post the pdf on the Changeways Clinic website, but we wanted to try to get the manual into the hands of responsible trained professionals. Consequently, we've decided to offer the manual upon email request.

To get a copy

Simply email us at products (at) changeways.com. State your profession, country, and a brief reason for wishing a copy of the program, and we will reply with pdf versions of the client manual and related forms for your use and for reproduction for your own clients.

Once you have the manual, you may make as many copies for as many of your own clients as you wish. We do not require that your service be free of charge or covered by a government-funded health program. Many users of the Core Program are in private practice.

For more information on the translations, visit www.changeways.com - specifically the translation page here.

What if I don't speak (or read) Arabic?

The translation includes many of the graphics from the English-language version, and a few bilingual bits. If you have an English-language copy of the manual, you should be able to tell what you are handing to the client. We imagine that many users of the translation will be English-speaking clinicians already familiar with the Core Program, who wish to provide a translated version for their Arabic-speaking clients.

The fine print 

The Clinician Guide for the program has not been translated, because it is considerably longer than the Participant Manual and translating it would have been an enormous job. This English-language guide is available from our offices as well, but regrettably we do have to charge for it. We have created an electronic pdf version available upon request. This allows us to supply it at lower cost than the hard-copy version. If you don't have a copy, simply inquire about this when you write us.

The pdf translation (and any documents purchased or received from Changeways Clinic) is provided specifically to the professional requesting it. It may not be forwarded on to others without the written permission of Changeways Clinic, nor posted in any way on the internet.

Many thanks to the team of Sharareh Haji Ghorbankhani and Hevin Kurdi for the many hours of work they spent on this project. It is their wish that the program be made available as widely as possible for the benefit of the greatest number of people.