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Tuesday 25 September 2012

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:

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

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

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. 

Tuesday 18 September 2012

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:


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. 


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) 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 - 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. 

Tuesday 11 September 2012

Resources: The Crisp Question

“Who am I?”
Quentin Crisp and graduate student

That’s a question asked recurrently in therapy. By teenagers struggling to define themselves. By 20-somethings trying to find their path in the world. By midlifers who sense that life has somehow gone astray. By people in long-term relationships, wondering how much of them is really dictated by their partner, or adopted via some never-discussed negotiation. A central part of the question is the distinction between elements of the self that come from within, and elements constructed as part of a socially acceptable act.

Part of a therapist’s job is to hand the client sharp knives with which to dissect their concerns and experiences; ways of turning random observations into genuine insight. These knives often come in the form of questions, metaphors, and stories.

When questions of identity and one’s future course come up, I have returned again and again to a question posed by one of the most insightful and interesting people I have met or whose books I have read: Quentin Crisp.

Crisp was a flamboyantly gay Englishman employed for much of his life as a model for government art schools in Britain – a profession that provided the title of his autobiography and the subsequent film: The Naked Civil Servant (in which he was played by John Hurt).

He survived the Blitz in World War II and the distinctly disapproving social environment of midcentury London and in his early 70s abruptly moved to New York City, where he knew next to no one. Over the next two decades he became a fixture of the city, appearing repeatedly on David Letterman, performing on stage (especially in his one-man show An Evening With Quentin Crisp) and in the odd film (for example, as Elizabeth I in Orlando), and writing a dozen books about his life and philosophy. He is the subject of a well-known song by Sting (An Englishman in New York). He died in 1999 at the age of 90, about to open a run of his show in his native England.

Crisp is known for his eccentricity, his blue-mauve hair, and his Wilde-like epigrams. Some examples of the latter:

  • Fashion is what you adopt when you don’t know who you are.
  • In an expanding universe, time is on the side of the outcast. Those who once inhabited the suburbs of human contempt find that without changing their address they eventually live in the metropolis.
  • It’s no good running a pig farm for thirty years while saying, “Really, I was meant to be a ballet dancer.” By then, pigs will be your style.
  • An autobiography is an obituary in serial form with the last instalment missing.
  • Euphemisms are unpleasant truths wearing diplomatic cologne.
  • The very purpose of existence is to reconcile the glowing opinion we have of ourselves with the appalling things that other people think of us.
  • Never get involved with someone who wants to change you.

I met Crisp in the mid-1980s.  One of my very few “brushes with fame” stories is that I briefly appear, unnamed, in one of his later books. Behind the makeup and hair dye was an astute intelligence and a determined adherence to a rigourously individualistic perspective on life. His views and insights are legion, and some have found their way into my clinical work.

Crisp believed that his question is the critical one for a human attempting to define an identity. I think it easily beats Camus's “Should I commit suicide today?” Here it is:

If there were no applause and no criticism, who would you be?

Crisp’s question is a classic of counterfactual thinking. It invites us to imagine a world in which nothing we do can possibly attract the love and approval of others, and nothing can trigger their displeasure. In this imaginary world, what might govern our behaviour? Motivation would have to come from within, and be produced by our own interest, rather than our desire to impress or escape disapproval.

It’s tempting to imagine that the answers would reveal an essential psychopathy. Perhaps we would rob banks, kill our enemies, and neglect all of our relationships. But none of these tend to come up in people’s answers. Instead, separating out the obscuring muck of our desire to impress others seems to lead to a greater clarity for most. “I would quit law school.” “I’d end this relationship.” “I’d take up improv as a hobby.” “I’d take a year off.” “I’d get rid of this huge house and the mortgage that goes with it.”

Notice what Crisp doesn’t say. Once you’ve figured out what you would do on his imaginary planet, he doesn’t order you to act on your insight as though you lived there. His question is designed to clarify your options, not to prescribe one over the others. The truth is, we live in a world of applause and criticism, and at least some of our behaviour will always be governed by the hope and fear they create.

But knowing why we do things enables us to make our choices more consciously. I can know that I am choosing accountancy to pacify my parents and no longer have to pretend to myself that I have an intrinsic interest in the field. I can see that going to the office party is my effort to avoid the boss’s disapproval; I do not need to feel guilty for not enjoying it more.

Crisp wrote that the one thing that most people have that is truly theirs is their individuality, and it is the one thing that many people most want to be rid of. His was an extreme example of living as an expression of self - one that might be beyond many of us. But his thoughts and writing on the issue stand as a monument to the idea of separation/individuation. And his question has proven to be a useful tool for many of my clients.

Tuesday 4 September 2012

Process: Greeting the Client

The cliff over which students would throw me.

Although I’ve been a therapy supervisor for ages, I suspect that I would be a terrible training coordinator, hated by all. In Vietnam, some commanding officers were apparently so unpopular they were “inadvertently” tossed a grenade, a creative human resources solution known as “fragging.” I’d get the therapy equivalent from students, I’m sure. Spit in the coffee. Something.

Whereas much therapy training is done in broad strokes (“Be empathetic!”), my natural OCPD-ish style is to be behavioural and nit-pickingly prescriptive.

I once told a training coordinator I know that if I was doing a course on psychotherapy, I would probably spend an entire day on how to get the client from the waiting room. Not that I’m so great at it, mind you, just that I have (considered? irrational?) beliefs about how it should be done.

Today: One of my pet peeves. I hesitate to post about it because half of all therapists reading it will roll their eyes and say “That’s too obvious to comment on” and the other half will say “That’s too reductionistic for words.” Oh well.

So your client has arrived and is in the waiting room. Hopefully on time, you head out to greet him or her. (Just did a coin flip: It’s a man.) You have a good working relationship. He stands up and about 60% of the time (yes, I’ve counted: remember the OCPD?) he says something along the lines of “Hey, how are you?”

“How are you” is a social reflex, obviously, not an expression of deep curiosity, so rather than going into your bum knee and the mailing you received that morning from the tax bureau, you offer some version of the customary response. “I’m fine, thank you.” “Oh, I’m very well.” And so on.

And then there’s the moment that puts my teeth on edge. The clinician, ambling down the hall with the client, does the customary thing and returns the tennis ball. “And how are you doing?”

If I had a training class I’d set up the role play, lie in wait for the offending phrase, then jump to my feet, shout “Aha!” and begin the process of becoming despised.

Think about the situation: Perhaps your assistant is there, perhaps another clinician is lurking about, or perhaps the clinic has hidden corners where someone might be sitting out of the client’s view. It’s not as private a spot as the consulting room, a magical space where the rules of normal social interaction are suspended.

And out here in the socially conventional hallway, the client will issue the standard reply. “Oh, I’m good.” “Great.” “Fine, thanks.”

Then we’ll take another four steps into the room, close the door, and the client is faced with retracting their reply. “Umm, actually, not so great.” There’s the natural reluctance to launch into painful experience, plus a tiny drag on the process from having to contradict something they just said. The clinician has also put a small dent in the alliance by insensitively asking the client how he’s doing in a public space.

A student I was supervising raised the obvious question. “What should I do?” I suggested she waste time.

The client asks how you are as he’s getting up and getting his coat, umbrella, and notebook together. Relax and take your time with your reply. What’s the rush? Then make some other appropriate but inconsequential comment that will occupy the rest of the walk to the office. “Beautiful day out there.” “Looks like it’s started to rain.”

The client precedes you into the office, the door clicks shut behind you, and you’re in the different social space of the consulting room. Sit, pause, and then return the ball in a way that communicates your genuine interest, rather than social banter. “And how are you?” And the real work begins.

FYI: On October 18 2012 I’ll be presenting a day-long workshop called “Process Made Simpler: A Behavioural Guide to the Therapeutic Alliance” at the Holiday Inn Vancouver Centre. Registration info here. (I’ll also be offering it for Alberta Health Services in Calgary November 23.) And no, I won’t spend more than two minutes on getting the client from the waiting room. Promise.