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Wednesday 31 October 2012

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 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 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

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.

Tuesday 23 October 2012

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.


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.

Tuesday 16 October 2012

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.

Tuesday 9 October 2012

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.

Tuesday 2 October 2012

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.