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Monday 9 December 2013

The Black Dog of Depression

Sometimes it's possible to communicate a great deal in a few short minutes. In this video, produced by the WHO, the experience of depression is described using Winston Churchill's metaphor of the black dog.

Online Course

Is there an alternative to a medication-based approach to depression? If someone takes medication, is there more they can do in order to maximize the effect? Consider seeking the help of a qualified psychotherapist trained in cognitive behaviour therapy.

In addition, our clinic 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.

Tuesday 19 November 2013

Graduated Exposure in Flying Phobia

The usual way of treating fears and phobias is by graduated exposure. For a person afraid of dogs, we might do sequential exposure exercises like this:

  • Gazing at photo of happy dog
  • Gazing at photo of snarling dog
  • Repeated viewing of happy dog video on Youtube
  • Viewing friend’s placid dog in dog carrier 50 feet away
  • Viewing friend’s placid dog in carrier 10 feet away
  • Friend sits with leashed dog 10 feet away
  • Same, 5 feet away.
  • Friend sits with muzzled and leashed dog, place hand on dog’s back

… and so on.

The details vary depending on the specifics of the person’s fear, but the idea is the same: a stepwise approach of the feared object. Once we have a set of tasks, we look for big gaps in the difficulty level and then fill them in, by making an easy task harder or a harder one easier.

This is all very well, but how do you do it with flying phobia? Sure, we can look at photos of airplanes, visit airports, and sit at the ends of runways watching takeoffs and landings. But sooner or later the person has to go from observing aircraft to taking flights. Inevitably, that’s a big step. How do we make it a manageable one?

Answer: By a careful analysis of actual and possible safety behaviours. A safety behaviour is something that makes a feared situation more tolerable.

Someone with a fear of shopping malls, for example, might only go with a trusted friend, take antianxiety medication beforehand, study maps of the mall to find washrooms and escape routes, and carry water, tissues, and cell phone. We can take the same exposure exercise (say, shop for 30 minutes in the housewares department at Sears) and manipulate the difficulty level by altering the safety behaviours (take medication or not, go with someone or alone, carry cell phone or leave it in the car).

We can do the same thing with flights. Here are some common safety behaviours that nervous flyers use:

  • Sitting in certain rows, near front, back, or exits.
  • Sitting by a window or on the aisle.
  • Traveling with a trusted companion.
  • Taking anti-anxiety medication before the flight.
  • Having anti-anxiety medication in carry-on baggage.
  • Drinking alcohol before or during the flight.
  • Having puzzle book or other distractions.

It’s sometimes difficult to create an ideal desensitization hierarchy for flying phobia, because sufferers typically avoid flying frequently. But where circumstances permit, we can create exercises with a range of difficulty using the same basic experience.

Let’s imagine a nervous flyer in London with family in Paris – about an hour’s flight away. We could recommend that he make a point of taking frequent trips during his therapy. After the usual early items on the hierarchy (photos, videos, airport visits), it’s time for actual flights. Here is a set of flights based on an imagined set of his preferences:

  • Fly in the evening (easier) after a light dinner (drowsier), having taking a benzodiazepine tablet, sitting in aisle seat near the front of the plane (sooner to deplane; less visuals of a crowd of strangers) next to spouse (comforting and a distraction), equipped with water, tissues, mystery novel, and over-the-ear headphones.
  • Same, but with half a tablet.
  • Same, no tablet, bottle in carry-on.
  • Same, but seated midway to the back.
  • Same, but seated in the second to last row.
  • Same, but seated in middle seat, spouse on the aisle (still easy to push past if needed).
  • Seated on aisle, spouse directly across aisle.
  • Same, spouse seated directly behind.
  • Same, spouse seated 5 seats behind.
  • Same, but with earbuds, dull nonfiction book, no water.
  • Same, spouse not on board.

With the number of safety behaviours we’ve identified, it would be easy to come up with a dozen more options. We could then rate the difficulty of each, discard some of them as unnecessary, and get started.

The only real trick is defining the features that would make that first flight tolerable. This often involves stocking up on safety behaviours, which goes against the instincts of good behaviour therapists, whose main agenda is helping the client relinquish these behaviours. But in the case of flight phobia, allowing and even enhancing these behaviours temporarily may be what enables the client to get off the ground.

Tuesday 22 October 2013

How common is suicide in depression?

Every profession has its myths and memes: ideas for which there is little or no concrete evidence, but which are believed anyway. We like solidity. All too aware of how much we do not know, it’s comforting to be able to say, “Well I do know a few things for certain.”

In the field of mental health there is perhaps even more ambiguity than in most other professions, hence a stronger desire to seize on certain ideas and hold them tight.

One of these is the oft-repeated adage that 15% of people who experience a major depressive episode will eventually go on to end their lives. I have heard this notion – and seen it repeated in government mental health planning documents – more often than I can count.

One reason for its appeal is the urgency which it attaches to depression treatment. The way to get taken seriously in the healthcare system is to be treating a lethal illness. If we can underline the severity and lethality of a disorder, it is more likely to receive funding.

There is no question that depression treatment is underfunded and undersystematized in healthcare, both in Canada and in the United States. The World Health Organization has estimated that unipolar major depression accounts for more years lost to disability or premature death than any other single health concern in countries with developed market economies (WHO, 2008). More than heart disease, more than cancer.

My office faces a tower block in Vancouver constructed specifically for research into cancer. Good, I’m happy for that. But if anyone thinks that a new tower will soon go up devoted to depression, they’re dreaming.

So what about that 15% figure? Ask someone citing it where it comes from and they will not know. It is an old certainty, somehow established in the mental health consciousness.

There’s just one problem. Like many old certainties, it’s wrong.

Do the math. Take the reasonably well-established lifetime incidence of depression – about 10% in most surveys, though this rises to a high of 16.9% in the United States (Andrade et al, 2003). Look at the average age at onset and the remaining years of life expectancy, then calculate how many suicides you’d need each year to hit the 15% mark. Compare that with the actual annual suicide figures – something that most countries keep close track of.

The result is generally more suicides than we get from all causes in total. Even if every person who ended their life was diagnosed with major depressive disorder (something that is very much counter to the facts), we still do not have sufficient numbers of deaths. The 15% figure is impossible.

So where does this 15% figure come from?

Find references to it and sift backward in the literature and you arrive, most often, at Guze & Robins, 1970. This early meta-analysis (a statistical compilation of earlier studies) reviewed 17 studies and came up with the 15% figure. A later review upped the figure to 18.9% when additional studies were added (Goodwin & Jamison, 1990).

The classic debunking article in this area is Bostwick & Pankratz (2000), a slightly acid-tinged corrective which is difficult to read without sensing impatient rage and eye-rolling on the part of the authors. They point out a few little problems.

First, the studies looked at in these earlier meta-analyses were largely of previously hospitalized patients, not of the depressed population as a whole. People who are hospitalized generally have a more severe form of the illness, and often find their way to hospital precisely because there is a fear that they will end their lives – or have actually attempted to do so.

Second, the studies don’t actually look at how many people in their samples eventually committed suicide. They look at deaths in the few years after hospitalization (the highest-risk period), and calculate the percentage of these that were attributable to suicide. Of course, the majority of people did not die; they went on beyond the date of the study, presumably to pass on eventually from any of the diverse causes that will one day get us all.

This is a particularly groan-inducing distortion of the data. Try the same calculation for anyone else. If we look at deaths during teen years (a relative rarity), we discover that unintentional injury accounts for 48% of cases in the US (Minino, 2010). Imagine someone taking this figure and saying “The teen years are hugely dangerous: 48% of teenagers will die of injuries!” We’d smack them and send them back for remedial statistics classes. In mental health, we run out and repeat the insight endlessly.

Third, the studies in the early meta-analyses generally relied on definitions of depression that have since been broadened significantly. It’s much easier to get a diagnosis of depression today than in 1970, when the category was restricted to the most severe cases. Taking a statistic from those cases and blithely applying it to the depressed population of today is a glaring error.

As well, most of the studies blend unipolar and bipolar patients in their samples. Given that the rate of suicidality is likely to differ between these groups (with most estimates suggesting a higher rate for bipolar 1 disorder than for major depression), this muddies the result further.

These errors don’t tend to cancel each other out. Each of them, taken singly, is likely to lead to a gross overestimate of suicide rates among the depressed. Together, they make the resulting estimates almost worthless. And yet Bostwick and Pankratz cite textbook after textbook that not only accepts the figures, but applies them to the overall spectrum of people with mood disorders.

So what’s the real figure?

The short answer to this question is that we simply don’t know, but that the 15% figure is certainly wrong.

Bostwick and Pankratz struggle with the limitations of the data, but suggest an estimate of 8.6% for those who had been hospitalized specifically for suicidality.

When the analysis is of patients hospitalized for affective disorders, whether or not they experienced suicidality, the lifetime risk drops to 4.0%.

When studies with blended inpatient and outpatient populations are examined, the risk is estimated at 2.2%.

'But we still do not have an estimate for a good sample of never-hospitalized patients, nor for unipolar depression exclusively – both factors which would likely lower the risk estimate still further.

Simon and Von Korff (1998) looked at the incidence of suicide among members of a health plan in Washington state who had been diagnosed with depression. The risk of suicide varied from 224 per 100,000 person-years for people who had been treated with inpatient care, down to 0 per 100,000 for those treated by their primary physician without medications. (One cannot take from this that treatment is itself a risk factor, as severity generally dictates the level of treatment a person receives.) Compare these figures with the population-wide suicide rates in the United States - 12.0 per 100,000 - and Canada - 11.5.

It seems likely that people diagnosed with unipolar clinical depression but never hospitalized have a suicide risk that is elevated beyond the general population. There is, however, a surprising lack of evidence that can be brought to bear on the question of just how great this elevation really is. And a really picky reader could insist that we lack conclusive evidence that nonhospitalized unipolar depression raises the rate at all. (Personally I think that would be an overstatement, but someone could argue about the quality of the evidence quite effectively.)

Pending better estimates, it's hard to say what the real risks are for "garden-variety" clinical depression. But can we please, please stop citing the 15% figure? It isn’t correct, it never was, and it’s long past time to lay it to rest.


Andrade, L., et al. (2003). The epidemiology of major depressive episodes: Results from the International Consortium of Psychiatric Epidemiology (ICPE) surveys. International Journal of Methods in Psychiatric Research, 12, 3-21.

Bostwick, J. M. & Pankratz, V.S. (2000). Affective disorders and suicide risk: A reexamination. American Journal of Psychiatry, 157, 1925-1932.

Minino, A. M. (2010). Mortality among teenagers aged 12-19 years: United States, 1999-2000. NCHS Data Brief No. 37.

Simon, G.E., & Von Korff, M. (1998). Suicide mortality among patients treated for depression in an insured population. American J of Epidemiology, 147, 155-160.

WHO (2008). The global burden of disease: 2004 update. Geneva: World Health Organization.

Online Course

Is there an alternative to a medication-based approach to depression? If someone takes medication, is there more they can do in order to maximize the effect? Consider seeking the help of a qualified psychotherapist trained in cognitive behaviour therapy.

In addition, our clinic 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.

Tuesday 17 September 2013

PsychologySalon at VPL: Achieving Your Vision

Tuesday September 24 at 7 pm

Vancouver Public Library

Central Branch, Alice MacKay Room (Beneath the concourse)

What do you want, really?  What would you be doing if you took your life seriously?

Life is like a sailing trip.  You want to enjoy the ride, but every now and then you have to look at the map and put your hand on the tiller.

How do you do it?  We all set goals, but often we don’t reach them.  Or we feel overwhelmed by the amount of effort it will take to achieve them.

Fortunately, psychology has discovered principles that help. This PsychologySalon evening covers the strategy, the concepts, and the traps along the way.

Bring pen and paper!  We’ll invite you to consider your own life goals and discuss how to work toward them.

Sunday 15 September 2013

Stress Management: An Online Course on Diaphragmatic Breathing

For the past number of months we have been developing a 13-hour course for mental health professionals on how to treat depression in a group format.

This course has now launched and is available online, along with all of the documents required to run a group. Here’s the preview video:

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About the Protocol

The Core Program was developed at UBC Hospital in Vancouver Canada. Originally restricted to patients who had previously been hospitalized for major depressive disorder, it was designed to enhance self-care using cognitive behavioural principles.

The contents include:

  • An orientation to the CBT model, including an acceptance-based approach to difficult emotion.
  • Behavioural activation strategies, to be introduced in Session One and forming a major part of every session thereafter.
  • Psychoeducation about the nature of depression and the nature of stress.
  • Lifestyle management strategies, including specific recommendations in areas including diet, sleep hygiene, exercise, and enjoyable activity.
  • Cognitive material, including demonstrations of outside-awareness cognition, common forms of distorted thinking, and cognitive traps associated with both rising and falling moods.
  • Cognitive change strategies, including awareness, cognitive challenging, and a set of worry management strategies.
  • Social life enhancement, including strategies to build and deepen a social network, and core concepts regarding assertive communication.
  • Relapse prevention strategies including planning for future stressful periods, identifying risks for backsliding, and developing strategies for dealing with relapse should it occur.

Growth of the Program 

Our mandate was to implement the program on-site, then enable other mental health agencies to offer it in their own communities. The plan was to have it operating in three other communities in British Columbia. Once it had been instituted in over 50 communities we began to lose count.

The two-day training program has now been offered in communities across Canada and Australia, as well as in Hong Kong. Groups based on the model have been offered in China, the United Kingdom, the United States, and in South America.

The program has been translated into Arabic, Farsi, and Spanish, and an earlier edition is available in Chinese (traditional and simplified character sets).

Much of the material was also simplified and incorporated into a self-guided manual, The Antidepressant Skills Workbook, designed for family physicians to offer to patients newly diagnosed with depression.

Online Course Contents

The online course offers over 50 short lectures, most of them 5 to 20 minutes long to enable users to access the material they need in a brief and accessible format.

As well, a variety of ancillary documents are supplied in three different formats: US spelling on USLetter, Imperial spelling on USLetter (for Canada), and Imperial spelling on A4 (for other countries).

  • A complete set of slide handouts in both 3-per-page and 6-per-page format, totaling over 500 slides in all.
  • The complete 94-page Participant Manual designed to be distributed to clients – manual designed to work also as a set of separate handouts for use in individual therapy. This manual may be printed and reproduced for clients.
  • The 226-page Clinician’s Guide, with complete teaching instructions, in-session exercise ideas, and a Quick Reference composed of “cheat sheets” that the clinician can take into session as reminders.
  • A set of additional documents including goal-setting forms, cognitive challenging sheets, feedback forms, and an attendance form.
  • Free access to the Farsi, Arabic, and Spanish translations of the manual, and to the Antidepressant Skills Workbook (which is available to anyone online at no charge).

These materials (without the slide handouts) are also available for sale in digital ($55) or print ($90) format from the Changeways Store.

Group Rates

Group practices, employee assistance firms, HMOs, public agencies, and health regions may wish to purchase multiple spaces for their own employees. We are able to arrange discounts for groups of more than 5, with steadily greater discounts for groups of over 10, 50, 100, and 500 employees. To discuss the program or arrange a group discount, simply **contact us**.

The PsychologySalon Discount

Take 25% off the standard course fee simply for accessing the course through PsychologySalon.  The coupon code for the discount is “core2.” Here’s the link to the course.

Tuesday 10 September 2013

Therapy and Personal Change Tasks: Significant Versus Do-able

A completely unrelated photo from PsychSalon Farms:
Suspicious damage in the orchard, September 2013.

Sometimes people present for therapy saying that they don’t know where they want to go or what they want to achieve. Therapy becomes a process of generating and winnowing the possibilities.

But often people know exactly what they would like, only the task seems too immense. Find a career. Overcome my fear of heights. Deal with the past trauma. Leave home. Graduate.

Contemplating these enormous goals they feel the energy drain out of them like air from a balloon. Or they feel so overwhelmed that a sense of pointless futility overtakes them.

In therapy, we often try to identify the “Ultimate Goals” – essentially “What would you like, eventually?” And then we break these down to “Immediate Goals.” “What could you do this week that might take you toward one of those Ultimate Goals?”

And here we get stuck. The person can’t think of any Immediate Goals. Or they are dismissive of any ideas that come up. Or the therapist suggests a possibility only to sense the client pulling back and away.

And the culprit, 20 feet away,
anxiously watching the harvest.
In my experience, the most frequent problem is that the person is trying to arrive at an Immediate Goal that meets two criteria:

1. It is small enough that it feels achievable.
2. It is large enough to feel like a significant step.

People are looking for the middle path – the “sweet spot” between something so big it’s overwhelming and so small it feels trivial. They’re trying to find a goal that sits in the gap between the two.

The trouble is, usually there is no gap. No sweet spot. If a goal is big enough to seem significant, it’s too big to accomplish with the person’s existing amount of energy and motivation. If it’s small enough to accomplish, then it’s too small to seem like real progress. This trap often explains why the person has felt stuck – perhaps for months, perhaps years.

The way out is simple and unsatisfying. Pick something small enough to be achievable, knowing that it will seem insignificant and trivial. In other words, keep the first criterion above, and relinquish the second.

So a person who wants to overcome their fear of escalators might go to a shopping mall food court and sit near the escalator to watch it for an hour, forbidden from using it personally. A person who wants to become more social might take a newspaper to a coffee shop to read rather than sitting with it at home. Someone wishing to clean up a neglected house might focus only on the bathroom sink.

There is an emotional cost to doing this. Inevitably, a part of the person’s mind will snort with derision. “This is ridiculous, any idiot should be able to do this. This isn’t getting anything important done, it’s just reminding me of how incapable I am. It’s too small, and I’ll never get to my bigger goal at this rate. And frankly my therapist who is suggesting this is an idiot too.”

This happens sufficiently often that we can propose it as a rule. If we are on the right track, an early goal in personal change should feel trivial, insignificant, foolish, and unsatisfying. If it feels challenging, we’ve chosen something too big.

Ultimate Goals often feel questionable. Will I ever have a partner? Will I really graduate? Will I truly feel comfortable in crowds?

Good Immediate Goals, however, are those that feel completely achievable. “Of course I can step outside my front door for five minutes.” “Yes, I can leave home without unplugging the coffee grinder.” “Okay, I can vacuum the front hall.”

But for a person who has felt stuck, any goal that seems achievable will also seem faintly idiotic. Rather than fighting this sense of idiocy, we can mark it and treasure it.

Idiocy isn’t a barrier. It’s the way out of the trap.

Online Course

Behavioral activation is a major component of the cognitive behavioral treatment of depression. If you are depressed, consider seeking the help of a qualified psychotherapist trained in cognitive behaviour therapy.

In addition, our clinic 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.

Wednesday 28 August 2013

British Columbia: Yoho National Park

This week I’ve regressed to the traditional “What I did for my summer holidays” theme, as I suspect everyone has had more than their share of psychology.

Yoho (Cree for ‘awe,’ so essentially “Awesome National Park”) is located in eastern British Columbia, bordering Alberta’s more famous Banff National Park. It’s smaller as well, at 1313 square km (relative to Banff’s 6641 sq km) and easy to miss as you drive through.

Great engineering maybe, but the nature is better.

Yoho is perhaps most famous for its least impressive sight, the spiral tunnels. When the Canadian Pacific railway was built in the late 1800s, the designers opted for Kicking Horse Pass, which has a sharp steep slope that initially required a 4.5% grade. This wiped out the first train to attempt it, and eventually they constructed a pair of tunnels that entered Mount Stephen, looped inside the mountain, and emerged higher up. A great engineering feat, but the “tah dah” watching trains go through the tunnels is actually not so astonishing.

Emerald Lake
Yoho is great to drive through. For one thing, if you’re going east it means you survived the worst stretch of the Trans Canada Highway between Golden and the park (they’re trying to do something about this, but they have a long way to go).

The real attractions, though, are off the highway. One of the best, I understand, is the Lake O’Hara  hiking area. This takes more organization than I could muster driving back from an Alberta family wedding, so I didn’t see it. You can hike the 11km access road to the area, or you can advance-book a public bus that drives you in, allowing you to hike directly from there, camp at the small campground, or stay at the luxury lodge there. The daily quota for the bus is 42 people to ensure the area is not over-run. Maybe next year.

This year we stayed in the tiny (200 people or so) former rail town of Field, home of the park’s visitor centre. Every house there seems to be a B&B or backpacker lodge. We booked the Canadian Rockies Inn.

Let’s stop there for a moment. Imagine what something with that grand name might look like. Towers? A Fairmont Chateau like the Banff Springs? Actually, it’s a brick split-level ranch-style house that used to serve as the town’s RCMP station and has only three huge rooms presided over by Luc the proprietor, who takes time to give copious advice on what to do, where to hike, and anything else you want to know about the park. (I’d stay there again in a minute.)

British Columbia towns can sometimes be a dead zone for food, but Field has a great restaurant, Truffle Pigs, that rivals anything Vancouver has to offer. Even if you’re just driving through, this is enough to make Field a destination stop. And it’s half the price it would be in any city.

So if you’re too disorganized to have pre-booked the O’Hara bus and too lazy to walk 11 km to the trailhead, what do you do?

Wapta Falls, Kicking Horse River
Wapta Falls is a short (4.6km return) flat hike near the western border of the park to a 30m drop in the Kicking Horse River. Easy and a nice payoff for small energy investment.

Emerald Lake Lodge
Emerald Lake, near Field, has a beautiful bring-your-wallet lodge composed of duplex cabins on a peninsula jutting into a stereotypically turquoise lake. There are restaurants, a 5.2 km circuit trail of the lake, and canoe rentals for a ridiculously Canadian experience. We rented one for an hour, which is about all you need.

Then there’s Takakkaw Falls. Yoho Valley Road, just east of Field, leads upward in a fairly civilized way to a set of very steep, narrow switchbacks, beyond which is a great drive through a mountain valley to the falls and the trailhead for the Iceline, which was our destination.

When we got to the falls there were full-size tour buses in the parking area. How did they possibly turn to get up the switchbacks? (Driving a standard-sized vehicle I had to reverse at one point to get around one of the bends.)

The chilling answer: They didn’t. Buses and other large vehicles drive up to the first switchback, then have to reverse up the hill to the next switchback, then forward to the next. Coming down the hill they do the same thing, but backwards. I have no ambition to experience this personally.

Not for the faint hearted.
The falls are worth seeing, a 254 meter free-fall drop down a rock cliff. Visitors can walk almost to the base, where the falls are more like rain.

The Iceline Trail is billed as one of the best hikes in the Canadian Rockies. We got up above the treeline following the trail from the Whiskey Jack Hostel close to the Takakkaw Falls area. Then, inevitably, a lightning storm came up and we retreated back from the exposed top. Next time for sure.

Yoho may be smaller than Banff, but it gets much less press and so is much less of a tourist circus than Banff and Lake Louise (both great places, but packed for much of the summer). My impression was of only a few hundred visitors within the park while we were there during primetime summer holiday season. For example, we saw only two people (I think) on the Iceline trail while we were on it.

I’ll be back.

Takakkaw Falls from Iceline Trail

Monday 12 August 2013

Fall 2013: The Professional Training Lineup in Vancouver

Time for an update on the Continuing Education workshops that Changeways Clinic will be offering this fall in Vancouver.

What if you're not located in Vancouver?

Well, come visit us and make some CE a part of the trip. Or check out our workshop guide here and arrange to have a program in your own city or region.

September 11-12

The Changeways Core Program: Evidence-Based Group Treatment for Depression

The Changeways Core Program is the most widely-used group depression treatment protocol in Canada, and has been implemented in Australia, China, the United States, and Great Britain. Chinese, Farsi, Arabic, and Spanish editions are also available.

Designed from a cognitive-behavioural and psychoeducational perspective, this evidence-based program is designed for adults coping with depression or adjusting to difficult life experiences.

The two-day training workshop provides all the materials necessary for professional therapists to offer this program - in a group format, or as an adjunct to individual therapy. The program is approved for 13 CE credits from the Canadian Psychological Association.

For our workshop calendar and online registration: Click here.
For a downloadable pdf describing the program: Click here.

October 25, 2013

Process Made Simpler: A Behavioural Guide to the Therapeutic Alliance

"Be empathetic," they say. "Be warm. Build up an effective working alliance."

But we seldom hear exactly HOW these mysterious tasks are to be accomplished. The so-called non-specific factors in therapy are acknowledged to account for the lion's share of variability in psychotherapy outcome, but they are seldom made explicit.

Whether one adopts a therapy model believed to work entirely through the alliance, or a technique-focussed model such as cognitive behaviour therapy, an effective working relationship between clinician and client is a prerequisite for change. This workshop presents specific, behavioural practices designed to maximize therapeutic progress.  Good for 6.5 CE credits (Changeways Clinic is an accredited CE supplier with the Canadian Psychological Association).

For our workshop calendar and online registration: Click here.
For a downloadable pdf describing the program: Click here.

November 29, 2013

Private Practice Made Simple: Creating and Sustaining a Successful Business

Therapists routinely say it.  “I was never trained how to run a business.”

We were taught assessment strategy, how to conduct therapy, and when to refer - but not how to perform many of the central activities involved in running a private practice.  So we stumble through, gradually picking up ideas and skills as we go along, and about the time we’re planning our retirement we begin to think we understand.

But running a practice doesn’t have to be difficult.  Many of the skills can be communicated and learned relatively easily.  This program covers a wide variety of strategies to make your practice more successful, more effective, and more fun.  Good for 6.5 CE credits (Changeways Clinic is an accredited CE supplier with the Canadian Psychological Association).

For our workshop calendar and online registration: Click here.
For a downloadable pdf describing the program: Click here.

*   *   *

That's it? Well no, there are some other programs going on, but others are hosted by particular agencies or organizations for their own staff. These are the ones available for mental health professionals to sign up for.

We hope to see you this fall.

Tuesday 6 August 2013

The Therapeutic Alliance: A Benefit or a Liability?

When talking about self-help or internet-based approaches to psychological therapy or self-management, people routinely point out a problem with such therapist-absent approaches: The demonstrated value of the therapeutic alliance.

The alliance is a general term for the complex relationship between therapist and client, composed of mutual understanding, empathy, an agreement on the goals and methods of change, and so on. Studies routinely show that the quality of the alliance is a stronger predictor of therapeutic change than is the modality of psychotherapy being delivered.

If this is the case, then self-care focused strategies have a real problem. How can there be a genuine alliance if there is no real relationship with the clinician? We might sense that the author of a self-help book or the teacher in an online course is a nice person, but clearly they have no real relationship with the user.

If the potent factor in therapy is the relationship, and we have a therapy with no relationship, how could the therapy be effective? In nutritional terms, it would be missing the crucial vitamin.

Arguments like this presume that the effect of the alliance is, in a sense, additive. Sure, there may be some useful information in a less personal modality like a self-help guide, but the relationship adds something important.

Could the relevance of the relationship be subtractive, instead?

In order to find a relation between alliance quality and outcome, there has to be variability in the alliance. Some therapist-client pairs have to have a better alliance, others a worse one.

We have been presuming that the good alliance adds something extra to whatever is delivered in therapy. What if this is not true? What if, instead, a bad relationship subtracts from the impact of what is delivered? In other words, what if the alliance looks important not because a good alliance is so great, but because a bad one fouls things up so badly?

If the alliance is only subtractive (which I suspect is unlikely), then it would actually be better to have a form of therapy with no alliance at all. A self-help book, a therapy guide, an online lecture-format course, all of which have no off-putting relationship factors, would be the ideal form of therapy.

I raise the issue because of the profound effects clients sometimes report from purely receptive therapy efforts – like reading self-help books. Even my own: I often get notes of appreciation from readers of The Assertiveness Workbook, saying how much it has helped them in their lives. It would be nice to take these accolades as evidence of my abilities as a therapist. “Look how much they benefitted just from reading something I wrote – imagine what they’d get from actually meeting with me.”

It’s a nice thought, but glosses over the obvious anxiety. Perhaps I expressed myself clearly in the book but would be less concise, less organized, and less effective in person. As well, readers of the book can imagine me as any kind of teacher they like. In person they might discover that they don’t like my way of speaking, the shape of my nose, or my obnoxious habit of interrupting. Perhaps I am literally a better therapist on paper than I am in person.

I suspect this is often true. How often have we met our therapeutic gurus and been disappointed with their narcissism, or imprecision, or sloppy technique? Reading their words we can see and understand their points, reflect on how the ideas relate to our own lives, and calmly decide how to put changes into effect. Faced with a sneezing, ill-dressed, imperfect individual, the waters are sometimes only muddied.

And gurus or not, we have all seen individuals dispense undeniably good advice in such a ham-handed manner that no one in their right mind would accept it. Forget my name, act as though you don’t care, shout me down, and then tell me to exercise, be nice to myself, eat my vegetables, and make enjoyable activity a priority in my life. I’ll do the opposite just to spite you.

I imagine that in actuality the effect runs both ways. A good therapist can add to their content with a warm, inspiring nature, and a bad one can subtract from otherwise good material by alienating the client. But we only hear about the former, leading many to assume – almost certainly wrongly – that the alliance is crucial for people to get anything out of a psychological intervention. The evidence on therapist-absent approaches suggests otherwise.

Online Course

Can you perform therapy on yourself? Well, in a word, no. Psychotherapy is inherently an interaction between client and clinician. But you can use many self-care strategies on your own.

Our clinic 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.

Tuesday 23 July 2013

Video: Economic Inequality and Mental Health

We constantly hear how the solution to mental health problems in society is the provision of more mental health services. As a service provider myself I can see the appeal of this argument, but it has some problems.

It’s a bit like saying the way to have fewer house fires is to hire more firefighters. Mental health clinicians tend to arrive on the scene once the problem is already occurring. The determinants of societal mental health are typically factors other than the availability of treatment resources.

One such factor may be economic inequality. British researcher Richard Wilkinson has examined correlations between economic indicators and a variety of factors,  including the incidence of mental illness in societies.

Wilkinson finds no strong evidence for a link between the level of a nation’s average income and the frequency of mental illness, at least not among moderately developed nations. Increasing wealth does not seem associated with reduced mental illness, teenage births, obesity, or premature mortality.

But average income is only one possible economic measure. Another is the distribution of income among members of the population. Wilkinson looks at the gap in income between the top 20% and bottom 20% of earners. When he compares nations on this ratio, relationships begin to emerge.

Nations with greater differences tend to have poorer mental health, more teenage pregnancy, more obesity, more violence, and more premature death than nations with a more nearly equal income distribution. The benefits appear to accrue not just to the poor, but also to the (relatively) wealthy within more equal cultures.

The data are necessarily correlational, but they are quite suggestive nevertheless. They point to a likely conclusion: that the incidence of mental illness probably has less to do with the availability of mental health services than with broader aspects of societal and cultural design. Simply throwing more therapists or medications at a population is unlikely to accomplish a great deal.

Consider viewing Wilkinson’s 18-minute TED talk on the subject here:

Monday 1 July 2013

Resources: Breathing Made Easy

Happy Canada Day, everyone.

To mark the occasion we are releasing 250 free spaces in the online course Breathing Made Easy at  The normal price is $15.

The coupon code is canadaday.

There is a promo video at the link below that you can view to find out more about the course without signing up.

Here's the link:

The offer expires July 10, but if you join before that time you can continue to access the course for months afterward.

Wednesday 26 June 2013

Readings: Anxiety Disorders in The Anatomy of Melancholy

A Condensed Edition
I’ve been reading a bit from The Anatomy of Melancholy by Robert Burton (1577-1640), a contemporary of Shakespeare. He was a scholar at Oxford University and spent most of his life writing and rewriting the book, which is something of a dog’s breakfast of observations, anecdotes, humourous asides, and advice for those afflicted by melancholy - what today we would call depression.

Although much of the content is only tangentially related to the subject of depression, Burton reveals the motivation behind the work in his preface:

"I write of melancholy, by being busy to avoid melancholy. There is no greater cause of melancholy than idleness; no better cure than business."

Essentially it was a self-help book: by occupying himself with its creation, Burton strove to extricate himself from the depression he himself experienced.

One of his passages is striking for its descriptions of anxiety-related conditions, paralleling modern observations about the same conditions.  Here’s a passage, broken up by my interruptions:

Montanus [2nd century Christian convert who believed himself a prophet] speaks of one that durst not walk alone from home, for fear he should swoon or die. 

This sounds intriguingly like what today we would call agoraphobia. Directly translated as "fear of the agora (marketplace), in fact it is a fear of physical symptoms overtaking a person while they are away from home. It is the symptoms that are feared, not the marketplace.

A second fears every man he meets will rob him, quarrel with him, or kill him.

Paranoia perhaps – or hypervigilant stress?

A third dares not venture to walk alone, for fear he should meet the devil, a thief, be sick; fears all old women as witches, and every black dog or cat he sees suspecteth to be a devil, every person comes near him is malificiated [possessed, I think, though I may be mistaken], every creature, all intend to hurt him, seek his ruin; 

Supernatural fears seem to be somewhat less common these days, but may find their counterpart in fears of alien abduction, etc. And it is not uncommon to hear a fearful person describe strangers as malevolent beings ready to judge or harm them.

another dares not go over a bridge, come near a pool, rock, steep hill, lie in a chamber where cross beams are, for fear he be tempted to hang, drown, or precipitate [throw] himself. 

Now this is interesting! Burton, referencing Montanus, describes the thinking underlying most fear of heights, which is actually a fear of loss of impulse control. Notice that he is not saying the person wants to commit suicide: They fear throwing themselves off the height on impulse. They don't want to do it. But they worry they might anyway, on impulse.  This is exactly what people with fear of heights report - a sense of being drawn or tempted over the edge. In effect, they aren't afraid of heights, nor of falling (no one fears that the bridge might be unsound and about to collapse). They are afraid of jumping.

If he be in a silent auditory, as at a sermon, he is afraid he shall speak aloud at unawares, something indecent, unfit to be said. 

This is a fairly standard obsessive thought seen in many with OCD. I'll start to yell or say inappropriate things in a play, or at a concert, or in church. They don't generally do it, but there is a fear that they might.

If he be locked in a close room, he is afraid of being stifled [suffocated; unable to breathe properly] for want of air, 

This is the core fear underlying most cases of claustrophobia. It isn't the enclosure, usually, it is the sense of being unable to breathe - despite conscious knowledge that there is plenty of air and that suffocation is not a real danger.

and still carries biscuit, aquavitae, or some strong waters about him, for fear of deliquiums [essentially, fainting], or being sick; 

This describes the habit of many people who suffer panic attacks of carrying objects as safety aids. Common ones these days include cell phone, anti-anxiety medication, water bottle, and so on. many who suffer panic attacks of compulsively carrying safety aids (water, cell phone, antianxiety medication) in the event of an attack. Aqua vitae and strong waters, in Burton's case, essentially means booze. And indeed some folks with anxiety problems do this too.

or if he be in a throng, middle of a church, multitude, where he may not well get out, though he sit at ease, he is so misaffected. 

This describes a person who manages to suppress the desire to flee but only with great distress.

He will freely promise, undertake any business beforehand, but when it comes to be performed, he dare not adventure, but fears an infinite number of dangers, disasters, etc.

Every therapist has seen this: the person who fully understands the idea of facing one’s fears and selects a task that seems perfectly reasonable to them in the office, but never winds up being carried out.

*   *   *

Burton may not have managed to cure his own mood disorder, but he certainly had an understanding of many aspects of anxiety and its manifestations.

Thursday 20 June 2013

Thank God That's Over: Exodus International Closes Its Doors

This week the largest US sexual conversion therapy organization, Exodus International, apologized for its work and announced that it will be closing.

For over 40 years it has been the figurehead in the “ex-gay movement,” telling lesbians and gay men that with a combination of prayer, support, and therapy it is possible to change their sexual orientation and become heterosexual. Exodus not only provided direct services, it was the umbrella organization for like-minded groups throughout North America.

Perhaps you’ve seen their ads. Over the years, leaders of Exodus and related organizations were portrayed in large print ads in major American newspapers, putting faces to the claim that orientation change was real.

Then, with a regularity that became either tragic or comical, depending on one’s perspective, those portrayed in the ads would come out, admitting that they hadn’t changed at all and renouncing the organizations that they had helped to deceive thousands of well-meaning gay and straight people.

They often seemed surprised by the relatively chilly reception they received in the gay community. Having been prime agents of antigay sentiment for years, here they were, ready to join the club. What’s the problem, guys, what did I miss?

The humour fades when one considers the human lives affected by the ex-gay organizations. People would spend years attempting to become heterosexual,  earnestly lied to by leaders who would proclaim their own bogus changes. “It’s not the program, it’s you: If you tried hard enough, it’ll work!” If they were good enough Christians, they could be changed – so apparently they weren’t. Confusion, guilt, a sense of failure, and depression would often ensue.

At Changeways Clinic we have seen many men and women who have attended ex-gay organizations and have then spent years pulling their lives back together. It has been frustrating to be putting together what agencies elsewhere were merrily pulling apart, but the groups kept going and going.

Now Alan Chambers, the president of Exodus International, has issued a public apology for the damage caused by the organization, and has announced that it will be closing its doors.

Here’s an excellent interview with Chambers in The Atlantic.

Of course, the damage done won't evaporate with the close of the organization. And surely no one is naive enough to expect Exodus or the other groups to take responsibility for correcting that damage -  financially, morally, ethically, or in any other way.

For them it will be enough to issue an apology, look sorrowful, then move on with something new. As even the Atlantic article's title says: "Let's Do Something Different."

I have an even better idea. Just stop. You've done enough.

Wednesday 12 June 2013

Intermission: Time for a Break

So it's been over two years of psychology - more than enough for anyone. This week let's take a break and do something else.

One of the joys of travel is discovering signs, menu items, and misphrasings that provide a welcome jolt. And one of the cardinal rules of travel is that you never point out the problem to anyone who might correct it. Like a pristine campground, your job is to leave it as is for others to enjoy.

Of course, you don't always have to leave home for these. Here are just a few ...
I've always loved this Australian realty firm. I'll take a dozen.

A good Cambodian Buddhist recommendation.

Vancouver. Just the other day I was planning a party
to celebrate the blandness of daily life. Ultimately I went with another tile,
one that exclaimed the tedium of meaningless existence.

So much easier than leashing the tail and dragging him everywhere.

A reminder of the importance of branding. No waiting!

A great anticonsumerist reminder. It turned out
 this was exactly right: I didn't need anything.
A proconsumerist point of view, for balance.

Also available: Chocolate Bypass, Butterscotch Crutch, and Strawberry Eyepatch.

In an airport, is this a hopeful or pessimistic sign to see?
Is it just me, or is calling your restaurant S.O.L. self-defeating?
Okay, time to get back to psychology.

Tuesday 4 June 2013

Medications: Is Depression Still Profitable?

This spring, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, has been released amongst a torrent of criticism. Much has been made of various changes to the diagnostic criteria for individual disorders.

But the louder cries have argued that the revision is driven as much – or more – by the wishes of large pharmaceutical firms than by science or public need. With each succeeding revision of the manual, a larger proportion of the population has been diagnosible as having a mental disorder deserving treatment – often a proprietary drug treatment. The range of human experience deemed “normal” has correspondingly shrunk.

Much of the fury in this most recent debate has centred on the diagnosis of depression – particularly Major Depressive Disorder. More on the issue can be found here. This is a familiar battleground, as the field has undergone years of controversy about the effectiveness of the antidepressant medications (see here, here, and here). In a few short decades, this drug class has climbed to the number two position in overall sales, second only to the cholesterol-lowering statin drugs.

These drugs have been immensely profitable for the pharmaceutical industry, and many have questioned whether the profit motive has driven their marketing more than the science underpinning their use. But is the party now winding down?

Medication Development and Patents

It costs a huge amount of money to develop a medication for market. It must go through a series of trials demonstrating its safety and its effectiveness (generally relative to placebo; it need not be shown to be more effective than preparations already on the market). Some drugs get partway through this process and prove to be duds, with the result that the development costs are lost. It’s a risky business.

For a private corporation to bother, there has to be some hope of recovering the development costs (for the successful drug, and for the drugs that never made it to the pharmacy) and making an eventual profit. So the drugs are patented, meaning that the developer has the sole right to produce and market that preparation, and they can pretty well set their own price for it. These patents expire, however, and then other companies can manufacture the same medication, driving the price down markedly through competition.

Once a drug is off patent (generally after 20 years in North America), the profitability is sharply reduced. The motivation to promote the product to physicians and public largely evaporates. (This is why drugs advertised for years as miracle cures suddenly vanish from the airwaves.) A company that has two medications in the same class (two antidepressants, for example), one on patent and the other off, will shift most of its promotional budget to the former.

Many pharmaceutical companies have only a few real “blockbuster” drugs, so the looming expiry of a patent on one of their main moneymakers is ominous. For example, a 2012 article in U.S. Pharmacist estimated that the sales of the antidepressant Lexapro amounted to 59% of the overall sales for Forest Laboratories. The major firms survive by having a pipeline of new drugs (which will have new patents) on the way.

You can see the problem. What if a new drug class is developed, the various companies all go out and make minor variations on these, they promote the medications (and public awareness of the disorders they treat), and then the pipeline dries up, with no new preparations arriving on the market? The high profits associated with the patented medications will vanish with the patent expirations and not be replaced.

What about antidepressants?

This is the situation in which the industry finds itself in the case of antidepressants. In the 1950s there were no antidepressant medications. Then the tricyclic antidepressants came out and rapidly gained a foothold in the market. In the 1980s the selective serotonin reuptake inhibitors (SSRIs: Prozac, Luvox, Paxil, Zoloft, Celexa) began to appear, then a variety of other variations (such as the serotonin and norepinephine reuptake inhibitors (SNRIs: Effexor, Pristiq) and others (Wellbutrin, Remeron). Just when one drug would go off patent, another would appear.

But the flurry of antidepressant development has passed, and most of the patents have now expired. Take a look at the most widely used antidepressants (most dates are USA expiries):

Prozac (fluoxetine) - patent expired 2001
Paxil (paroxetine) – patent expired 2003
Luvox (fluvoxamine) – patent expired 2000
Zoloft (sertraline) - patent expired 2006
Celexa (also Cipramil; citalopram) – patent expired 2003
Effexor (venlafaxine) – patent expired 2007
Remeron (mirtazapine) - patent expired 2010
Lexapro (also known as Cipralex; escitalopram) - patent expired 2012
Cymbalta (duloxetine) - patent expires June 2013
Wellbutrin (also Zyban; bupropion) – patent expires August 2013
Pristiq (desvenlafaxine, a modification of Effexor) - patent expires 2022

Antidepressants continue to be prescribed at rates that some find alarming and well beyond the range of conditions and severities for which there is adequate research support. But with the reduction in cost associated with patent expiry, the overall dollar value of sales has declined from a peak of $15billion in worldwide sales in 2003 – and shows signs of declining further in the years to come. Thomson Reuters Pharma predicts total sales under $6billion by 2016. This is all coming from price reductions associated with patent expiry, not from a decline in prescriptions for these medications.

For example, Cymbalta, the patent for which expires this month, is presently the #2 selling antidepressant in the United States, with overall worldwide sales of $2.7billion. This revenue will not all vanish, obviously, as the medication will go on being prescribed, but the price will most likely drop by 70% or more, eliminating most of the profits for Eli Lilly and most motivation to promote the drug to the public.

And what’s in the pipeline? Not much, apparently. AstraZenica’s TC-5214 crashed and burned in 2012, and development was halted on both agomelatine and aprepitant. Certainly there isn't anything that anyone is describing as a “game-changer” with markedly greater effectiveness than what we have now.

Will this be good for the depression treatment field? Hard to say. Your thoughts?

Online Course

Is there an alternative to a medication-based approach? If someone takes medication, is there more they can do in order to maximize the effect? Consider seeking the help of a qualified psychotherapist trained in cognitive behaviour therapy.

In addition, our clinic 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.

Wednesday 29 May 2013

"Original Practices" for Shakespeare: Faithfulness or Fundamentalism?

The Festival Theatre's thrust stage.

Last week I was teaching about group therapy in Kingston Ontario, and decided to stay on and drive to Stratford, close to where I went to graduate school in the last millenium. The festival at Stratford was a welcome diversion from psychology research so I would attend regularly, and since moving to Vancouver I’ve often taken the opportunity to stop in while visiting Ontario in the summer.

Monday night I attended the Festival’s opening of Romeo and Juliet (Shakespeare’s cautionary tale about teenage impulsivity). It was helmed by British director Tim Carroll, who has a long association with London’s Globe Theatre, an open-air recreation of the theatre that Shakespeare’s company originally played in.

Like most companies presenting Shakespeare, Stratford often shifts the circumstances of the play somewhat. Sometimes it’s World War I, sometimes the future, sometimes the gender of one or more characters is switched.

The current version of Romeo and Juliet is done in “Original Practices,”(OP) meaning naturalistic lighting, no amplified music, no sound assist, and very little directorial blocking (telling the actors where to stand and when). This is the way the plays were done by Shakespeare himself, largely out of necessity. There was no electrical light, no audio technology, and, apparently, there was often no director of the play in the modern sense.

So how does this work in the enclosed Festival Theatre at Stratford? After all, without artificial light no one would see anything at all.

The sense of an afternoon performance is given by having most of the house lights on, so the audience is plainly visible, and no use of lighting effects for shifting the mood or audience’s attention.

The increased presence of the audience allows the actors to address the crowd directly. Shakespearean soliloquies are directed straight at the audience rather than looking like spontaneous inner dialogue. Bit players can kibbitz with those in the front row. In the case of Stratford’s R&J, the Nurse angrily heaves bread loaves at a retreating character, landing many of them in the seats. An illiterate Peter, given an invitation list, helplessly hands it to someone in the front row for assistance. A few comic bits work well this way.

But for a play to succeed it has to engage the audience. Vast swaths of the population hate Shakespeare because it has been presented to them as a dusty museum piece – a cultural vegetable that is supposed to be good for you even though it is just about indigestible. And for the most part, that’s the result of the OP production of R&J. When you contemplate the fact that these are the conditions in which most audiences saw Shakespeare’s work in times past, the overwhelming thought that occurs to you is “Oh, those poor people. How did it ever catch on?”

The answer, it seems to me, is that the audiences themselves were different people. They lived in a world of drudgery, plague, and strife. Never having known amplified music, complicated lighting effects, or stagecraft, they didn’t expect it. The experience of seeing a group of people putting on a play would have been profound.

In 1933, the original version of King Kong frightened, amazed, and thrilled audiences. The special effects were astonishing. Today, it’s still possible to watch the film and appreciate it, and you can find yourself wondering “How on earth did they manage that in the 1930s?” But it’s a different experience, and tends not to grab you by the throat the way it did its original audiences.

In elementary school I saw my first stage production – a musical put on by the high school down the road. To my eyes, the illusion was complete. An altogether different universe appeared on stage in front of me, and infinitely old, mature, and accomplished professionals seemed to vanish altogether in their roles. It would be nice to see a film of that production – I suspect that although I could appreciate their efforts, it would have a much-diluted effect on me now.

What I’m suggesting is that theatre is interesting not because of what appears on stage, but because of a relationship between the production and the minds of the audience. The effect of a play depends on both the mechanics of the play and the characteristics and history of the audience. It’s possible to reconstruct the former but not the latter, and as a result the relationship is completely different.

For example, imagine seeing an “original practices” version of a Sophocles play – declaimed in ancient Greek. This would be a profoundly interesting experience if done well – but it couldn’t possibly produce the same effect on a modern audience as an ancient one. Not because the modern audience cannot feel the same things, but because the stimuli that elicit those feelings have shifted.

As a result it seems inevitable, at least to me, that OP productions will tend to reproduce the form but not the impact of the plays. Certainly that seemed to be the case Monday night. The audience response was remarkably lukewarm for a season-opener and people scattered into the night quickly. The reviews have been unenthusiastic, to put it mildly. (A particularly brutal and mean-spirited review by Richard Ouzounian in the Toronto Star seems to be an example of wounded childish rage rather than sober judgement.) One reviewer talked of staying awake by counting his fingers.

The proponents of OP seem to feel that they are being loyal to Shakespeare, eschewing the bells and whistles that really can just distract from the plays themselves. But what would Shakespeare himself have done?

“Okay, Will, we’ve had 400 years of technological development and have invented whole new fields of sound, lighting, and blocking – and unlike you we now have the money to have sets and furnishings – either naturalistic or impressionistic. Whaddaya want?”

It seems inconceivable that he would go for the difficult conditions under which he had to labour. Or that he would see his own Globe Theatre as being, coincidentally, the pinnacle of theatrical presentation. My guess is that he would seize upon modern technology and exploit it mercilessly to sharpen (not distract from) the presentation of his plays. And he would look upon the OP purists as having missed the point.

But go.

The Stratford Festival is one of North America's greatest theatrical experiences, and richly deserves an audience. I saw four plays while I was there and three of them (the other three) were terrific. Blithe Spirit shows a classic Noel Coward at his witty, brittle, and somewhat brutal best. Mary Stuart portrays a fictional meeting between Elizabeth and Mary Queen of Scots before the latter's execution, a complex dance of motivations and political intrigue that avoids pointing fingers at obvious villains - this may be the hit of their season. And The Who's Tommy (which I attended because it fit the schedule, not because I was drawn to it) is a big, expensive production that completely engaged the audience and seems clearly designed to travel elsewhere when it is done at Stratford. Plus, the town of Stratford itself is beautiful and well worth a visit.

Tuesday 21 May 2013

Sexual Orientation and Gender Identity in Film: Some Resources

One of my sidelines is talking to groups of healthcare workers about lesbian, gay, bisexual, and transgendered (LGBT) issues. People often come dragging their feet to these talks, anticipating dire and politically correct drabness, but we usually wind up having fun. I prefer to give these talks outside big urban areas – people in smaller centres often come with more genuine curiosity and an open point of view, whereas urbanites often shrink with the paralyzing fear that they might ask or say something wrong.

The talks are invariably too short to give as much detail as people might like, so I provide suggestions for further reading. I know, however, that most people have an “I really should read this” pile from floor to ceiling, so the odds are this is a futile gesture. Isn’t there a more entertaining way to learn about these communities without slogging through a diversity education text?

Why yes, in fact, one can develop at least some familiarity with things by watching selected movies. Film portrayals of LGBT populations are notoriously problematic – distorted, needlessly tragic, stereotypical, or outright wrong. And I risk the wrath of readers by mentioning any of the below, all of which can, I’m sure, be found wanting by someone. No doubt I am leaving some readers’ favourites off the list, either because I’ve genuinely neglected them or I haven’t liked them myself. But I’m open to comments and suggestions.

Trailers for most of these movies are available on the internet (for example, at

The Adventures of Priscilla, Queen of the Desert (1994). Three Australian drag queens set out from Sydney across the outback in an unreliable bus, heading for an appearance in Alice Springs. Along the way they deal with unsympathetic attitudes, their own personal issues, and questions related to gender, familly, and even parenthood. Comedy.

Boys Don’t Cry (1999).  A dramatization of the life of Brandon Teena, a trans teen who lived as a boy. Tragedy follows the discovery of his biological gender. A documentary, The Brandon Teena Story, is also excellent. Drama.

Breakfast with Scot (2007). A very light Canadian film in which a gay male couple (one a lawyer, the other a former NHL player) take on temporary custody of a boy who turns out to be much more flamboyant than either of them, pushing their noses in their own discomfort with being out of the closet. Comedy.

Brokeback Mountain (2005).  Ang Lee’s celebrated film in which two men, hired to herd sheep, fall in love and continue their affair for years afterward. Sometimes criticized for being yet another angst-filled and unhappy portrayal of gay men, the performances are uniformly excellent and the place of their relationship alongside heterosexual marriages is quite true to life. Romantic Drama.

But I’m A Cheerleader (1999).  A cheerleader is sent to a sexual reorientation therapy camp by her concerned parents. A fairly silly film but one that mercilessly and deservedly parodies the idea of gathering gay teens together to make them heterosexual. Arguably a bit hard on the religious. Over the top comedy.

The Celluloid Closet (1995). A documentary about the portrayal of lesbians and gay men in film from the beginning of the medium to the 1980s. Surprising, moving, and often very funny. Worth watching for dozens of moments, not least the one in which screenwriter Gore Vidal reveals the subtext of Ben Hur. Narrated by Lily Tomlin.

Cloudburst (2013). An elderly American lesbian couple, threatened with being split up by well-meaning relatives, flee to Canada to get legally married. Olympia Dukakis is gruff, hard-edged, and surprisingly vulnerable as she realizes that she may not be able to cope with the increasing disability of her partner.

C.R.A.Z.Y.  (2005). A young gay man growing up in Quebec deals with homophobia and his difficult relationship with his father. An acclaimed portrayal of the difficulties of coming out and father-son conflict. Comedy-drama.

Forbidden Love: The Unashamed Stories of Lesbian Lives (1992). A National Film Board of Canada documentary about the experiences of lesbians in Canada in the 1940s-1970s, interspersed with references to a subgenre of lesbian pulp novels. Enlightening and often very funny, as the interviewees, many of them quite elderly, describe the machinations required to live within a disapproving culture.

Fire (1996).  Canadian Deepa Mehta’s film about a Delhi family in which an unfulfilled wife begins a love affair with another woman within South Asian culture. Drama.

The Kids Are Alright (2010). The offspring of a lesbian couple attempt to locate their sperm donor father. What could easily have become easy slapstick develops considerable depth in its examination of a lesbian family and the complications of finding and integrating the birth father. Comedy-drama.

Longtime Companion (1989). A harrowing chronicle of the impact of HIV/AIDS in 1980s gay life. For those who did not live through this time, when over half a million people in Canada and the US died (well over a hundred times the death toll of 9/11), the film is a sobering look at the reality. Drama.

Ma Vie En Rose (1997).  A Belgian family struggles with their young son’s self-identification as a girl. Humourous at times, but with a deeply compassionate and serious look at the conflict that can ensue. Drama.

Mambo Italiano (2003). An Italian-Canadian man stuggles with coming out to his traditional parents, against the wishes of his police officer boyfriend.  The histrionics of his Montreal-based parents (Paul Sorvino and Ginette Reno) are beautifully (over)played. Comedy.

Milk (2008).  The story of Harvey Milk (played by Sean Penn), a gay community organizer in San Francisco, who was elected to city council (the first openly gay American elected to office) and who was subsequently assassinated.  Drama.

Prayers for Bobby (2009). Sigourney Weaver plays a deeply religious mother who cannot accept her son’s homosexuality, with tragic results. Based on a true story. I found this one a bit far-fetched at first, particularly the point of view expressed by the mother.  But a young man I know watched this, riveted, and said at the end “That’s my mother. That’s my life.”

A Single Man (2009). One day in the early-1960s life of a gay college professor planning to commit suicide following his partner’s death in a car accident. An examination of life for people who had to be secretive in order to survive, and the toll it cost them, as well as the surprising sources of light in dark places. Drama.

Transamerica (2005).  A trans woman learns that she fathered a son, who accompanies her on a cross country trip just before she undergoes surgery. One of the few films to deal directly with trans issues, done with a good budget and designed for the general viewing public. Comedy-drama.

The Wedding Banquet (1993). An early Ang Lee film in which a gay Taiwanese man living in New York stages a sham heterosexual wedding for the benefit of his parents.  An interesting portrayal of problems within bicultural gay relationships, and very very funny. Comedy.