December 30, 2011

Psychotherapy for Normal People: Therapy Poll Results

Last month, a new friend told me about his therapy experience over dinner. I'm used to people telling me about their therapy, but the next day, my friend sent me a text to remind me to keep our conversation confidential. That got me wondering about how people perceive therapy--is seeing a mental health professional still stigmatized, or is psychotherapy accepted as normal these days? To find out, I decided to take a poll to see how many of my peers had been to therapy (and were willing to admit it).

Method: I posted the following as my Facebook status two or three times in one week: "Informal research project: Have you ever been in family, group, or individual therapy? Send me an email to say yes or no." The response rate was low (n = 8) so I created a Facebook event and invited all of my Facebook friends (n = 154). I sent two reminder emails within the following month.

Participants: I received 48 responses, 60% from women (n = 29) and 40% from men (n = 19); participants ranged in age from 25 to 48 years. Sixty-three percent of respondents lived in Montreal at the time of the poll (although a few others were former Montrealers), and 83% were Anglophone. Seventy-nine percent of respondents were white and urban, with post-secondary education; the other 21% were two of those three things.

Results: Fifty-eight percent of respondents (n = 28) reported that they had been to therapy. Most of those in the affirmative camp responded with a simple yes, but some further confided that they had sought therapy subsequent to a break-up or other crisis, had gone to couples therapy with their partner or former partner, or had been sent to therapy as a child during their parents' divorce. Interestingly, more than a few respondents in the no camp added that they maybe should seek therapy, or that they would like to.

The gender statistics revealed little. Of the respondents who said yes, 58% were women and 42% were men. Of those who said no, 65% were women and 35% were men. These numbers reflect the overall gender ratio in the sample of respondents, and don't suggest that one gender is more likely than the other to have been to therapy. Of the female respondents, 55% said yes and 45% said no. Of male respondents, 63% said yes and 37% said no. These numbers reflect the overall proportion of yes and no responses, and don't seem to suggest anything about gender and psychotherapy. 

Discussion: Nearly 60% of respondents acknowledged having gone to therapy at some point in their life. Although this seems like a pretty straightforward result, it's possible that the stats were falsely inflated by selection bias (i.e., I'm friends with the kind of people who go to therapy) and/or by self-selection bias (i.e., people with therapy experience were more likely to respond). Alternatively, it's possible that the actual statistics of therapy attendance are much higher, but that people who seek therapy don't want to admit to it, even anonymously (i.e., maybe every single one of the 106 non-respondents has been to therapy!). I also don't know whether or not the results indicate that it's common among my peers to seek therapy, because I don't know how many respondents independently sought psychotherapy in adulthood, and how many were sent to a therapist during their childhood. I wish I had been more specific with my question!

Conclusion: Even with the identified limitations to the research design, I feel comfortable concluding that psychotherapy is statistically normal among youngish white, urban, educated adults. I hope that this finding demonstrates that therapy is for normal people, and contributes to the destigmatization of psychotherapy.

What do you think? Are you surprised? Are you convinced?

December 22, 2011

Too Much Empathy

Judging from reactions to my two recent posts on the subject, most people believe that some form of empathy (cognitive or emotional; innate or learned) is a key characteristic for healthcare professionals such as doctors and psychologists. But is it possible to overempathize? A recent experience suggests that it is:

Last week at the chronic pain centre, I had the opportunity to see two therapists consecutively interact with the same patient, with two very different outcomes. The therapists were co-conducting a psychological assessment of a new patient who was extremely and visibly depressed. The patient walked into the office slowly and hunched over. He didn't make eye contact during the introductions, and slouched in his chair, tears falling unchecked even before the interview started.

The first therapist was shaken by the patient's appearance, and unsure that he was in a condition to answer three pages of questions about pain, mood, and functioning. She began the evaluation anyway, but the interview rapidly went nowhere. The patient spoke slowly, softly, and infrequently, and continued to cry. The therapist felt insensitive probing someone in such obvious distress, and spoke to him more and more slowly and softly. As palpable despair crept into the room, the therapist started fumbling her words, and within ten minutes, she too was slouched in her chair, feeling helpless.

The second therapist took over. She obtained the patient's consent to continue the evaluation and then, sitting up straight and speaking at a normal volume, she continued the interview. When the patient stumbled or got stuck, the therapist rephrased the question to make it easier. Her attitude and questions expressed empathy, but she maintained composure and didn't behave as though her questions were an imposition. 

How did the patient react? He sat up straighter. His tears gradually stopped. He raised his voice to a normal volume and made more eye contact. He joined the conversation and the second therapist was able to obtain the information necessary to formulate a treatment plan.

What happened here?

In a fit of unhelpful overempathy, the first therapist had fallen head first into the patient's emotional world, taking on his hopelessness and helplessness.  The second therapist didn't take on the patient's mood; instead, she maintained her own competent and upbeat manner, and her energy spread to the patient. Her composure conveyed a message of strength: whereas the first therapist's behaviour communicated "You (and I) are too fragile to complete this interview," the second therapist's attitude said to the patient something like "I see that you are in immense physical and emotional pain, but I believe that you have the strength to communicate your situation and participate actively in your treatment."
In the therapy room, part of the therapist's job is to be in control, to model competence and mental health, and to convey appropriate optimism to the patient. To do so effectively, the therapist needs to strike a balance between empathy and some degree of emotional separation. In this case, the first therapist's excessive emotional empathy maintained and propagated the patient's despair, and prevented the therapist from doing her job. The second therapist's appropriate empathy allowed her to maintain composure, do her job effectively, and propagate hope. The patient's reaction made it clear which attitude was more helpful!

December 18, 2011

Pain Psychology

In September, I started an internship at a chronic pain centre. The pain centre is a multidisciplinary hospital clinic that employs various types of healthcare professionals, including doctors (e.g., rheumatologists, anesthesiologists), nurses, a physiotherapist, and a team of psychologists. About two thirds of pain centre patients see one of the psychologists at some point during their treatment.

Why do chronic pain patients need psychological help?

Pain patients need psych help because chronic pain often impairs functioning significantly, creating considerable distress. Imagine not being able to go to work, walk around the block, or lift your child. Imagine going from playing competitive volleyball to walking with a cane, or from working construction to being unable to stand for more than fifteen minutes at a time. Imagine explaining to family, friends, and colleagues that you have constant pulsating pain shooting down both of your legs, or that you wake up every morning with what feels like a 100-pound weight pressing on your spinal cord. Then imagine years of this--sometimes without a clear diagnosis--and you can see why some pain patients need psychological help.

When pain centre doctors refer a patient to the psychology team, the first thing the psychologist does is a complete psych assessment. The goal of the assessment is to get a global portrait of the patient, and to answer the following questions:

a) What is the state of the patient's mental health? For example, the patient may be depressed, anxious, suffering from post-traumatic stress (e.g., pain onset subsequent to a work or car accident), or self-medicating with alcohol.

b) Did the patient's psychological problems develop before or after pain onset? For example, a depressed pain patient may have been psychologically healthy before pain onset; a patient with a personality disorder has probably had interpersonal problems all his or her life.

c) Do the patient's psychological problems exacerbate, maintain, or perpetuate the pain? For example, an extremely anxious patient may focus excessively on every tiny sensation in his body, fearing increased pain with every movement; his hypervigilance exacerbates the pain, reinforcing his fear of movement and creating a vicious cycle. A severely depressed patient may stay in bed all day for months; her decreased strength and flexibility maintains her pain.

d) Does the patient's psychological state present a barrier to treatment? For example, an extremely depressed patient may need to start taking an antidepressant before he would be able to benefit from therapy. The patient with a dependent personality may rely heavily on pain centre staff and, at some level, fear getting well enough to be discharged. The occasional patient is receiving good worker's compensation benefits or enjoying receiving care and attention from loved ones, and has little interest in getting better; this is a clear barrier to treatment and is important to assess.

We use this information, as well as information about pain history, family history, and work and relationship history, to formulate a treatment plan. The number one goal of psychological treatment at the pain centre is always to increase patients' functioning and improve their quality of life. In individual and group therapy, we help patients increase the number of pleasurable activities in their day, implement a healthy sleeping and eating schedule, and start exercising again if possible. We teach them how to manage stress, and how to communicate effectively with doctors and loved ones about their pain. Most patients' pain is only manageable, not curable, and many patients' pain isn't even diagnosable. Lack of diagnosis is understandably difficult to accept, and a big part of our job is helping patients adjust to this reality. We help them move from grieving their former activities and abilities ("I used to be able to...") to considering available adapted activities ("Now I can...").

Chronic pain eats away at quality of life, and our objective is to increase patients' functioning, restore some level of activity, and help them live better with their pain. When patients start to make some of the changes described above, they often find that their physical health improves and their mood lifts. Pain doesn't go away, but if fades somewhat or feels more manageable.

NB: Psychology is a key element of a multidisciplinary approach to pain, but psych treatment doesn't replace medical intervention--rather, most patients receive concurrent medical and psychological help.

November 30, 2011

Learned Empathy

Is empathy an innate trait or a learnable skill?

Following my recent post about cognitive and affective empathy, a friend sent me a CBC story about oncologists who participated in a study that tested a computer-based empathy and communication skills training program. The doctors in the study were recorded during interactions with their patients, and received one month of feedback and training on how to recognize and improve their response to patients' distress signals. They were taught how to present information about prognosis empathetically, and how to identify opportunities to allow patients to talk about their feelings. The doctors were subsequently measured on "emotion-handling skills" (i.e., naming, understanding, respecting, supporting, and exploring emotions, rather than changing the topic, joking, denying the emotion, or ending the conversation). Patients' perceptions of their physician were also measured.

Results: At the end of the study, the empathy-trained doctors responded empathetically to their patients twice as often as did a control group of doctors who merely attended a lecture on communication skills. More importantly, patients whose doctors were in the training group reported greater trust in their doctor and greater perceived empathy from their doctor, and were more likely to report that they felt understood as "a whole person."

I thought this was pretty great--what's better than doctors who are willing to improve their bedside manner and patients who benefit? Not everyone agreed. In fact, several commenters on the CBC story seemed quite offended by the idea of empathy as a teachable skill and argued that in-born empathy is a required trait for good doctors.  

This seems misguided. Insisting on strong innate empathy as a prerequisite for access to healthcare professions would exclude many intelligent and intuitive people who have excellent diagnostic and technical skills and who want to help others. I'm not suggesting that doctors don't need empathy, but who cares whether or not it's innate? It's hardly uncommon for professionals to take continuing education courses to brush up on skills and to fill gaps in their training.

Another commenter wondered whether the doctors in the study really learned empathy or whether they simply learned empathy behaviour. For the purposes of the doctor-patient relationship, I'm not sure there's a difference. The oncology patients in the study knew that their doctors were participating in a program to improve their empathy skills, but they still reported that they felt better understood and listened to--that is, they felt that their doctors were empathetic. That the doctors learned empathy from a computer didn't bother the patients and didn't limit the positive impact of the program on the doctor-patient relationship.

Any intervention that improves healthcare professionals' clinical skills and makes patients feel better supported should be applauded and pursued. I would love it if my doctor took an empathy course. Likewise, I would love it if I had a therapist who participated in a skills training program to improve her ability to identify and respond appropriately to my distress signals. Wouldn't you?

November 17, 2011

Apology Rules

Some people (ahem) can't stand it when someone is mad at them. They apologize repeatedly--calling and emailing to say how sorry they are and to see if the other person is still mad.

Is this effective? Not usually. The wronged party might issue forgiveness eventually, but it's mostly just to get the apologizing to stop. It's often an unsatisfactory resolution for both parties, leaving one annoyed and the other emotionally exhausted.

The last time this happened, I started thinking about some ground rules for apologies. Some readings on assertiveness and communication skills helped me identify two rules that can help you (and me) apologize appropriately, while keeping a level head.

1) Figure out what you did wrong and take responsibility for it. This rule has two steps and is particularly important when we make a mistake that initiates a chain of unfortunate events. Example: your friend confides in you that he's dating someone new, but hasn't yet told his recent ex. You can't resist sharing this news with your work friend, who knows both parties. Unexpectedly, your work friend declares that your friend's ex has "the right to know" and calls her up. The next thing you know, your friend is livid with you because his ex confronted him in furious tears, and now won't speak to him and is refusing to share custody of their beloved cat. You are dumbfounded by this turn of events and your impulse is to apologize to your friend profusely and repeatedly, begging desperately for forgiveness for your awful sins. What do do instead:
  • Identify your crime and apologize for it. You shouldn't have gossiped with your work friend; for that, you should apologize directly and genuinely.
  • Don't apologize for the parts that aren't your fault. While it's true that your behaviour triggered the chain of events, you aren't accountable for your work friend's decision or for the ex-girlfriend's dramatic reaction. You can, and should, be sorry that your initial mistake prompted the whole mess, but you still aren't responsible for other people's behaviour and you don't need to apologize for it. 
2) Let the apology fit the crime. If it's hard for you to tolerate someone being upset with you, you may use the understandable but unhelpful strategy of "keep apologizing until you're forgiven." The problem with this strategy is that eventually, the apology no longer fits the crime. Example: you accidentally bump a guy on a crowded bus and he spills his coffee on the floor. You apologize sincerely, but rather than accepting your apology or your offer to buy him a fresh cup, the guy continues to berate you as though you had purposefully grabbed the coffee from his hand and thrown it in his face. Your impulse is to apologize even harder, but wait a minute--you didn't abduct his first-born child; you merely spilled his $1.25 cup of coffee. If he doesn't accept your first or even your second apology, it's time to stop apologizing and walk away.

This rule applies to your friend and his ex as well. Say you issue a sincere apology for gossiping and for initiating the ensuing trouble, and your friend remains as angry as if you had personally kidnapped his cat. His anger doesn't fit the crime, and if you keep apologizing, soon the apology too will no longer fit the crime. It's time to walk away and give your friend some time to cool down.

Apologizing is hard and not over-apologizing can be even harder. Keeping in mind these rules can help you make a sincere and appropriate apology, with minimal anxiety and without going overboard.

November 11, 2011

Inside Out

You know how you sometimes look at other people and feel like they are smarter than you are, more together or more successful than you are, and have a more fulfilling life than you do? How it sometimes seems like you're always stressed or depressed or panicked or angry, whereas others are well-adjusted and high-functioning?

News from the front line: Other people look at you and think the same thing. 

Yesterday I attended a workshop on mindfulness in psychotherapy. During one exercise, we were invited to get in touch with the thing that we like the least about ourselves, the thing that makes us different from and inferior to everyone else. As we wrote down our shameful secrets, people sniffled, people wiped away tears, but not one person raised their hand to say "There's nothing wrong with me. I'm just as good as everyone else." Later, the workshop leader showed us images of cue cards on which former workshop participants had described their inferiority: I'm too selfish; I'm defective; I don't fit in anywhere; I'm not as smart as others; and I don't measure up.  

Wait--what? How can everyone be different and inferior? Why does everyone think they don't fit it and don't measure up? What makes us think that we are the only one who doesn't have it all under control?

I think I know the answer: It's the phenomemon of comparing your insides to other people's outsides. Consider that painful emotions and judgmental thoughts are invisible; so is the sinking belly feeling and the tight chest feeling. So while we're extremely aware when these processes occur in our own body and mind, we don't see or feel them happen in other people. All we see are their sleek exteriors, and when we compare them to our own rumpled interior, of course we come up short!

What the workshop exercise made clear is that everyone's interior is rumpled and everyone is comparing their insides to others' outsides. It's not a fair comparison, and it's one that's practically guaranteed to make you feel bad. It might help to remember this next time you're feeling inferior.

NB: Facebook is a great example of this phenomenon, which explains why reading your news feed can leave you feeling like everyone is more fulfilled/having more fun than you are. No one posts statuses like "I'm so jealous of my friend's new baby I can barely breathe," "Wracked with guilt for not calling my sick grandmother again today," and "I feel like an imposter in my new job" (rumpled interior). Rather, we post about our our triathlon success, our adorable new nephew, and what a great time we had in Costa Rica (sleek exterior).

October 29, 2011

If You Don't Understand, Ask

Therapy Policy: If you don't know what your client is talking about, ask.

I learned this lesson during my first doctoral internship, which was my first experience conducting therapy in French. Over the course of eight years living in Quebec, I've achieved considerable fluency in the French language, as well as in the nuances of Quebec slang, politics, and culture. However, everyday French conversation and conducting therapy in French are not comparable, and the learning curve during that first internship was steep. 

At the beginning, wanting to prove myself as an Anglo therapist in a Francophone environment, I opted for the "it's no big deal" approach and ignored the language issue. To avoid drawing attention to my Anglo-ness, I didn't ask clients to repeat unfamiliar terms or to explain comments that weren’t clear to me. This strategy was not effective. In supervision, I learned that my comédien client was not a comedian but, rather, an actor. When I expressed surprise in supervision over a client’s shocked response to a rude, but not out of character, comment from her partner, I learned that choqué means angry, not shocked. When I asked a colleague what my client might have meant when she said that her mother was "the kind of person who watches Occupation Double” (a Quebec reality TV show), my colleague wondered why I hadn’t simply asked the client.

In discussion with my supervisor, I realized that I was worried my clients would reject me for being an Anglo imposter who could never understand them. But my solution--pretending to understand when I didn't--was hindering therapy. When I consciously shifted to a more open and curious approach, my clients responded positively. They appreciated my acknowledgement of our differences and enjoyed the opportunity to explain their cultural references. Who knew!

Now I'm in a new steep-learning-curve internship--at a chronic pain centre. I'm not used to working at a non-psychiatric hospital; I hear unfamiliar terminology used every day to describe pain, medical procedures, medications, etc. What's more, I've never worked with pain patients before and many of their experiences are unfamiliar. 

I'm doing much less pretending this time around. One thing that helps is seeing my superiors--physicians and psychologists alike--do things like Google a medication they've never heard of, right in front of patients! They don't seem worried that patients will think they're incompetent because they admit to not knowing everything. A second thing that helps is noticing that patients want me to really understand their experience; they're not annoyed when I say "I'm not quite sure I understand; what do you mean by...?" Rather, they appreciate it.

This time, my policy is "If you don't understand, ask" (and, where medical terminology is concerned, "if you don't know, look it up"). 

So far, so good.

October 10, 2011


A good therapist should be empathetic, right? Most people, myself included, would automatically agree--but what is empathy, anyway?

Until recently, my loose and unexamined definition of empathy was the capacity to put yourself in someone else's shoes and feel as he or she feels. So when in clinical case discussions, colleagues mentioned how awful they felt about a given client's situation, or that tears came to their eyes during a client's particularly moving story, I called that empathy. And when other colleagues reported that this never happens to them--that they never vicariously experience clients' pain or take clients' problems home with them--I called this lack of empathy. I figured that the former group were the more sensitive, more human, and all-around better psychologists, and that there was probably something wrong with the latter group.

However, subsequent to a conversation on this very topic, a friend pointed me to the Wikipedia page for empathy, which lists definitions of the term by various theorists. To my surprise, many of them were not consistent with my definition. Rather, several referred to a cognitive component of empathy, that is, empathy as the ability to understand another person's thoughts, feelings, and motivations, without necessarily experiencing them.

Examples of this type of definition include "the ability to put oneself into the mental shoes of another person to understand her emotions and feelings" and "a complex form of psychological inference in which observation, memory, knowledge, and reasoning are combined to yield insights into the thoughts and feelings of others." These definitions involve perception and appreciation of how the other person is feeling, but don't imply stepping into his or her shoes.

Other definitions suggested that empathy has both cognitive and emotional components. For example: "There are two major elements to empathy. The first is the cognitive component: understanding the other's feelings and the ability to take their perspective. The second element to empathy is the affective component. This is an observer's appropriate emotional response to another person's emotional state." Another definition proposed that empathy is "the capacity to a) be affected by and share the emotional state of another, b) assess the reasons for the other’s state, and c) identify with the other, adopting his or her perspective." 

Reading these interpretations changed my personal definition of empathy and eliminated my judgment of therapists who don't feel their clients' pain. The more I think about it, the more I believe that, in combination with warmth, compassion, and therapy and problem-solving skills, cognitive empathy is enough.

What do you think? Would you appreciate seeing your therapist wiping away tears when you describe your troubles, or is it enough if he or she can understand where you're coming from and why, and can use that knowledge to help you move forward?

September 29, 2011

The Suicide Question

The other day, a research participant questioned me about the usefulness of asking clients whether or not they feel suicidal. He was completing the Beck Depression Inventory (BDI), a popular research and clinical measure of depressive symptoms, including suicidal thoughts. Question 9 of the BDI requires the respondent to choose from the following:

a) I don't have any thoughts of killing myself,
b) I have thoughts of killing myself but I would not carry them out
c) I would like to kill myself
d) I would kill myself if I had the chance

My participant wanted to know, who would actually admit to wanting to kill himself or herself? Given all the stigma surrounding suicide, wouldn't most people just lie?

Good question: Is it effective to ask clients flat out whether or not they are considering suicide?

The answer is yes. Doctors, psychiatrists, and psychologists are trained to ask the suicide question, without hesitation and without euphemisms. We ask it in a sensitive but straightforward manner, and clients invariably respond honestly. They either express surprise and say "What? Oh, no, I'm not at that point," or admit that yes, they've thought about it, at which point we empathize with their suffering and follow up with questions to determine whether or not they have a plan or a timeline.

I've never witnessed or heard of a client who reacted to the suicide question with shock or anger, and I've never heard of a client who lied (i.e., said he/she wasn't suicidal and then committed suicide). Rather, clients are relieved to be able to address the issue candidly. When a health care professional asks about suicidal thoughts in the same tone of voice used to ask about sleep and appetite, it removes the stigma, allowing the client to bring the dark, scary secret out into the open. To this end, some psychologists have their depressed clients complete the BDI at every session, providing a weekly measure of suicidal ideation, as well as of mood, sleep, appetite, and activity level.

Frequently asked question: Won't asking about suicide plant the idea if the person wasn't already considering it? This is a common fear, especially for non-professionals who aren't sure whether or not to broach the suicide question with a loved one. The answer is no. If someone isn't contemplating suicide, he or she won't start considering it because you asked; and if someone is thinking about it, he or she will probably be relieved that you brought it up, even if it's uncomfortable.

If you think that someone you know is contemplating suicide, ask the question.

September 19, 2011

Decision and Will Power Fatigue

Subsequent to my post about will power and rules, my sister sent me an article about decision fatigue and will power fatigue. Apparently, decision-making and self-control take up energy, and if you have to make many decisions or exert continued will power, you end up in a state of ego depletion, a condition of low mental energy that can lead to poor self-control and bad decisions. In ego depletion, your brain is too tired to weigh advantages and disadvantages, and resorts instead to one of two strategies: you become reckless and obey impulses rather than thinking decisions through (e.g., yes, I should buy these shoes, eat this entire pie, take this shortcut through a deserted park at night), or you avoid making decisions by sticking to the status quo (e.g., I'll just get the same bottle of wine I always get; I'll just continue dating this person for now).

Decision fatigue occurs a) when you have to make decision after decision, and b) when your blood sugar is low. One of the studies cited in the article found that Israeli prison parole boards more often granted parole to prisoners whose cases were reviewed first thing in the morning or right after lunch. In contrast, prisoners whose cases were reviewed right before lunch or at the end of the day were less likely to be granted parole; suffering from low blood sugar and decision fatigue, the parole board couldn't undertake the mental work of evaluating cases and therefore opted to stick to the status quo (i.e., prisoners remain in prison).

Decision fatigue can happen in any situation that requires numerous or repeated decisions. Imagine sitting down with a decorator to outfit your new home. At the beginning, you and your partner eagerly contrast and debate the merits of various dimmer switches, cabinet knobs, and shades of hardwood; after a long day during which you choose from thousands of options for lighting, counter-tops, and flooring, when the decorator pulls out paint chips, you're liable to groan and say "Just paint the whole thing cream!" To avoid hasty or bad choices in decision-heavy situations (e.g., wedding planning), your best bet is to make your choices when you are well-fed, and in more than one session.

Will power fatigue occurs when you have to exert repeated or prolonged self-control. Will power fatigue explains why, when you're trying to cut back on drinking, you're able to turn down champagne  at a wedding the first few times it's offered, but by midnight, you're so depleted from saying no that you grab and chug three glasses. Will power fatigue also explains why, after months of resisting your gorgeous, flirtatious, available co-worker, one night you give in and cheat on your partner.  To avoid will power fatigue, your best bet is to get out of the situation that requires continued will power (e.g., tell the waiters at the wedding that you don't drink, so they won't keep offering to fill your glass; don't go to post-work cocktail hour when your co-worker is there).
Are some people more prone than others to ego depletion from will power or decision fatigue? According to one of the researchers interviewed for the article, self-control and good decision-making aren't personality traits; rather, the people with these skills are the ones who organize their lives to conserve will power and avoid decision fatigue. They don't go to all-you-can-eat buffets, browse online for items they can't afford, or schedule important meetings late in the afternoon. Further, they establish routines or habits that prevent them from having to make decisions or exercise will power.

Here's where my post about rules fits in. If you have a strict routine of going to the gym after work Monday through Thursday, or a rule that you never watch TV on weekends, you don't have to use will power or make decisions; it goes without saying that you're going to work out four times per week and you aren't going to stream the latest episode of House until Monday. If your firm rule is that you only eat dessert on special occasions, you don't have to decide and redecide every time you walk by the plate of cookies some demon left in the lunchroom at work.

In this way, rules, routines, and smart planning allow you to conserve will power and save your decision-making energy for important decisions or unexpected situations.

September 11, 2011

Stages of Change

Change is a process and most people don't make big behaviour changes in one shot. The Stages of Change model describes the processes involved in quitting a habit or implementing a new behaviour. Originally developed to explain the behaviour of smokers attempting to quit, the model can be used to explain any behaviour change, from changing your diet to leaving your partner to learning a new language.

There are six stages:

Precontemplation: People in this stage don't intend to take action in the forseeable future. They may be uninformed, unaware, in denial, or not ready to deal with the problematic behaviour or situation or its consequences. For example, someone in this stage might not realize the direct relationship between his knee pain and the extra twenty pounds he's carrying, or may have already tried to quit smoking three times without success and not feel like trying again. Another person in the precontemplation stage may not be ready to admit that her partner is emotionally abusive or to consider leaving the relationship. People in this stage avoid talking or thinking about the problem, and don't want help.

Contemplation: People in this stage are aware of the problem and are thinking about making change in the next six months or so. Although they can see the advantages of making the change, they also see the disadvantages and aren't sure that the benefits will outweigh the costs. For example, someone contemplating quitting smoking wonders if the irritability, possible weight gain, and loss of pleasure is worth the long-term health gains. The woman with the abusive partner isn't sure that the emotional pain and financial instability inherent in ending the relationship is worth it. Someone contemplating learning a new language weighs being able to communicate more easily in her new city against the time and cost of committing to learning a second language. People in the contemplation stage are open to talking about the potential change and to receiving information and advice.

Preparation: People in this stage are committed to taking action in the next month or so, and have started preparing. The person who intends to quit smoking researches different smoking cessation methods and chooses one. The person who plans to become a vegetarian discusses it with his partner and buys a couple vegetarian cookbooks. The woman with the abusive partner starts looking for apartments and asks a friend for a therapist referral, and the person in the new city purchases language software and sets up a weekly language exchange with a native speaker.

Action: People in this stage make specific and observable changes; they are very open to talking about the change and receiving support from others. The person in the abusive relationship ends the relationship and moves out. The new vegetarian no longer eats meat, and the smoker stops smoking and starts sporting a patch. The person in the new city is meeting weekly with her language exchange partner and studying on her own a predetermined number of hours per week.

Maintenance: In this stage, people can successfully avoid temptation, and are increasingly confident that they can maintain the change. The vegetarian rarely craves meat and the person who quit smoking is able to enjoy a glass of wine or cup of coffee just as much without a cigarette. The woman who left her abusive partner feels empowered in her independent life, and the person in the new city finds herself looking forward to her weekly language exchange and using her new language regularly.

Relapse: Even people who eventually successfully change their behaviour don't follow a straight path to change, and usually relapse at some point. The vegetarian may cave at a barbeque and the smoker may give in to a craving during a stressful period. In a moment of loneliness, the woman who left her partner may give in to his pleas for a second chance, and the person in the new city may get busy at work and discontinue the language-exchange or let the software gather dust. The key to managing relapse is to analyze how and why it happened (e.g., you were busy; you were stressed; you were drinking; you were isolated), put a plan in place for next time, and start again at the preparation or action stage (i.e., don't go back to precontemplation or contemplation).

How is the Stages of Change model helpful?

For therapists, the Stages of Change model helps pace therapy appropriately. It's easy to assume that because a client came to therapy, he or she is ready to change. For example, if a client shares that she's considering leaving her abusive partner, her therapist could easily jump ahead and start trying to help the client deal with loneliness and financial insecurity. But if the client is only at the contemplation stage, what she needs is to have her experience validated and to explore her ambivalence about her relationship.

Similarly, a doctor whose patient vaguely mentions quitting smoking at some point might inundate the patient with pamphlets about smoking cessation programs. If the patient is in precontemplation, the pamphlets will end up in the recycling and may even decrease the likelihood that the patient will bring it up again. The therapist and doctor would both be better off acknowledging the client/patient's control over the decision, encouraging further exploration, and leaving the door open for a move to the preparation stage.

The Stages of Change model isn't just for professionals! You can use it on yourself or on the people around you. If in November, your partner mentioned joining the gym after the holidays, and you wonder why he never uses the six-month gym membership you got him for Christmas, it's probably because he was only in the precontemplation or contemplation stage, and your gift was more appropriate for someone in the preparation or action stage.

If you're having a hard time following through with your new plan to limit your Internet use to one hour in the evenings, maybe it's because you leapt from precontemplation to action without stopping in the contemplation stage to deal with your ambivalence ("What if I miss important emails or information?") or without stopping in the preparation stage to make a concrete plan ("Am I going to just put away the laptop or will I turn off the modem altogether? What if my partner wants to show me something online?"). It's easy to relapse and get discouraged if you move too quickly or misjudge your stage.

NB: As with any stage model, not everyone goes through every stage for every change, and not necessarily in this order.

September 04, 2011


The DSM is full of curious and non-intuitive disorders like Dissociative Fugue (sudden, unexpected travel away from home, with inability to recall one's past), Voyeurism (recurrent, intense sexually arousing fantasies involving the act of observing an unsuspecting person in the process of disrobing or sexual activity), and Factitious Disorder (intentional production or feigning of physical or psychological signs or symptoms, with external incentives).

Trichotillomania (TTM) is another one. This DSM diagnosis is characterized by repetitive pulling out of one's own hair, accompanied by pleasure, relief, or gratification at the time of pulling, but also usually accompanied by longer term or global distress about the behaviour. This is not the cliched image of the frustrated person pulling out clumps of hair; rather, hairs are selected and plucked one by one from any area of the body, but most often from the scalp, eyebrows, eyelashes, or beard. People with TTM might pull out their hair in front of the bathroom mirror, on the phone, or on the bus; they might use their fingers or a pair of tweezers; they might do it when they are relaxed or when they feel stressed.

Why do people pull out their hair?

In some ways, hair-pulling is a bad habit akin to biting your nails or picking at your skin. You know that pain/relief/pleasure/regret you feel when you pull off a scab or yank out a hangnail? People with TTM will tell you that there's something similarly satisfying about feeling around in your hair until you find a perfect one--usually a hair with a weird colour or texture--and yanking it out of your head. It's rewarding and it feels good to fulfill the urge to pull.

In other ways, TTM is more than just a bad habit. It seems to cause more distress than do nail-biting and skin-picking--significant enough distress to land TTM a spot in the DSM, where it is currently listed as an impulse-control disorder, along with Pyromania, Kleptomania, and Pathological Gambling, among others. In the new version of the DSM (DSM-V, to be published in 2013), TTM will be listed as an Obsessive-Compulsive Spectrum Disorder instead, in recognition of the overwhelming urge that precedes hair-pulling, and the repetitive and compulsive nature of the behaviour.

Some research has found that people with TTM are most likely to pull out their hair when they're bored or during sedentary activities like watching TV or reading, while other research has shown that hair-pulling happens the most when people are anxious, depressed, stressed, or angry. Some research has shown that people with TTM are often perfectionists who have very high standards; when they fail to meet their own elevated standards, they become frustrated and impatient and that's when they pull out their hair.  Still other research suggests that there are two types of hair-pulling: one that is habit-like and happens without conscious intent and one where the person with TTM consciously and deliberately grabs the tweezers and heads for the bathroom mirror. None of this research, however, explains why people start pulling out their hair in the first place.

Trichotillomania is not a trivial disorder. A lot of people with TTM feel a great deal of shame, frustration, and distress about their hair-pulling and go to great lengths to hide the behaviour and its consequences--going on pulling sprees when they're home alone, wearing a wig, and avoiding swimming, hairdressers, and windy days. TTM can create relationship issues (e.g., your partner doesn't understand and keeps frustratedly batting your hands away from your hair or demanding that you stop it) and problems at work (you can't focus because your hands drift up to your head every time you sit down at your computer).

If you suffer from TTM, know that there are treatments for this problem. Some are behavioural (i.e., they focus mostly on just plain stopping the behaviour, mostly through increasing awareness of the habit and introducing an alternative habit, kind of like gum chewing instead of smoking), and others focus on mindfully accepting the urge to pull and dealing with the difficult emotions that often precede and follow hair-pulling. These treatments help a lot of people decrease their hair-pulling or stop altogether.

August 15, 2011

Rain Check

Earlier this summer, I took a six-week workshop about dealing with emotions using (among other things) mindfulness and CBT strategies. Of the things I learned in the workshop, my favourite was that the word emotion comes from a Latin root that means to move through or to move out.

I love this! It reminds me that emotions are transient in nature, and that the way out is through (that is, that experiencing tough emotions makes them dissipate much more quickly than does avoiding them). But what's the best way to move through (and therefore, beyond) painful feelings?

There's an acronym that can be used to deal mindfully with uncomfortable emotions: RAIN. It's often taught in Buddhist meditation circles, but you definitely don't have to be Buddhist or even into Buddhism to use it. All you need is to be willing to try it, even when it's hard.

R is for Recognition, the first step to mindfulness in the midst of powerful or painful emotion. Recognition means that you take a second to acknowledge and label the emotion, asking yourself what exactly you're feeling and naming it (e.g., fear, guilt, anxiety, shame). Identifying and labeling emotions forces you to step outside the swirly vortex of feelings, at least briefly. It normalizes emotions and reduces their power.

A is for Acceptance, which means deciding that whatever you're feeling is okay. Give yourself permission to experience any emotion under the sun. You don't have to like the emotion or be happy that you feel that way, but you also don't need to judge yourself for it (creating secondary emotions). When you have a feeling that you find hard to accept (e.g., rage at a loved one), it can help to think of the emotion as your own secret. No one can see how you feel inside; you get to decide whether or not to act on it or express it, and if you don't, no one will ever know how you felt. The idea of your emotions as secret can help you accept them, whatever they are.

I is for Investigation. One way to be mindful with your emotions is to stop trying to think about what they might mean or how you can get rid of them and to instead explore how they feel in your body. In the investigation step, you adopt an attitude of curiosity about how the emotion manifests itself physically, what it feels like inside you. Ask yourself how you know you're feeling a particular emotion: what tells you that you're disappointed, anxious, or scared? Is your face cold, are your limbs prickly, or your belly made of lead? All emotions have some kind of physical manifestation and bringing your attention to it forces you out of your head, away from avoidance, and into the present experience.

N is for Non-identification. This means remembering that the definition of emotion involves movement, and adopting a "this too shall pass" attitude. It means creating some space around the emotion, rather than being one with it. Think of it as a visitor who dropped by. You can open the door and let it in, and acknowledge that it's present. You can even sit in in the living room and serve it tea, but you don't have to identify with it or get tangled up in it. The emotion isn't who or what you are.

The next time you feel your emotions taking over, try letting it RAIN!

August 04, 2011

Will Power versus Rules

If you want to make a difficult behaviour change, forget about will power and try making a rule instead.

I just finished reading The End of Overeating: Taking Control of the Insatiable American Appetite by David A. Kessler, a book about the psychology and physiology of compulsive eating and the role of the food industry. In the 'self-help for overeaters' section, the author recommends that, rather than counting on will power, overeaters should implement strict and absolute rules to eliminate struggle when faced with foods that trigger overeating. According to Dr. Kessler, absolute rules eliminate the need for will power! Here's why: Will power is invoked in the moment. The second you're faced with a desired stimulus (let's say cake, but it could also be a desirable but unnecessary purchase, or reading your favourite news sites and blogs rather than starting to work in the morning), will power pits the force of your desire for the reward (food, purchase, Internet) against the force of your determination to resist, creating discomfort.

In contrast, a rule is a long-term principle created in advance and not in the presence of the desired/rewarding stimulus. A rule (e.g., "No dessert") is based on experience and on a rationale (e.g., that much sugar makes my heart race and gives me a sugar hangover the next day; I want to maintain my weight; I know if I have one piece, I'll end up having seconds and thirds) that allows you to inhibit your normal behaviour (see cake, eat cake), without struggle ("I want it--no, I shouldn't have any--but it's a party and I deserve it--but what about my weight--okay, maybe a small piece"). Having an absolute and completely integrated rule allows you to avoid the impossible task of remembering your rationale at the moment you're faced with the desired stimulus--the rule is so internalized that it's a given.

A budget rule is another example: say you and your partner decide that travel is one of your most important values, and that in order to save money to travel, your rule is to never eat out when you're in town. When you receive an invitation to go out for dinner, you don't debate or agonize or argue over it, because the decision is pre-made: you're not going. No struggle and no will power necessary!

The distinction between rules and will power caught my attention because this year, I stopped eating grains--no pasta, bread, rice, and no most desserts--and have been training (running) harder than ever before. Observing me decline brownies and skip social occasions to go for long training runs, a few people have commented on my will power. This comment makes me feel uncomfortable because it rings untrue: if I have so much will power, why don't I stop eating family-sized bags of Nibs in one sitting, repeatedly interrupting my work to check my email, and scratching mosquito bites until they become scars?

The concept of rules provides an explanation: I am following two completely integrated and internalized rules: 1) No grains; 2) The training schedule is law. These rules are congruent with the definition provided by Dr. Kessler: both were created in advance (in January and years ago, respectively), for rational personal reasons (related to physical and mental health) based on my experience and consistent with my long-term goals, and they allow me to inhibit my default behaviour (i.e., eat any and all available baked goods; sleep in/prioritize social life). So when I turn down a fresh cinnamon bun, it's not because I have will power (which implies that I struggled with the decision), it's that my rule dictates that cinnamon buns aren't even an option. Same with following my training schedule: I don't struggle over getting up early or skipping your party to run; it's not hard and it doesn't involve will power. (Think about vegetarians who used to enjoy meat. I don't think they struggle every time someone offers them a burger; they're just following their very integrated rule.)

I think what might take will power is the initial creation of the rule--making the rule and sticking to it until it becomes entirely integrated. The two rules above are the only ones I've succeeded in internalizing to the point that there's no struggle. Among myriad others, I've tried "11pm is bedtime," and "no email checking until lunchtime" without success.

NB: The use of absolute rules isn't entirely positive, and rules aren't for everyone. I think they may be more helpful for abstainers (people who are successful with a 'cold turkey' or all-or-nothing approach) than for moderators (people who can successfully indulge moderately or occasionally). (Read about this distinction here.) Further, the inherently rigid nature of rules can create problems (e.g., following your training schedule to the letter even when you're injured; following your no-dinners-out rule even when it's your best friend's milestone birthday party).

What are your rules? Do they work?

July 17, 2011

Marsha Linehan

Renowned American psychologist and researcher Marsha Linehan recently acknowledged that she struggled with borderline personality disorder--a notoriously treatment-resistant disorder characterized by dysfunctional interpersonal relationships, emotional instability, and self-harming or suicidal behaviour--in her adolescence and early adulthood. This is big news: it's not every day that a senior and distinguished psychologist reveals that she suffered from a severe mental illness, particularly one that is as heavy with stigma as is BPD. The story is all the more interesting because researching and treating borderline personality is Dr. Linehan's life work.

According to the New York Times article, as a self-destructive and chronically suicidal teenager, Linehan was hospitalized for symptoms that would meet the current DSM criteria for BPD. Diagnosed instead with schizophrenia, Linehan was treated with Freudian analysis, seclusion, antipsychotics, and electroshock therapy. When she was discharged from the hospital at age 20, the doctors gave Linehan little chance of surviving.

Subsequent to a quasi-religious experience in her 20s, Linehan discovered and embraced the concept of radical acceptance. Radical acceptance is a Buddhist concept that means accepting on a deep level, without judgment. According to Linehan, she stopped feeling suicidal and began to love herself when she stopped focusing on the gulf between the person she wanted to be and the person she was. Linehan went on to study psychology and used the concept of radical acceptance to form the foundation of Dialectical Behaviour Therapy, an effective treatment for BPD. Based on the opposing principles of acceptance and the need to change, DBT succeeded where other treatments for BPD failed.

No matter how you feel about religious epiphanies, Linehan's public exposure of her past is significant. First, her admission offers the hope of a meaningful and fulfilling life to individuals with BPD and other serious mental illnesses. Second, Linehan is lending a famous face to mental illness (à la Margaret Trudeau), showing the public that mental health problems aren't just something that happens to people in movies, psychiatric hospitals, and homeless shelters. Third, that Dr. Linehan's experience suffering from BPD informed the development of one of the first empirically-validated treatments for the disorder collapses the usual divide between the world of academic research and the patients who benefit from the research.

Finally, Dr. Linehan's disclosure demonstrates significant courage. BPD is a diagnosis given primarily to women, and is burdened with more stigma and stereotypes than perhaps any other psychiatric disorder. By admitting to BPD, Linehan has made herself vulnerable to skepticism, sexism, and invalidation. However, I expect that in this case, the disclosure will only more firmly entrench Dr. Linehan as a valued pioneer and significant contributor in the field of psychology.

July 14, 2011

Criteria Controversy

How do you know if a given behaviour or group of symptoms constitutes a psychiatric or psychological disorder? This is an important question, and particularly relevant right now as psychiatrists work on the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), to be published in 2013.

Proposed additions to the DSM like Internet Addiction and Premenstrual Dysphoric Disorder (PMDD) are raising the ire of DSM critics who argue that the manual medicalizes and pathologizes normal behaviour. While this criticism is valid and worthy of discussion, people making this argument have the frustrating habit of selecting one symptom from the list of DSM criteria for a given disorder and using it to claim that the criteria describe normal behaviour. The most recent person to do so is Ian Brown of the Globe & Mail. In his article, Brown gives the example of one criterion for the proposed DSM-V diagnosis of compulsive hoarding: "Persistent difficult discarding or parting with possessions, regardless of the value others may attribute to those possessions."

According to Brown, this symptom describes "anyone with a basement." Such is the problem of selecting and criticizing a diagnostic criterion in isolation. Anyone wishing to make a similarly unsophisticated argument could choose "Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances" from the proposed criteria for binge eating disorder (BED) or "Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) prior to most menstrual cycles" from the proposed criteria for PMDD. They could argue that they often overeat at dinner parties and experience mood swings before they menstruate and that the inclusion of BED and PMDD in DSM-V would unfairly pathologize their behaviour.

This argument fails to acknowledge a) the other diagnostic criteria for the respective disorders and, importantly, b) the additional criterion of significant distress. The diagnostic criteria for most of the DSM disorders include "Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." This is a key criterion: If you have a basement full of junk, but it's not bothering you or anyone else (and not causing a health or safety risk), no one is going to accuse you of being a compulsive hoarder. If you overeat at dinner parties and binge on chips during the Superbowl, but it doesn't cause you lasting distress (or health problems), no one is going to label you with binge eating disorder. Writers like Brown are advised to keep the distress criterion in mind--as well as the entirety of the criteria for a given disorder--when they're fretting about the pathologizing of normal behaviour.

NB: My endorsement of the significant distress criterion is not a defense of the singular use of the DSM to decide what is and isn't a clinical problem. If your symptoms or behaviour don't cause you distress or impairment, you probably don't have a clinical problem. But: if you experience significant distress or impairment despite having only minor symptoms, it's still a problem. That is, if you binge eat only four times per year at holidays or only experience mood swings every third time you menstruate--but it causes you significant distress or impairment--ignore the doctor telling you your symptoms are subclinical according to the DSM, and seek help elsewhere. Distress is distress.

July 05, 2011

Emotions About Emotions

Mental health tip: Don't have emotions about your emotions.

Psychologists differentiate between primary or "clean" emotions and secondary or "dirty" emotions. The first are the emotions you feel in direct reaction to what's going on. You feel sad because your cat died, or jealous because your colleague got the job you wanted, or lonely because you're alone. Secondary or "dirty" emotions are the ones you feel in reaction to your primary emotions. You feel guilty that you're sad about your cat when your friend's brother just died, or ashamed that you're jealous of your colleague's new job instead of happy for her, or embarrassed that you're not good at spending time alone.

Secondary emotions indicate a struggle against or judgment of the initial emotion. They are the direct result of thinking I shouldn't feel this way. This reaction is common; one major culprit is the widespread belief that happiness or contentedness is the norm, and that strong or negative emotions are bad or abnormal or harmful and should be avoided at all costs. Despite ample evidence to the contrary, many of us believe that happiness is the normal baseline, and use this belief to berate ourselves for feeling bad.

The idea of happiness as normal is being challenged by a relatively new therapeutic approach called Acceptance and Commitment Therapy (ACT). ACT is based on, among other things, acceptance of difficult emotions, thoughts, and impulses. A primary objective of ACT is to use mindfulness to accept difficult or negative experiences (emotional or other) as normal, and to let go of the struggle to be free of them.

If you're thinking "Isn't this kind of incongruent with CBT, where you're supposed to identify the distorted thought that created the negative emotion and adjust the thought so you can get rid of the emotion?" the answer is yes. This is a critical debate between CBT and ACT. Proponents of ACT think that CBT is too focused on changing or getting rid of negative emotions, promoting the idea that pain, anger, and anxiety (among other emotions) are bad or abnormal.

I believe in both. If your unpleasant emotion is the result of a distorted thought, then by all means: identify the distortion, modify the thought, and enjoy the accompanying shift in feeling. However, if you're experiencing a primary emotion in reaction to something that's really happening, consider that strong negative emotions are normal and part of what makes you human. Try saying to yourself "I should feel this way. Given what's going on, of course I feel this way." Give yourself a break and don't pile on that unnecessary second round of judging emotions.

NB: The examples above of primary or clean emotions are not the only acceptable ones. If you feel relieved that your cat died or angry because you're lonely, that's okay too! When we feel less intuitive emotions, that's when we're even more likely to start layering secondary emotions, and probably when it's most important not to.

June 14, 2011

Believe Me

Behaviour doesn't persist for no reason. Any habit or way of being that you repeat or maintain even though it causes problems for you is probably being reinforced, often through underlying beliefs. This holds true for both everyday habits and chronic mental health problems.

Everyday Habits

Say you're someone who is always late. Your lateness frustrates others and means that you're often stressed out and rushed. You always tell yourself to try harder to be on time and promise to do better next time, but you're still always late. Why? Examine your beliefs: what do you really think about promptness? You might realize that you believe that people who are on time must be less busy and are therefore less important. Alternatively, you might realize that you believe that being late (e.g., for a work meeting) makes you look good--like you're working so hard you couldn't tear yourself away from your desk.

Say you just moved to a new city and you're always tired because you stay up late every night emailing or chatting online with friends from your old city. Every day when you're falling asleep at your desk in the afternoon, you promise to get to bed early, but every night, you go online to catch up with your friends. What beliefs are preventing you from getting into bed at a decent hour? Maybe you believe something like "Out of sight, out of mind," and are scared your old friends will forget about you if you don't talk every night.

Finally, say you're someone who is constantly in conflict with your partner, who unfailingly answers the question "How's it going with your boyfriend/girlfriend?" with a litany of crises and dramas. You may purport to envy a friend who always replies "Pretty good, nothing to report" to the same question, but look at your beliefs: do you secretly believe that your perpetual drama makes you seem intriguing? Alternatively, do you believe that if you don't create conflict and "keep things interesting," your partner will get bored and leave you?

Chronic Mental Health Problems

Individuals who suffer from Generalized Anxiety Disorder--a disorder characterized by chronic and excessive worry--have beliefs about worry that make it hard for them to stop. They believe that worrying (e.g., about their children) demonstrates love and support, that worry helps control outcomes (e.g., if I worry about my plane crashing, it makes it less likely to happen), that worrying in advance can prevent negative emotions if the worry comes true (e.g., if I worry that my partner will leave me, it will hurt less if it happens).

People with other chronic mental health problems also have beliefs about the usefulness of their condition. I had a client whose belief about her chronic anxiety made her reluctant to change: although being anxious most of the time decreased her quality of life, she believed that if she reduced the anxiety that fueled her spotless home, compulsive list-making, and hyper-organization, she would no longer be productive or efficient. She believed that if she weren't anxious, she'd never get anything done.

People with chronic depression may also develop beliefs about the advantages of certain aspects of their condition. An individual whose depression is such that she goes through life spotting flaws and seeing the world through a negative filter may fear that if she becomes less depressed, she'll lose her ability to think critically and spot potential pitfalls, decreasing her effectiveness at work. Similarly, someone who believes that his depressive tendency toward moody contemplation or rumination is the foundation of his artistic career may fear that working on his depression will make him less creative.

People may also have beliefs about happiness that make them reluctant to embrace or strive toward happiness: they may believe that happiness is boring, that it's shallow or ignorant, or that it's selfish.

Try identifying and testing the beliefs that motivate your habits and behaviour. If it turns out that your belief isn't true (e.g., your partner is actually considering leaving you because of all the conflict and drama), you may find it easier to change your behaviour. If your belief turns out be true (e.g., your old friendships fade when you go to bed early instead of chatting online), you can still use that information to change your behaviour (e.g., chat with your friends on your lunch break instead; accept that friendships change and seek friends in your new city).

Unidentified underlying beliefs make problem habits resistant to change. Identified beliefs provide insight and a springboard for change.

June 08, 2011

Few Good Men

The New York Times recently published an article about the pervasive lack of male psychologists and psychotherapists. It's unequivocally true that clinical psychology has become a female profession: about 95% of the students in my PhD program are women, and the majority of the psychologists at the research centre where I work are female. This gender disparity is new: at least half of my professors and supervisors are male and most of my female professors and supervisors are relatively young, indicating that a shift occurred in the last generation.

Following the NYT article, a Psychology Today blogger wrote that the evacuation of men from psychologist and psychotherapist positions corresponds to the increased difficulty of earning a good living in these professions. Men seem to be less willing or less able to afford to work in low paying jobs. Moreover, the decreased proportion of men in psychology corresponds to a decrease in the field's status and prestige. The same blogger wrote that, rather than being seen as respected and qualified health care experts, clinical psychologists are viewed as part of a generic mass of mental health workers, indistinguishable from counselors, social workers, and other professionals who do not enjoy the power of psychiatrists to prescribe medication. (NB: psychiatry has not witnessed a gender shift to the same extent.)

Does it matter if your psychologist is male or female? Is one gender better suited than the other to deal with certain issues?  Another Psych Today blogger argues that the overrepresentation of women in the field is problematic because it decreases the appeal of psychotherapy to men. Men are already traditionally reluctant to seek therapy, and the inability to find a male therapist may discourage them from getting the help they need. This is a plausible argument: male would-be clients might feel more comfortable speaking with a male therapist about sexual dysfunction, anger or dominance issues, or the pressures of fatherhood,. That said, men may feel more comfortable opening up to a female therapist about less "manly" problems like sadness, fear, and anxiety. Similarly, female clients may feel less confident in a male therapist's capacity to understand body image issues or motherhood or fertility issues, but more comfortable disclosing to a male therapist about traditionally unfeminine issues like aggression or partner abuse.

But if men need male therapists and women need female therapists to properly understand their experience, do disabled people need disabled therapists, visible minorities need visible minority therapists, and elderly people need elderly therapists? As someone who is pro-therapy, to some degree I believe that anything that encourages someone who needs help to get help is good. That is, if the prospect of having a therapist who looks like you or is of your gender will encourage you to seek therapy, that's positive. However, this type of client-therapist matching introduces the risk of a client (or therapist) assuming that her South Asian therapist (or client) has had the same South Asian experience as her, or that his blind therapist has had the same blind experience as him, creating a significant risk of stereotyping, misunderstanding, and disappointment.

Our training as psychologists is supposed to be broad enough to allow us to be empathetic and helpful to clients of both genders and of a wide variety of experiences and walks of life. I have never had a male psychotherapist: I've had a few good and a few bad female therapists, but I can't say that any of them seemed particularly suited or particularly poor at helping me address my problems because of their gender.

Would you prefer a therapist of your own gender? How come?

May 23, 2011

Ask Yourself This

Whenever I reread the list of cognitive distortions, I re-notice how they pepper my everyday thoughts. If you've started noticing your own distorted automatic thoughts, you may be wondering what you're supposed to do once you've identified them.

Here are three questions that will help you evaluate and alter your thoughts. NB: the point isn't to change our thoughts to think positively; rather, the point is to think realistically because realistic thoughts create helpful emotions and promote behaviour change.

1) What is the evidence for and against this thought? This exercise requires you to play devil's advocate with yourself, using objective facts. Say you're overtired and you lose your temper and yell at your daughter for knocking over her cup of milk. Your automatic thought might be "I'm a bad parent." Your supporting evidence might include things like you were so tired that you didn't read to her before bed even once this week, and you didn't put any vegetables in her lunch today. But if you look for evidence that contradicts your thought, you'll remember things like that you stood in line for two hours last weekend to register her in a good summer camp, and that your daughter's teacher recently told you that she seems overall happy and well adjusted. Considering the evidence will allow you to adjust your thought from "I'm a bad parent" to "I'm short-tempered when I'm tired but I'm a good parent in general."

Another example: You're having lunch alone at a cafe, feeling lonely. Looking out the window, everyone who walks by seems to be with family or friends and you automatically think "I'm the only person who's alone." That all the passersby are in groups supports your thought, but if you look for evidence against the thought, you might notice that there are four other people in the cafe who are reading or working alone. This direct and concrete contradictory evidence will help you adjust your thought from "I'm the only person who's alone" to "I'd rather be with a friend or partner right now, but I'm not the only one who's alone."

2) Is there an alternative explanation? This one is especially good for automatic thoughts about others' behaviour. If you're talking to someone you just met at a social event and he keeps looking away during the conversation, your automatic thought might be "I'm boring and socially awkward." But if you try to generate alternative explanations for his behaviour, you might come up with "He's keeping an eye out for a friend who hasn't arrived yet" or "He's shy and socially awkward." Second example: You don't get the grant you applied for and you automatically think "My application sucked." Generating alternative explanations, you'll come up with possibilities like "There were more applicants than usual this year" and "The funding body had a smaller budget his year." 

Final example: After your interview on Monday, your potential employer says she'll call by Thursday at the latest. By Thursday she hasn't called and you automatically think, "I didn't get the job." Alternative explanations for her behaviour include "She hasn't decided yet" and "Something  came up and she didn't have a chance to call." It doesn't mean you did get the job, but it allows you to change your thought from "I didn't get the job" to the more realistic "I don't know yet if I got the job."

3) And if it were true--is it that bad? If all the evidence supports your negative thought and you can't find alternative explanations, maybe it's true. If so, ask yourself: Is it that bad? The answer to this question works in two ways. First, it can help you realize that even if your automatic thought reflects reality, it's not the end of the world. For me, it's been the most useful for the thought that someone is upset with me. I'm prone to friendship paranoia (my own coined term, not a DSM diagnosis!) and have been known to interpret the slightest lack of warmth as a sign that my friendship is at risk. Recently, though, I've learned to consider that even if a friend is irritated or angry with me, it's not the end of the world. It's uncomfortable, but it's also normal, and most relationships can withstand a bit of conflict. Realizing this helps me calm down enough to apologize if necessary and otherwise, to let it go.

The second way that "and if it were true--is it that bad?" works is that when the answer is yes, it is that bad, it can motivate you to change. If all evidence indicates that your grant application did suck, you are the only person who is alone, or that you are socially boring or awkward--and these things bother you--maybe you'll get someone to edit your next grant application, try speed dating, or work on your social skills. This is the behavioural part of cognitive-behavioural therapy, where you actually change the way you behave (in turn changing your thoughts and emotions).

Up next: shorter blog posts.

May 16, 2011

Don't Believe Everything You Think

News Flash: Just because you think something doesn't mean it's true.

A lot of our thoughts are distorted or irrational and directly promote depression, anxiety, and anger, among other mental health scourges. Cognitive-behavioural therapists use the non-exhaustive list below to point out the things and ways we think that are unrealistic, distorted, and just plain false.

1) All-or-nothing thinking: You see things in black and white, as all good or all bad. You say things like "Everything sucks," and "That was a complete waste of time." The hallmarks of all-or-nothing thinking are words like complete, total, everything, and everyone.

2) Overgeneralization: You see a single negative event as part of a never-ending pattern of defeat. If you don't get a call back after your job interview, you think "I always screw up." If you plan a barbeque and it rains, you think "Nothing ever works out for me." Words like always and never figure prominently.

3) Labeling: This is an extreme form of overgeneralization. Instead of naming your own or someone else's specific behaviour, you attach a global negative label. Rather than say " I lost my temper and yelled at my son," you say "I'm a bad parent." Instead of saying, "My boss gave me an unfair evaluation, you say "My boss is an asshole."

4) Negative filter: You pick out negative details and dwell on them exclusively, not letting in any positive information. You focus on the one rainy day in the sunny week or the one snag in a project or relationship that is otherwise going quite well, darkening your overall perception until you see the whole world through a lens of negativity.

5) Disqualifying the positive: You reject positive experiences by insisting that they're trivial or somehow don't count, maintaining a negative perspective that's incongruent with reality. You say things like "I only got the job because no one else applied," and "Sure I finally completed my PhD--but most of my friends finished school a decade ago!"

6) Mind Reading: Without sufficient evidence, you arbitrarily conclude that someone is reacting negatively to you. You think things like, "Now that she knows I'm single, she thinks I'm a loser, "and "He didn't come over and say hi right away; he's wishing he hadn't invited me."

7) Fortune Telling: You predict failure and negative outcomes. You anticipate that things will turn out badly and are convinced that your prediction is already an established fact. You think things like "There's no way I'll win that competition," and "I'll never meet someone I'll love as much as I loved my ex."

8) Catastrophizing: You believe that what happened or might happen will be so awful and unbearable that you won't be able to stand it. In this case, it's not that you misperceive what happened or might happen--it's that you exaggerate the consequences and minimize your ability to deal with it. You believe things like "If he broke up with me, I'd fall apart," and "There's no way I can handle moving again this year."

9) Emotional reasoning: This one is neatly captured by "I feel it, therefore it must be true." You assume that your negative emotions are a reflection of reality and think things like, "Because I feel intimidated by him, he must be smarter than me," and "Because I'm scared of flying, it must be dangerous."

10) Should statements: You have rigid standards or expectations and you use them to judge yourself, others, and the world. You think things like "It shouldn't be this hard for me to stick to my diet," "I should have been able to handle that on my own," and "These people should treat me with more respect."

11) Personalizing: You assume total responsibility for negative events and arbitrarily conclude that they are your fault or reflect your inadequacy. You think things like, "If I were a better therapist, my client would do her homework," and "If I were a better mother, my daughter would have more friends."

Cognitive-behavioural therapists love this list and use any excuse to whip it out. It's been given to me by countless professors, supervisors, and workshop leaders, and by more than one therapist. I've in turn given it to my own friends and clients.

Next up: what to do once you've identified your distortions.

May 09, 2011

What is CBT?

We often say things like "I don't know why I feel anxious," or "All of a sudden, I felt so mad... out of nowhere!" or "I don't know why I acted the way I did." Here's a question: what were you thinking at the time?

Cognitive-behavioural therapy (CBT) is a psychotherapy approach that emphasizes the role of automatic thoughts in feelings and behaviour, and suggests that our feelings and behaviour aren't caused by people, situations, and events, but are instead caused by our thoughts about people, situations, and events.

Example: say your parents call three different times in one evening. How do you feel? If you think, "They're always trying to run my life," you might feel irritated or indignant and avoid returning their calls; if you think, "They love me and are excited for my upcoming trip home," you might feel warm and fuzzy and call them back the next morning; if you think "They're trying to reach me because something bad happened," you might feel worried and call them back that night even if it's late.

Another example: your work colleague walks by in the hall and doesn't say hi. If you think, "He thinks he's awesome now that he got that promotion," you might feel insulted and gossip about it with your office mate; if you think, "He's probably distracted; I heard his daughter's sick," you might feel sympathetic and send a quick email to ask how he's doing; if you think, "He's still mad about that mistake I made last week," you might feel anxious and avoid running into him again. In each of these cases, your reaction isn't the direct consequence of the event, but is the consequence of your thoughts and your interpretation of the event.

CBT is based on three principles: thoughts affect behaviour; thoughts can be monitored and altered; and changing thoughts can change behaviour. Learning the CBT lesson that emotions and behaviour don't come out of nowhere can help people who experience a lot of upsetting emotions or who are unhappy with certain elements of their behaviour gain some control over their feelings and actions. Cognitive-behavioural therapists first teach clients that a lot of distress is created by distorted or unhelpful thoughts, and then help clients adjust their thinking by teaching them to evaluate the validity of their thoughts and generate possible alternative thoughts.

CBT has proven to be an effective treatment for a variety of anxiety, mood, sleep, personality, substance use, and eating disorders, as well as for problems like chronic pain, stress, anger, and relationship issues. As a CBT student, client, and therapist, I'm here to tell you that it works. I believe in it and I recommend it.

Up next: examples of specific CBT concepts and interventions.