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.