December 11, 2012

Don't Believe the Hype

Although most of us would agree that worry, anxiety, and depression are unpleasant, these experiences are sometimes associated with positive beliefs. This is problematic because such positive beliefs make these mental health scourges resistant to change.

Example: Generalized Anxiety Disorder (GAD) is a disorder characterized by chronic worry and subsequent anxiety and physiological symptoms (e.g., muscle tension, headaches). People with GAD habitually create worry chains of worst-case scenarios, often starting with "what if" (e.g., My boss asked to see me, what if I made some kind of serious mistake, what if I get fired, how will we pay our bills? or My head hurts, what if it's something serious, what if it's fatal, who will take care of my kids?).

Although most GAD patients say they're sick of worrying and wish they could stop, it's well established that most people with this disorder have positive beliefs about worry. Among other things, they believe that worrying offers protection from feared outcomes (e.g., if I worry about my son being in a car crash, it's less likely to happen), that worrying is a positive personality trait (e.g., I'm the family worrier, it's how I show my love), or that worrying shelters them from potential future negative emotions (e.g., if I worry about losing my job, it won't hurt as much if I actually do).

Positive beliefs about unpleasant psychological symptoms aren't limited to GAD. A depressed patient told me that during her childhood, she and her siblings and their divorced parents scoffed at happy-seeming nuclear families, assuming that the happy families were either faking or stupid or both.  As an adult, my patient still believed that being happy was synonymous with being phony and dumb and that being depressed meant that she was smart and authentic. I had a patient with an eating disorder who believed that her bulimia made her dramatic and interesting. Whenever she attended a social function involving food, she would refer to her "serious eating issues," generating instant curiosity and solicitousness. She believed that recovering from her eating disorder would make her boring and pedestrian. Finally, I used to believe that anxiety made me productive. I spent years resisting mindfulness and other enormously helpful relaxation techniques, believing that I'd never accomplish anything if I weren't anxious.

In such cases, the best strategy is not to simply tell people that their beliefs are wrong, but to get them to test the beliefs. My depressed patient took inventory of the people she knew who seemed happy. She found that many of them were both intelligent and genuine, demonstrating that her belief wasn't altogether accurate. My GAD patient practiced not worrying when his son made the five-hour drive to visit; he noticed that not only did his son arrive safely, but he enjoyed their visit more because he wasn't a worried wreck by the time his son arrived. My bulimic patient made a list of people she found interesting and noticed that none of them had eating disorders--and that two of her friends who also suffered from eating issues hadn't made the list. She also made a list of the qualities that she admired in herself, and identified a number of interesting and enviable traits that weren't related to her eating issues. For myself, I took a closer look at whether or not I was actually more productive when I was feeling anxious. I noticed that while anxiety occasionally propelled me into action, it more often drove me to produce unrealistic to-do lists that raised my stress level and stifled productivity. I also observed that on days when I was more relaxed, I was happily productive.

It's counterintuitive that we want to hold on to being anxious, worried, eating disordered, and depressed, and it can be frustrating for friends, family members, and therapists who want to help us make change. In such cases, exploring beliefs about symptoms helps. Worked for me!

December 04, 2012

The Pleasure Principle

In the upcoming season of excess, what can we do when faced with temptation? When tempted to eat a third piece of pie, drink a fourth glass of wine, or buy a fifth adorable gift for our adorable niece, how can we exercise restraint? If you're wondering how to face the overeating, overdrinking, overspending, and other overs that run rampant in December, here are some ideas:

One way to handle situations that require will power is to have a predetermined rule. As discussed in an earlier post, using a rule means not having to make decisions, thereby avoiding poor choices borne of decision fatigue and ego depletion. For example, if you have a non-negotiable rule that you go to the gym before work every Monday and Wednesday, you don't have to make a decision when your alarm goes off in the morning, you just hop out of bed. If you have a non-negotiable rule that you don't drink coffee after 2pm, there's no will power involved in turning down your colleague's offer to pick you up a latte, because afternoon coffee is simply not something you do. 

Rules are rigid, though, and it takes time for them to be integrated to the point that no will power is required. I have a friend who has a novel approach: My friend pretty much never eats dessert. When others are impressed by her will power or accuse her of denying herself pleasure, she replies that rather than denying pleasure, she's giving herself a different kind of pleasure--i.e., the gratification of feeling fit and liking how her body looks. This is a new angle and one that applies equally well to saving money, avoiding sweets, exercising, and other generally positive behaviours.

I like to call this the Pleasure Principle and I've adopted it for my own use in situations involving, for example, spending versus saving money and going to bed at a reasonable hour versus staying up late reading or playing around on social media. I could enjoy new boots or I could enjoy feeling confident about paying my bills at the end of the month. I could enjoy sending one more message or I could enjoy being pleasant and well rested tomorrow. If I decide to save my money or decide to turn off the computer and get in bed, I'm not denying myself the pleasures of new boots or Facebook--rather, I'm benefiting from an alternative pleasure.

How is the pleasure principle different from rules, will power, and doing your future self a favour? Rules imply rigidity, will power implies self-denial, and doing a favour for your future self implies doing something grudgingly, but for a greater or future good. The pleasure principle removes all of the negative implications, leaving you with pure pleasure--it's win/win.

This holiday season, keep the pleasure principle in mind when you're trying to resist the third piece of pie, fourth glass of wine, and fifth perfect gift for your niece. Let me know if it helps!

November 29, 2012


Psychoeducation is a core feature of cognitive-behavioural therapy--and any good therapy. The term refers to information that a therapist provides a patient about the patient's symptoms or disorder, about the therapy model, and about how treatment will proceed, among other things. A lot of psychoeducation occurs in the first few therapy sessions, but psychoeducation also involves explaining new concepts and providing a rationale for in-session exercises or homework assignments over the entire course of therapy.

As a therapist, I sometimes forget the importance of psychoeducation. Particularly when I feel an urgency about helping a given patient, I make the mistake of cutting short the education part to try to jump ahead to a more "active" treatment phase. To avoid this error, I have to remind myself that good psychoeducation is part of the treatment: patients consistently demonstrate great interest in the information provided, express relief to learn that their symptoms are normal, and show greater commitment to therapy following psychoeducation. In fact, often when therapy doesn't seem to be having the intended effect, it's because I went too quickly and failed to psychoeducate sufficiently.

I had an experience today that reminded me just how powerful psychoeducation can be: I have a patient who suffers from obsessive compulsive disorder (OCD), an anxiety disorder characterized by intrusive thoughts and by repeated compulsive actions designed to eliminate the anxiety generated by the thoughts. During our session, we were discussing the nature of OCD and I emphasized the fact that intrusive thoughts* (e.g., I could jump in front of this bus; what if I had sex with my best friend's partner; my hands could be contaminated from that weird meat at lunch; I could drop the baby off the balcony) are normal and common, and that most almost everyone--OCD or not--experiences them. My patient was so happy and relieved to hear this that he kissed my cheeks when he left my office--not our usual way of saying goodbye!

My patient's reaction reminded me that psychoeducation is an important part of my job. Here are some examples of information that can make a big difference for patients:
  • For patients with panic attacks: It's normal to think you're going crazy or to think you're having a heart attack during a panic attack. In fact, both are listed as panic symptoms in the DSM.
  • For patients who feel guilty about being depressed: It's normal to feel guilty when you're depressed. In fact, guilt is one of the DSM criteria for diagnosing depression.
  • For patients who fear their depression is making them stupid: Poor memory and difficulty concentrating are listed as DSM diagnostic criteria for depression.
  • For patients with generalized anxiety: Worry and anxiety are maintained by intolerance of uncertainty.
  • For depressed or anxious patients: Depression and anxiety can be maintained by beliefs about depression and anxiety (e.g., anxiety makes me productive; only stupid people are happy).
  • For patients with insomnia: Many cases of insomnia can be cured through simple sleep hygiene (e.g., always going to bed at the same time; not eating, drinking, or exercising right before bed; eliminating noise and light in the bedroom).
  • For mindfulness meditation clients: Meditating doesn't mean clearing your mind of all thoughts. Practicing mindfulness doesn't mean you'll be Zen all the time.
  • And my favourite, for everyone: Thoughts aren't facts. Not everything you think is true. 
The examples listed above are everyday facts for cognitive-behavioural therapists, but gifts for patients. It's like when your dentist explains to you that exposed roots are common and are often caused by overzealous brushing; when your lawyer informs you that you need your neighbour's consent to build a fence on your shared property line; or when my athletic therapist told me that imbalances in muscle strength can produce knee pain. The gift is information that produces understanding and/or relief and/or a direction for moving forward (e.g., get a soft-bristled toothbrush; set up a meeting with your neighbour; stop exercising late at night; consider ways of increasing your tolerance for uncertainty). 

* NB: Everyone has intrusive thoughts, i.e., thoughts that seem to come out of nowhere and are inconsistent with our real feelings and values (e.g., we don't really want to jump in front of a bus or have sex with our best friend's partner). The difference is that someone who doesn't have OCD treats the intrusive cognition as an annoying but passing thought and lets it go, whereas someone with OCD perceives the thought as both realistic and dangerous, and needs to perform a compulsive behaviour to alleviate the anxiety generated by the thought.

November 20, 2012

Anecdote: Parallel Therapy Universe

In September, I explained how psychologists are just like other professional that you might consult--with a specific set of skills, knowledge, and training. Today I had an experience that demonstrated the remarkable similarities between two very different types of therapy:

Before work this morning, I had an appointment with an athletic therapist. I told her my problem: "One of my knees hurts when I run." After asking some questions to understand the background and history of the problem, she maneuvered my legs around, testing muscles and ligaments to determine a diagnosis. Then she educated me: "Sometimes when you have surgery on one knee, that leg never fully regains equal strength; over time, the discrepancy between the two legs forces the muscles and ligaments to compensate--pulling in weird directions and resulting in pain." Next, she guided me through a few exercises that will strengthen the weaker leg. Once she was sure I understood how to do them, she prescribed a few for homework and made sure I wrote them down. She took notes during our session and put them in my file.

After my athletic therapy appointment, I went to work and met with my first patient of the day, a socially anxious man in his late twenties. He told me his problem: "I have to give a toast at a friend's wedding this weekend and I'm so anxious about it I can barely breathe." After asking some questions to fully understand the situation, I asked him to write down some of the thoughts and feelings that come up when he imagines giving the toast. His thoughts included "I'll go blank and won't be able to give the toast," "The other guests will laugh at me," and "If that happens, I'll be humiliated and devastated." Then I educated him: "Often people who are anxious both overestimate the likelihood of a feared event and underestimate their ability to cope with it."

Next, I guided him through an exercise that involved rating the probability of each thought: Given his ample preparation and the notes he planned to bring to the wedding, he rated the probability of forgetting his toast at only 15%. Given that most of the guests were friends of his, he rated the probability that they would laugh at him at only 10%. Given that he had experienced embarrassment during public speaking in the past--but allowing that humiliation and devastation were probably exaggerated predictions--he rated the probability of humiliation and devastation if he forgot his toast at 60%. Together we did the math (15% x 10% x 60% = .009% chance of his feared outcome occurring) and explored the impact of calculating the probabilities on his anxiety. Once I was sure that my patient understood how to apply this strategy, I assigned the use of probabilities in other anxiety-provoking situations as homework for next week. I took notes during our session and put them in his file. 

There you have it! Regardless of type, it seems that therapy involves explaining the problem, testing and diagnosis, education, introduction of a new skill or exercise, practicing the skill/exercise, and homework.

November 16, 2012

The Apple of my Eye

Why do people love Apple products so much? Sure, many of us also love our best pair of jeans, our favourite book, or our sharpest chef's knife, but I think it's fair to say that we have beyond-reasonable affection for our MacBooks, iPhones, iPods, and iPads--and that we don't feel the same way about our coffeemakers, alarm clocks, or the PCs we have to use at work.

What's this outsized love about?

Among others, two features of Apple products elicit affection:

1) Anthropomorphism is the attribution of human characteristics or motivations to animals (e.g., My cat knows when I'm sad and comes to purr on my lap), to non-living objects such as cell phones (e.g., My phone thinks I want to say 'spring' when I'm trying to say 'sprint'), or to phenomena like the weather (e.g., This snowstorm is trying to make me miss my bus). Apple products are deliberately anthropomorphic: they have ultra-responsive touch screens, which makes us feel like we're communicating with them; they're silver or white with a sleep light that throbs like a gentle heartbeat (e.g., MacBook), rather than black and machine-like with flashing red or green lights.

2) Not only do they breathe and respond to touch, but many Apple products are tiny, captializing on the cute response. The cute response is an evolutionary concept that refers to a variety of features (small, smooth, rounded) that, across species, make something look cute. Now think of Apple products: like babies and unlike boxy old computers, Apple products, including most of their icons and features, are characterized by a general absence of sharp corners and right angles. Add miniatureness, and we're in love. I mean, who hasn't cooed over an iPod nano or iPad mini?

Why do we anthropomorphize? Anthropomorphism is hypothesized to help humans make sense of our environments and feel greater control. That is, assigning human motivations to our cats, dogs, laptops, and iPods makes it easier for us to understand and interact with them. Further, anthropomorphism has been demonstrated to be more common in people who are socially isolated, where it fills a need for connection. Think of Tom Hanks and Wilson the volleyball in Castaway.

Why do we like things that are tiny and cute? Evolution science suggests that mammals are hardwired to respond quickly and lovingly to anything with big eyes, a high forehead, a small nose, and an undersize chin. These cute features signal extreme youth, harmlessness, and vulnerability; they trigger our caring instincts, which is key for evolution since the infants of most mammal species are pathetically helpless and would quickly die without parental intervention.

Apple products capitalize on anthropomorphism and the cute response, at least partially explaining our boundless affection for inanimate gadgets. These features are no coincidence, but rather a careful design and marketing strategy.

NB: The flip side is that when we anthropomorphize, we make non-human entities responsible for their actions, explaining why we feel confused--if not humiliated and betrayed--when our gadgets don't work (e.g., "I charge it every day! I always keep it in its little case! I didn't do anything, but it's suddenly dead! How could my phone do this to me??").

November 11, 2012

Confirmation Bias

Confirmation bias refers to our tendency to seek and favour information that confirms our pre-existing ideas, and to interpret ambiguous information as supportive of our beliefs. That is, we pay attention to and believe information that confirms what we already think, while ignoring contradictory information. So for example, if I believe that the city where I live has the best restaurants in the world, I'll notice and remember every delicious meal I eat in my city--ignoring any poor customer service or bad food experiences, and forgetting about delicacies consumed in other cities.

How does confirmation bias manifest in clinical psychology practice?

We all have automatic thoughts and core beliefs about ourselves, others, and the world. Some of our problematic thoughts and beliefs aren't quite accurate and, reinforced by confirmation bias, they can be quite resistant to change. Consider one of my patients--an undergraduate student who was depressed after a longterm relationship ended. She was very lonely after the break-up, and frequently had the thought that everyone in the world but her was in a relationship. This recurring thought meant that every time she attended a social event, she was hyper-aware of couples and failed to notice people who had arrived alone or with friends. In our sessions, my patient repeatedly compared herself to her two best friends, both of whom were in relationships, ignoring that her sister and her roommate were both single.

As her depression deepened, my patient's recurrent thought was reinforced by confirmation bias and consolidated into a biased belief: if she was the only single person in her peer group, she must be unlovable. The belief that she was unlovable was in turn reinforced by confirmation bias: when her friends organized a huge surprise birthday celebration, she reported they were just looking for an excuse to party. When her lab partner asked her out, she assumed it was only because he wanted to copy her notes.  Her confirmation bias prevented her from taking in any information that contradicted her belief that she was unlovable, maintaining both the belief and the depression. 

You don't have to be clinically depressed to experience the effects of confirmation bias. Think about the last time you woke up in a bad mood. You probably paid a lot of attention to the guy whose massive backpack took up an extra seat on the subway, or to the fact that the elevator at work was out of service again. You probably failed to notice the gorgeous weather, or the delicious lunch your loving partner packed you. Why? Because these things didn't fit in with your preconceived idea that day that the world was a lousy place.  

How can we challenge confirmation bias?

The trick is to realize when we're in the grip of confirmation bias, to identify the bias, and to be willing to test it. Example: I have a patient who has a high-powered job and young kids, but her life is more difficult than it needs to be because she believes that fundamentally, other people are incompetent. Not only does this belief create interpersonal conflict, but it means that she can never delegate responsibility for any task or chore to her colleagues, her husband, or her kids because they're liable to do it wrong.

After a bit of psychoeducation about CBT, and some work on cognitive distortions, she agreed to test her belief. Armed with the scientific hypothesis "Others are incompetent," she set out to complete the following assignment: for one week, record evidence that supported or contradicted her belief. Evidence that supported the belief included "My husband put my daughter's diaper on backwards" and "The construction on my street that was supposed to be completed two months ago still isn't done." Contradictory evidence included "The tech support guy at work fixed my printer," "The airline actually served me the gluten-free meal I ordered," and "My son did his homework while I was away."

Faced with clear evidence that others are not always incompetent, my patient was forced to reconsider her belief. She modified "Others are incompetent" to "Other people can be incompetent sometimes, but often get it right." My patient's new faith in her husband, children, and colleagues smoothed relationships and allowed her to delegate tasks, leaving her a bit of time to relax.

Challenging confirmation bias is tricky and requires an open mind. If there's a thought or belief that's making you depressed or anxious ("I never do anything right"), creating relationship problems  ("No one could ever really love me"), or generating stress ("Asking for help implies weakness"), try looking around for information you might be ignoring, and for possible reinterpretations of the information you've been using to justify your belief! 

NB: Sneaky confirmation bias occurs on sites like Facebook that use algorithms to feed us information. Example: If in following the US election, you clicked on and "liked" all your Obama-supporting friends' statuses and ignored all your Romney-supporting friends' posts, your Facebook news feed narrowed, showing you more news from your Democrat friends and fewer posts from your Republican friends. Through the Obama supporters' posted statuses and articles, you learned more about why the Democrats were the better party, and received little information that challenged this perspective--maintaining and strengthening your bias.

November 02, 2012

Do Me a Favour

Mental health tip: Do your future self a favour.

In a prior post, I discussed how you can motivate yourself to keep your resolutions and to do things you don't feel like doing by connecting behaviour with values. Another way to motivate yourself to take care of annoying errands and tedious tasks is to view them as favours for your future self. For example, you might not feel like taking the clean sheets out of the dryer and making the bed right now, but when your tired future self retires to your bedroom at midnight, he or she will probably be pretty pleased that you did him or her that favour this afternoon. Another example: if you shlepped around shopping all afternoon, you probably don't really feel like making one more stop at the drugstore to buy shampoo. You might feel more motivated, though, when you consider the thanks you'll get from your tomorrow-morning self, who won't have to shampoo with body wash.

It can help to imagine the pleasure of your future self as he or she receives your favour, in the same way you might picture the face of a loved one opening a perfect gift. I used this trick today: It's Friday and I'm headed out of town for the weekend; my refrigerator is nearly empty, but I was strongly resistant to the idea of going out in the cold rain to get groceries. To motivate myself, I pictured the comfort and relief of my tired late-Sunday-night self, whom I know will be pleased to find provisions for Monday morning breakfast. Building on this kindness to my future self, I even convinced myself to wash all of the dishes before leaving (rather than leaving the skillet "to soak").

You can't always do favours for your future self, and different people will have different priorities. I have one friend who consistently practices what she calls Operation Integration: when she arrives home, she always puts her coat, keys, and bag where they belong, and unpacks any other items--rather than abandoning them in the entry way or only putting half her things away. She doesn't always feel like taking the time reintegrate her belongings, but her ten-minutes-later self is glad the apartment is tidy, and her next-morning self is glad she knows where to find her keys!

What favours do you do your future self?

NB: You can also do your future self a favour by not doing certain things. For example, you might be finishing a lovely meal out and really feel like having coffee with dessert--but it's 10pm. It could help to consider not having coffee as a favour to your midnight self, who would like a decent night's sleep.

October 19, 2012

Ingratiation Investigation

I recently went to a friend's housewarming party. I knew she was thrilled with her new apartment and I exclaimed over the painting and decor as I came in and looked around. Her response: "Yeah thanks, it's great but the lighting is bad in the living room and I still need to paint the bathroom." Later that night, a friend and I were talking to an acquaintance who was excited to hear that my friend was planning to complete his first marathon this year. Instead of accepting congratulations on his upcoming achievement, my friend deflected it by pointing at me and saying "Yeah but she's run a ton of marathons." To which I responded: "Yeah but anyone could do it if they trained; I'm not a natural runner or anything." Still later that night, I overheard a friend dismissively refer to his innovative and successful start-up as "my non-profit thing."

What's going on here? Why are we all downplaying our pride and our achievements? Are we actually not proud? Do we not want others to be impressed?

My guess is that we're all just trying to ingratiate ourselves. In social psychology terms, ingratiation means using deliberate communication strategies in an effort to become more attractive or likeable to others. There are a few different strategies, including other-enhancement (complimenting others), conformity (agreeing with or making yourself seem similar to others), self-promotion (emphasizing your own attributes), and self-deprecation (observing something negative about yourself or belittling or undervaluing yourself or your achievements to avoid seeming arrogant and to help others identify with you).

Social norms dictate that bragging is obnoxious. Rather, we are supposed to be modest, and people who aren't modest violate our expectations. At the party described above, my friends and I were all engaging in social ingratiation via a combination of conformity and self-deprecation. By emphasizing the apartment's imperfections, deflecting congratulations and insisting that anyone can run a marathon, and dismissing business success, we were a) being careful not to brag, and b) making ourselves more similar to our listeners, who may not have run a marathon or launched a start-up, and who may also have home improvements they'd like to make.

Is it really necessary to downplay or outright dismiss achievements? Would I view my friends unfavourably if they confessed to being thrilled with a new apartment or to taking pride in a successful business venture? What are the advantages and disadvantages of this kind of ingratiation?

Advantages: Conformity allows you to avoid threatening or alienating others, something braggarts often do. Self-deprecation can be funny and can defuse awkward social situations (e.g., telling a story about your own gaffe to take the heat off someone else). Overall, using conformity and self-deprecation appropriately demonstrates good social intelligence.

Disadvantages: Too much self-deprecation will turn you into a person who can't take a compliment, which can be annoying. Further, if you deflect every compliment and deny every achievement or success by turning it into a self-deprecating story, people might eventually start questioning your self-esteem, your skills, and your honesty.

Moral of the story: Ingratiate often, don't brag, and use conformity and self-deprecation wisely.

October 02, 2012

Capacity for Composure

How come one day your computer melts down and deletes half your files and you cheerfully back up the remaining files and continue your day, yet on another day you have a tantrum when someone steps on your foot on the subway? Isn't losing your files inherently more upsetting than brief foot pain? What explains the difference in reaction?

The book I'm reading (The Mindfulness Solution; see sidebar) says that "what matters for our sense of well-being is our capacity to bear experience relative to the intensity of the experience." That is, our well-being depends on the intensity of our stressors, but perhaps depends even more on our capacity to bear stress.

Example: Last week, I was waiting outside for a friend to pick me up in her car to go for brunch. It was a lovely day and my friend was doing me a favour by driving, but I found the wait intolerable and spent most of the all-of-ten-minutes fussing and fuming. Thinking about it later and taking into consideration my capacity to bear experience, I was able to identify that I had been hungry, dehydrated, underslept, and in physical pain. This explains why a non-intense stressor such as waiting for ten minutes felt intolerable. In contrast, this week I remained calm and relatively cheerful during a two-hour drive in Friday afternoon rush hour traffic to pick up a parcel from an incompetent courrier service in a distant corner of the city. I was well rested, I wasn't hungry or thirsty, and I wasn't in a rush; that is, my capacity to bear experience was high and I was able to take a deep breath, accept the traffic, and enjoy singing along with the radio.

The moral of the story is that sometimes when we're all worked up and certain that our situation is unbearable, it may simply be that our capacity to bear stressful experience is low at that moment. The good news is that we can improve our ability to bear stress and distress, both in the long term and in the moment:

In the moment: We can often increase our capacity to bear experience by decreasing physical discomfort. If you're waiting in a long line in a stuffy building, try putting down your bag and taking off your sweater. If you know that hunger makes you cranky and intolerant, carry a granola bar in your bag at all times. Use the washroom before you leave the house so you don't get stuck in traffic with a full bladder. Keep Advil in your desk at work so you don't suffer through the day with a headache. Consider calling someone to vent for a couple minutes or asking for help. Or, if you're overtired today, consider putting the situation aside until you can get a bit of sleep. Not being rushed also helps: it's easy to tolerate the bus being a few minutes late if you're not already running late for the first of five back-to-back appointments.

In the long term: Mindfulness is an attitude of acceptance, openness, and non-judgment in the present moment; mindfulness meditation--one of the primary practices through which mindfulness is cultivated-- is essentially practice bearing experience. During mindfulness meditation, you sit and pay attention to yourself and to your surroundings as they are, accepting what's happening without piling on secondary emotions and without telling yourself stories about what's happening. It's called meditation practice because it's practice for real life; when stressful situations come along, you're better equipped to bear the experience with equanimity.

Further good news: You don't have to meditate to be mindful--all you have to do is pay attention and differentiate between the fact of what's happening (e.g., my computer deleted my files; a guy stepped on my foot) and the stories we tend to tell ourselves about what's happening  (e.g., my entire life's work has been deleted; that guy has no respect).

September 25, 2012

Lens Lesson

Everybody sees life through the lens of his or her own history. Try as we might, it's almost impossible to view any person, event, or situation completely objectively, without the impact of our experience and memories. Sometimes it's more obvious than others; for example, when someone cringes every time her boss says "Can I speak with you privately for a minute?" it's not hard to figure out that she's carrying the memory of another boss that said the same thing right before he fired her.

Sometimes it's more subtle though. You might not realize that your exaggerated fear of gaining a few pounds developed the time your ex offhandedly mentioned that your jeans looked tight, right before the relationship ended. Similarly, it might not be obvious that your resistance to buying birthday and Christmas presents is the result of the time you gave what you thought was an exceptionally perfect gift, only to receive a devastatingly indifferent response. Such experiences become the lens through which you see weight-related or gift-related situations, and seeing through the lens influences how you behave (e.g., obsessing over the scale, refusing to buy gifts).

Lenses are often composed of thoughts: "I'm not good at choosing gifts." "Gaining weight is unacceptable." "I could get fired at any time." One of my jobs as a cognitive-behavioural therapist is to help clients become aware of their "lens thoughts" and develop alternative thoughts that help them act differently and feel better. I tell clients that when they they feel down, anxious, or otherwise unhappy about a given situation or event, they can ask themselves the following questions:

a) What was I thinking?
b) Is it a lens thought? 
c) What might someone else think in this situation?

Example:  I have a client who was bullied mercilessly in high school and now feels extremely anxious in social situations. When someone so much as glances sideways at her, she instantly interprets the look as one of disrespect, dislike, and scorn. The impact of her social anxiety is that she feels sad and isolated, never attending a work party and avoiding situations like parent/teacher night at her daughter's school. When she received an email invitation to her cousin's baby shower, her immediate thought was "Everyone will make fun of how I look;" she felt shame and dread, and quickly discarded the email. Going over the example using the three questions above, my client was able to identify the thought as a lens thought; she acknowledged that another person who received a baby shower invitation might think something like "Oh great, a party! Hmmm, what will I wear? " This allowed her to label her upsetting thought as a relic from high school, and to focus on choosing an outfit she liked.

Recognizing lens thoughts and putting someone else in your shoes can help you adjust your perspective and change your behaviour.  The next time an event or situation is bringing you down, try the lens lesson!

September 14, 2012

Career Justification

In my very first post, I wrote about the difference between psychologists and psychiatrists. Recently, I started thinking about the difference between psychologists and laypeople (i.e., non-psychologists) after a friend asked me why anyone would consult a psychologist. His argument: If I'm a smart person and I know what my problem is, why wouldn't I just work on it on my own? What can a psychologist do that I can't?

This is a reasonable question and it got me thinking about the advantages of consulting a psychologist versus working on your issues on your own. Here are some reasons you might want to consult:

a) Psychologists have fifty minutes per week to dedicate to your problems. This may seem short, but it's a devoted and concentrated period. Left to your own devices, you might ruminate for hours or discuss with friends for weeks, but you're unlikely to sit down to undistractedly confront your issues or problem-solve.

b) Like any professional, psychologists have specialized knowledge, including knowledge of the DSM criteria for validated psychological disorders. Psychoeducation is a huge part of psychotherapy, and you might be relieved to learn that your gruesome intrusive images are a common symptom of obsessive-compulsive disorder, or that during a panic attack, it's normal to feel like you're going crazy.

c) Psychologists have experience working with people whose problems are similar to yours, and so have a good idea of what might and might not be helpful for your issue.

d) A psychologist is someone to check in with. Even if you already know what your problem is and what to do about it, it's not always easy to stay on track. A weekly meeting with a psychologist can act as a strategy session, a check-in, and a one-on-one support group. 

e) Psychologists are trained to notice avoidance, incongruence, and behavioural patterns, and to not let you get away with your BS. So if you never do your therapy homework, giggle when you talk about your suicidal thoughts, or abruptly change the topic every time the topic of your parents comes up, a psychologist will notice and gently address it.

f) Psychologists know techniques and strategies that you don't know or might not have thought of, such as activity scheduling and the what went well exercise for improving low mood; behavioural experiments and cognitive restructuring for testing dysfunctional beliefs; Socratic questioning to ferret out cognitive distortions; mindfulness meditation for cultivating attention and awareness; and exposure hierarchies for addressing phobias.

Psychologists aren't just wise listeners who dispense advice; rather, like any professional, we have specialized skills and training. So in the same way that you might hire a lawyer, a carpenter, or a dentist instead of defending yourself in court, building your own back deck, or giving your kids a fluoride treatment, many people find it helpful to consult a psychologist. Not every problem or every person needs a psychologist, however, and while I've encouraged many friends, family members, and acquaintances to consult, I wouldn't recommend it to someone who prefers to seek help from loved ones or to deal with their issues on their own.

It's your call. 

September 04, 2012

Anecdote: Jon Kabat-Zinn

I recently attended a CBT conference where I participated in a mindfulness meditation workshop led by Jon Kabat-Zinn. Kabat-Zinn is the founder of the Center for Mindfulness and the Stress Reduction Clinic at the University of Massachusetts medical school and the founder of mindfulness-based stress reduction; he is widely credited with having pioneered the integration of mindfulness and Western medicine and psychology.

At the conference, I had the pleasure of speaking with Kabat-Zinn during the workshop lunch break.  During the hour, a small and funny incident related to mindfulness and acceptance occurred:

Kabat-Zinn, the two other workshop attendees sitting with us, and I had finished eating and were discussing mindfulness applications. It was a hot day and the noon sun was beating down on our unprotected table. After a few minutes, Kabat-Zinn suggested moving to a nearby empty table in the shade. This prompted teasing from me and the two others: after all, the non-judging aspect of mindfulness prescribes not labeling some experiences (e.g., being in the sun) as bad and others (e.g., being in the shade) as good; mindfulness also involves letting go and accepting experience as it is, rather than struggling to change things all the time.

Teasing aside, this tiny incident demonstrates an important point about acceptance and about problem-solving. Acceptance doesn't mean that you don't do anything about your problematic situation--it just means that you try to maintain a non-judgmental and relatively objective perspective about what's happening (e.g., It's really hot and sunny at this table versus Oh my God I'm melting, I'm in hell); you try to maintain an awareness of your reaction to the problem (e.g., I'm having a hard time concentrating because I'm physically uncomfortable); and if there's a reasonable solution (e.g., switching tables), you go for it.

In the problem-solving quadrant, being unable to concentrate because of the heat was a "taking charge" type of problem, and there was nothing unmindful about switching tables. If we had sat in the sun sweating and being unable to connect due to physical discomfort, we would have been mistakenly placing the problem in the "giving up" quadrant and failing to take action in a situation over which we had control.

This is a minor but poignant example of identifying the type of situation and making a mindful choice about what to do. That it happened with a renowned authority on mindfulness only makes it more fun for me to retell.

September 02, 2012

Problem-Solving Solutions

Many of us know the basics of problem-solving: define the problem, brainstorm possible solutions, choose and implement a solution, evaluate the outcome, start over as needed. But despite knowing these steps, we can still find ourselves implementing a poor solution, avoiding a problem and not seeking solutions, and struggling with problems that don't have solutions.

I learned a problem-solving framework at a positive psychology conference I attended recently. It doesn't solve your problem, but it identifies the type of situation you're dealing with so that you can address it effectively by either problem-solving or letting go.

Here it is:

In your control
Not in your control
Take action
Taking charge
Don’t take action
Giving up
Letting go

a) Taking charge: Once you figure out that your problem belongs in this quadrant, this is the best kind of situation. You realize that you can take action, and so you do. For example, if you're unhappy at work, you either address your needs with your boss or look for a new job. If you're frustrated because you never have time to exercise or see friends, you stop and identify what's getting in the way, and look for ways to reorganize your time.

b) Giving up: When you're in this quadrant, you have some degree of control over your problem but you don't realize it, and so you feel helpless and resigned. For example, say you've been unhappy with certain elements of your romantic relationship for years, but don't bring it up with your partner because you feel like it's too late. Or that you've steadily gained weight over the course of a few years and are unhappy with your appearance, but conclude that it's your destiny to be overweight and that there's nothing you can do about it.

c) Struggling: Not having control is frustrating and anxiety-provoking, and we often respond to these emotions by trying to control the uncontrollable. For example, say your dog is dying and rather than accepting the facts, you repeatedly gouge your savings for expensive treatments that prolong his life by days. We're particularly prone to fruitless struggle when we try to control other people: for example, say you've rented a cottage for a week's vacation with your extended family, and you--and only you--believe it's important for everyone to eat three meals per day together; you spend a good part of your week cooking, assigning and organizing meal duty, and struggling to get your reluctant parents, kids, and siblings to the table for breakfast, lunch, and dinner--at the expense of your own enjoyment of the vacation.

d) Letting go: In this quadrant, you realize that there's little you can do about your problem, and you use that knowledge to let go and accept the situation as it is. Letting go can be as minor as finally accepting your freckles and putting away the foundation you carefully applied every morning for ten years, or as major as realizing that your baby doesn't know or care about your carefully-designed birth plan, and is probably going to arrive in his or her own way and on his or her own time.

I just learned this problem-solving framework, but I suspect that the more we can address problems by taking charge or letting go, the happier we'll be. Taking charge allows us to feel competent and act effectively; letting go can create a sense of relief; and knowing which quadrant we're in prevents us from attributing weight gain to destiny, sticking with a miserable job, trying to control childbirth, and hiding our pretty freckles.

August 21, 2012

When Panic Attacks

We use the term "panic" all the time, saying we panicked at our job interview, or had a panic attack when our child wandered into the street, but what do psychologists mean when they talk about panic attacks or panic disorder?

Panic isn't the nervousness you feel the morning of your presentation at work, the stress you feel when you're running late for an appointment, or the anxiety you feel when your partner is mad at you. A panic attack is a sudden surge of overwhelming anxiety and fear, accompanied by a flood of physiological symptoms; it develops abruptly and usually lasts no more than fifteen minutes. It may be triggered by something specific (e.g., public speaking, enclosed spaces, a stressful thought), or may come out of the blue.

The DSM defines a panic attack as a discrete period of intense fear, in which at least four of the following symptoms develop abruptly and reach a peak within ten minutes:

Physiological symptoms: palpitations, pounding heart, or increased heart rate; sweating; trembling or shaking; shortness of breath or a feeling of smothering; a feeling of choking; chest pain or discomfort; nausea; feeling dizzy, lightheaded, or faint; chills or hot flushes; and numbness or tingling, often in the extremities. Psychological symptoms: fear of dying, losing control, or going crazy; and derealization or depersonalization, i.e., feeling unreal, disembodied, or detached from your surroundings.

What does a panic attack feel like?

It feels like terror in your belly, an elephant sitting on your chest, and going crazy. Your heart feels like it's pounding out of your chest, the room seems to be closing in, and you can't breathe. Many people experiencing panic are convinced they're having a heart attack--in fact, over 40% of individuals who show up the emergency room with chest pain are actually suffering from a panic attack. On top of the discomfort of the physiological symptoms of panic, the feeling of derealization can make panic lonely and confusing because what's happening in your mind doesn't match what's happening in the external world; it's hard to understand why other people seem to be calmly and happily going about their business when, for you, the world seems to be ending.

A panic attack is not a DSM diagnosis, but panic disorder is. Panic disorder is diagnosed when recurrent panic attacks result in persistent concern about further attacks, worry about the consequences or implications of the attacks, or significant change in behaviour for fear of future attacks (e.g., refusing to give presentations at work, declining social invitations). At worst, individuals with panic disorder develop agoraphobia--the fear of being out in public, or in a place where they could panic--and begin to avoid crowded public spaces, or avoid leaving the home at all.

A panic attack can happen in the context of panic disorder, depression, or another psychological problem, or can simply be an isolated incident during a stressful period or situation. During a panic attack, it's not important to try to figure out what happened or what's wrong; instead, just focus on breathing slowly and trying to calm down. It can help to realize that you're having a panic attack and to remember that thinking you're going crazy and thinking you're having a heart attack are symptoms of panic. If you experience recurrent panic attacks, it may be time to see your doctor or consult a psychologist. Panic is eminently treatable and responds well to cognitive-behavioural therapy (CBT), among other treatments.

August 11, 2012

Letting Go

What is letting go?

We use the phrase "let it go" all the time, encouraging our friend to stop emailing his ex-girlfriend six months after the break-up or our partner to stop bringing up that thing we did that time. Letting go isn't easy--we're all attached to our ideas of how things should be, and we all have feelings, experiences, and relationships that we don't want to see end--but becoming too strongly attached or holding on for too long can create problems.

How does holding on create problems?

When we're holding on with all our might to a person, idea, or era, we become rigid and inflexible, and we miss out on opportunities. Think of the guy who passes up job offer after job offer while he continues to pour money into his failing start-up. Think of the former competitive gymnast who continues to train religiously into adulthood, trying to preserve her identity as an elite athlete. Think of the time you didn't enjoy a party or a vacation because you couldn't let go of your idea of how the party or the vacation should be or how you thought it was going to be.

The first step in letting go is to realize that you're holding on. There's a story about letting go that we tell in the mindfulness-based stress reduction course: in India, a clever way of catching a monkey was to attach a coconut to a tree, cut a small hole in it, and place a banana inside. The hole was large enough for a monkey to put his hand through to grab the banana, but too small for the monkey to remove his fist. All the monkey had to do to get free was to let go of the banana, but most didn't, remaining stuck to the tree. The moral of the story is that we often act like monkeys, not realizing that our own clinging is what's making us stuck.

Letting go can be exciting and liberating. The day the start-up guy files for bankruptcy is the same day he can accept an exciting new position; the day the gymnast hangs up her leotard is the same day she can register for the beginner's piano lessons she's been thinking about for years. The moment you let go of the vacation you hoped for, you can start enjoying the vacation you're having.

The next time you feel stuck, try asking yourself what's my banana? What can I let go?

July 22, 2012

I Object

Sometimes it feels good to get really mad--especially when you know you're in the right. We've all had the experience of being so wronged and feeling so furious that we feel like we just have to get it out. When the bank freezes our credit card even though we conscientiously notified them that we were traveling internationally, when our partner promises and then fails to put away the laundry for the third night in a row, when the renovation contractor consistently arrives late, we feel justified in our anger and it's a relief to tell someone off.

The problem is, this isn't always the best strategy. In fact, if we think in terns of objectives, it's often a bad strategy. Consider a few examples:

1) I recently had the experience of being so angry at my banking institution that as I dialed the customer service centre, I was practically shaking with excitement to let loose my righteous indignation. I raged at the customer service representative--which felt good in the moment--but when we hung up, my account was still frozen and the bank rep didn't seem too motivated to get to the bottom of the error. I had been so pumped up with righteousness that I failed to consider my objective: more than letting the bank know how I felt, I wanted access to my account. Did my behaviour facilitate the achievement of my goal? Not at all! I called back the customer service agent and apologized. It was embarrassing but by the time I ended the second call, the customer service rep was relaxed, apologetic, and eager to help. She promised to resolve the problem and call  me the next day (which she did!).

2) My friend's landlord has been consistently rude, picky about absurd details of the lease, and overall difficult to deal with. He recently raised the rent by $200 in a blatant attempt to get her to move out. My friend was livid; she decided not to renew the lease, and drafted a long email to the landlord detailing each episode in which he came over without calling, failed to complete repairs in a timely manner, or was otherwise unreasonable or non-compliant with the lease. I read the draft and asked her the key question: what are your objectives in this situation? My friend replied that she wanted to get her damage deposit back, use the landlord as a reference for her next apartment, and make sure he knew that he was a jerk. We reviewed the congruence between her actions (the email) and her objectives and decided that the email served only the third--and least important--objective. She decided that she wanted her damage deposit back and a good reference more than she needed to tell off the landlord, and decided not to send the email.

3) I had a client whose partner consistently worked late, leaving her alone in the evenings. My client felt hurt and sad and angry, and would repeatedly burst into tears the minute her partner walked in the door. I asked her the question: what are your objectives in this situation? When she replied that her goals were for her partner to realize how upset she was, and for him to come home earlier, I asked her how her partner usually responded to tears. When she replied that his usual reaction was to withdraw, she realized that it was time to rethink her strategy. By crying, she was achieving one of her goals (letting him know she was upset) but distancing herself from her second and more important goal. By reviewing her objectives, she was able to come up with a different strategy: talking to her partner about the problem--without tears--on the weekend.

In any situation--but in particular when we feel indignant and righteous--reviewing goals before acting can be a good idea. Simply letting out feelings isn't always an effective strategy, and it's risky to assume that others will change their behaviour just because we made our displeasure clear. The next time you find yourself gleefully/vengefully anticipating letting out your feelings or telling someone off, take a minute to consider what you're actually hoping for in the situation. You might end up changing your strategy!

July 16, 2012

Stress Reduction Mantras

In April 2011, I posted mental health mantras--phrases you can repeat to yourself during difficult times. Here are my 2012 mantras, designed specifically to help in those moments when you're amplifying your own stress unnecessarily:

1) You don't need to like everything. This is something you can tell yourself when you're having a tantrum (out loud or in your mind) because you don't like the new duvet cover your partner bought, or you're in the mood for sushi but your friends want to order pizza, or your secretary booked you on a 7am flight. If you're saying to yourself but I don't like beige, I don't like pizza, I don't like getting up early, consider that it's not necessary to like every single thing that happens, and that people deal with things they don't like all the time. Maybe your partner didn't like the paint colour you picked for the bathroom, or your friends didn't like the restaurant you picked for your birthday dinner. Remembering that no one gets to like everything can help you laugh at yourself a little and snap out of your huff.

2) I can do hard things. This is for when it's time to ask your intimidating boss for a raise, when you're packing to move for the fifth time in two years, or when you're living alone after the end of a long relationship, and all you can think about is how hard it's going to be. Certain things are hard and rather than telling yourself they won't be, try reminding yourself that hard is something you can do.

3) This is the fun part. This is for when you can't wait until your child is out of diapers, until you finish your degree, or until your new home is all painted and set up, and you're stressing yourself out trying to get there as quickly as you can. This is the fun part can help you slow down and connect with the excitement or pleasure of the process, making toilet training, earning a degree, and shopping and decorating less stressful and more fun. (For things that just plain aren't fun, see number four.)

4) This is part of it. This is for when you're excited to send your mom the perfect birthday gift you found but get stuck in an endless line at the post office, when you're going on a road trip but get caught in Friday afternoon traffic, or when you're registering for a course online using an absurdly non-user-friendly website. Dealing with waiting, traffic, and poorly designed Web systems become much more bearable if you can adjust your perception of them: rather than preventing you from sending the gift, getting out of town, and registering for your course, they're simply part of sending the gift, getting out of town, and registering. 

I hope these help--keep me posted!

June 25, 2012

Meds for Normal People: Medication Poll Results

A couple months ago, I was conducting a psych assessment with a pain centre patient with depression secondary to chronic pain and disability. Among other things, he reported low mood and frequent crying, rumination, change in appetite, irritability, poor sleep, and fatigue. After the assessment, I offered him short-term psychotherapy--and suggested the possibility of an antidepressant in addition to the medical interventions he was receiving for pain. (NB: I'm limited to suggestion because psychologists don't have prescription privileges).

The patient was dismayed! His eyes filled with tears and he protested "I didn't think it was that bad!" His reaction took me by surprise. I thought an antidepressant would be a positive intervention that could alleviate some of his depressive symptoms and allow him to benefit as much as possible from psychotherapy and from medical interventions for pain; he interepreted my suggestion of an antidepressant as an alarming sign that he was worse off than he thought.

My patient's reaction got me wondering about the current man-on-the-street perspective on mood-stabilizing medications. Time for a poll!

Method: I sent an inbox message to 169 Facebook friends, inviting them to respond to an anonymous online poll about medication. The question: Have you ever been prescribed antidepressant or anti-anxiety medication? The possible answers were yes, no, and yes but I didn't fill the prescription or didn't take the medication. To encourage participation, I posted three reminders as my Facebook status in the following three weeks. 

Participants: Fifty-five people responded. The anonymous nature of the poll precludes official sociodemographic data, but I would describe my sample of Facebook friends as roughly 70% white; 90% Anglophone; 90% urban; 80% professionals with post-secondary education, and ranging in age from 25 to 50 years old.

Results: 64% of respondents (n = 35) reported that they had never been prescribed medication for anxiety or depression. 31% of respondents (n = 17) had been prescribed medication, and 5% (n = 3) had been prescribed medication but hadn't taken it.  

Discussion:  I expected the percentage of medication-takers to be higher than 31%. This may be a bias borne of working in environments where many patients and clients take medication, but many of my friends, family members, and acquaintances also take or have taken antidepressant or anti-anxiety medication. To me, taking meds is both normal and common.

What do you think of these results? Are 31% (meds taken) and 36% (meds prescibed) greater percentages than you would expect? The statistic could be inflated by a response bias--that is, my Facebook friends who take or who have taken medication may have been more likely to respond. Alternatively, the statistic may reflect an over-prescription of antidepressant and anti-anxiety medication. I have personally had the uncomfortable experience of being handed a prescription for an antidepressant by a general practitioner who had met with me for ten minutes, and I know this isn't an uncommon experience.

Confusion and stigma surround the use of these medications, and it's not always easy to know who is a good candidate. I bet that of the 35 respondents who have never been prescribed meds, a few could have benefited from them at some point. I also wouldn't be surprised if a few of the 17 respondents who have used antidepressants or anxiolytics would have been just as well without it.

Opinion: Taking meds doesn't mean that you're weak, that you're an addict, or that you're severely ill; if you're prescribed medication for symptoms of anxiety or depression, it simply means that you're experiencing a very common symptom that medication can be partially effective in alleviating. I believe in the use of antidepressant and anti-anxiety medication as a tool for coping with or recovering from anxiety and depression, with a few ground rules:
  1. A person taking antidepressants or anti-anxiety meds should be closely followed by his or her prescribing doctor.  The doctor must be available to answer questions about side effects, increase or decrease the dose as needed, and check in once in awhile to make sure the meds are having the intended effect. Otherwise it's really easy to end up taking medication for years without evaluating its impact, or to start independently experimenting with dosage--both problematic.
  2. For uncomplicated anxiety and non-recurrent depression, medication is ideally a short-term solution and anyone taking meds is also in psychotherapy, working on identifying and resolving the issues that contribute to anxiety or depression. Therapy without medication is also an option, but sometimes symptoms of anxiety and depression can make it difficult to benefit from (or even attend) therapy (e.g., you're too depressed to get out of bed to go to therapy; you're too anxious to sit still for fifty minutes). A well-prescribed medication can provide the stability and lucidity necessary to allow therapy to do its work.

June 07, 2012

Let's Talk Change

Setting goals is easy, meeting them is hard, and not achieving them is discouraging. What's the best way to set realistic objectives that we can feel confident about meeting?

I learned a trick that's been useful in helping clients set and achieve goals. Say a client sets the objective of meditating for ten minutes five times per week. I'll ask him "On a scale of 0-10, how confident are you that you can achieve this goal?"

How does this question help?

1) Eliciting change talk. Say my client replies that his confidence level is six out of ten. My next move is to say "Hmm, six out of ten. Why not zero? Why is your confidence level at six instead of at two or three or even zero?"

This question may seem counterintuitive, but if I say "Why not seven or eight?" my client will produce a list of reasons why he can't meet his goal: he's too busy; he's not sure he'll be able to fit it in; he's not sure that meditation is for him. Suddenly he's resisting his goal. If I say "Why not two, three, or even zero?" the client will produce what's called change talk: it's not that hard, it's only ten minutes per day; he's been wanting to try meditating for a long time; it seems like something that could help him with stress. Suddenly he's making declarations about why he chose this goal and why it's important to him, boosting his own motivation.

2) Evaluating realisticness. Say my client replies that his degree of confidence in meeting his goal is one out of ten. I could still go for "Why not zero?" but it's important to consider that if his confidence is so low, the goal may be unrealistic and need adjustment. If my client has three children and works full time, meditating five times per week may not be possible for him. If we adjust the goal (e.g., meditating twice per week) and his degree of confidence increases to five or six out of ten, we're on the right track. I can then ask "Why not zero?" and he'll produce change talk: it's only twice per week, the kids go to bed at 8pm, leaving time for meditation in the evening; it will help him unwind at the end of the day.

The 0-10 confidence scale technique comes from motivational interviewing (MI), a coaching/counselling approach designed to increase motivation for change by helping people explore ambivalence and other barriers to change. MI incorporates the stages of change model, recognizing that people who want to make behaviour change or meet new objectives aren't always completely ready to do so.

I like to use the 0-10 confidence scale on myself and often find that low confidence is a symptom of an unrealistic goal (e.g., not eating out at all this week). I try to adjust my objective (e.g., eating out no more more than twice this week) until my level of confidence is at least six or seven, and then ask myself "Why not zero?" until I hear myself saying things like: I have the time this week to shop and prepare lunches; I actually prefer eating at home most of the time; I can put the money I save aside for my upcoming vacation.

Try it out!

June 05, 2012


Emotions can be inconvenient. Sometimes we experience intense and difficult feelings at work, during a social occasion, or at some other awkward moment. It's not a convenient time to explore the emotions in depth or to sit and have a good cry, so what's the best strategy? Ignoring feelings? Suppressing them?

Like thought suppression, emotion suppression doesn't usually work; paradoxically, it can make feelings more intense. The trick is simply accepting that the inconvenient emotions are happening and allowing them to be present. It doesn't make feelings go away, but allowing eliminates the struggle against the feelings, freeing up your energy and attention for other things.

Here are two strategies for allowing:

1) Replace but with and. Say you're at a a great social event that you really want to enjoy, and you can't stop worrying about something stressful you have to deal with the following day. You're saying to yourself I'm at this great party, but I'm really anxious. Replacing but with and means telling yourself I'm at this great party and I'm really anxious. Whereas the original phrasing implies that there's no way you can enjoy the party with anxiety present, replacing one small word creates a new sentence that implies that the two can co-exist: you're anxious and also, the party is great.

2) Draw a picture. A client told me this story recently: At work one morning, he received a personal email that provoked intense sadness, fear, and jealousy. He tried to ignore his emotions and turn his attention to his tasks, but the feelings got stronger and stronger. The client needed to focus on his work; remembering the concept of RAIN, he decided to switch strategies and try allowing his feelings to be present. He wrote sadness, fear, and jealousy on three respective post-it notes and stuck them to the side of his computer monitor, illustrating each word with an emoticon-style face.

What happened? Emotion post-its turned out to be a great way of simultaneously defusing from emotions and allowing them to be present. The feelings/notes remained present in the corner of the client's mind/computer monitor, but the struggle to get rid of them was over, allowing him to redirect his attention. The feelings/notes became less and less distracting and after half an hour, the client was absorbed in his work. When he returned to his desk after lunch and saw the post-its, he laughed.

Neither replacing but with and or drawing a picture involves ignoring, suppressing, or denying feelings, and both strategies can help manage intense emotions at inconvenient times. Let me know if you try either of these tricks!

May 15, 2012

Personality Disorders, Part 2

A personality disorder is a recurrent and pervasive pattern of maladaptive or inappropriate behaviour that causes significant distress or causes impairment in social, interpersonal, or professional functioning. People with personality disorders repeatedly think, feel, and react in ways that cause problems, and often elicit consistent reactions from the different people in their lives. Think of someone whose friends and colleagues all take advantage of him, someone whose romantic partners always leave her because she is so dependent, or someone who keeps getting fired because he refuses to work on projects that he considers to be beneath him. These are examples of enduring and problematic behaviour patterns.

How can you tell if someone has a personality disorder? A clinical supervisor once told me that when a client inspires an unusual or strong reaction during therapy, that's a big clue. After all, what happens in the psychotherapy office reflects what happens in the client's larger world; if I have a certain intense reaction during my limited contact with a client, changes are good that other people in his or her life do too. Example:

I have a new client who has a physical injury subsequent to a car accident. The injury is minor--something that doesn't usually disturb functioning for more than a month or two--but it has taken over the client's life. He remains significantly more disabled than what is expected at this stage, and family life revolves around his disability: The client's wife and children have put their regular weekend activities on hold to accompany the client to an outpatient rehabilitation centre an hour from home every weekend; the client's wife drastically cut her hours at work in order to care for him; and the client's children and extended family wait on him hand and foot. The client reports some tension as a result of his disability, but for the most part, his family members are extremely accommodating.

In a recent session with this client, I felt myself becoming intensely frustrated as he described his resistance to his doctor's proposal of a progressive return to work. However, despite my frustration, when the client wistfully expressed the wish for our sessions to be longer than the standard fifty minutes, I extended the session an extra fifteen minutes, keeping my next client waiting. When I looked at my schedule to book our appointment for next week and the client's preferred afternoon slot was unavailable, I accepted his proposal that I stay late at work and see him at suppertime.

After the client left, I felt unsettled: I don't usually spend more than an hour with any client, nor am I in the habit of extending my workday! I took a few minutes to explore what happened: Unusual client behaviour (asking for longer appointments; asking for an evening appointment)--check! Intense emotions (frustration) and unusual reactions (prolonging the session; rearranging my schedule) on my part--check! Probably replicating the client's family's behaviour of alternating between frustration and excessive accommodation--check!

It was fascinating to observe myself and the client replicating in therapy what I suspect is his dynamic wherever he goes. The client may or may not have a personality disorder, but my reaction to him tells me that it's something to explore. Clinically, it's not that important to establish whether or not the client has a personality disorder or which one he might have. What's essential is that we identify his maladaptive behaviour patterns so that I can help him by a) addressing the pattern in therapy, and b) making sure not to continue replicating/reinforcing the behaviour.

May 03, 2012

There's an App for That

Cognitive-behavioural psychologists encourage clients to not believe everything they think. One way to apply this suggestion is to imagine your mind as an email inbox and some of your thoughts as spam. In the same way that you don't take seriously every email informing you that you've just won £20,000,000, maybe you don't need to take seriously every thought that runs through your mind.

When you believe everything you think and react to your thoughts as though they were facts, you're experiencing what psychologists call cognitive fusion. Say I have a tough session with a client and I have the thought "I'm a bad therapist." If my heart sinks and a knot of shame forms in my belly, I'm fused with my thought--that is, I'm reacting as if the thought were a fact, rather than a mere string of words my mind created. What's problematic about fusion is that we can get so wrapped up in a fused thought that we fail to notice or incorporate any information that disconfirms it. For example, say a depressed client were fused with the thought "Life is hell." Cognitive fusion would maintain his grey-coloured glasses and prevent him from noticing anything pleasant about the world around him.

Cognitive defusion is used in psychotherapy to help clients unhook from painful and stressful thoughts. A lot of defusion techniques involve using mindfulness to see thoughts and emotions as transient external events, observing them in the same way you would observe a bus drive by or a pen fall to the floor. You might picture your thoughts like leaves on a stream, each one just floating into and then out of consciousness, or you might add the words I'm having the thought that to the beginning of your sentence, so that instead of saying to yourself "I'm an idiot," you would say "I'm having the thought that I'm an idiot." In so doing, you acknowledge that your thought is just a thought, not a fact.

Other defusion methods include saying the fused thought out loud over and over until it loses meaning, saying it in a silly voice, and singing it. I went to a conference a couple weeks ago where I attended a workshop on cognitive defusion techniques; the presenter showed us an iPhone application called Songify that he uses to help his clients defuse from thoughts. The app records you speaking, analyzes your speech, organizes it into a chorus and verses, and maps it to your choice of melody, adjusting your pitch and syncing your words with the beat. He played us a demo of a client saying "I'm a loser." It was impossible not to laugh at the electronic but melodic "I'm a loser" song and it really made the words seem like just words. Apparently the client felt the same way.

I tried Songify recently with colleague, testing some of the thoughts we sometimes find ourselves fused with. It worked! Not only did we have a good laugh, but hearing our thoughts sung out loud to a melody gave us some distance from them, letting us see them for exactly what they are--mind spam, rather than literal truths.

April 15, 2012

Mindfulness-Based Stress Reduction

This winter, as part of my new job at a mindfulness and psychotherapy clinic, I lead a course in Mindfulness-Based Stress Reduction (MBSR). MBSR was developed by Jon Kabat-Zinn at the University of Massachusetts medical school. Mindfulness--a state of accepting and non-judging awareness and attention in the present moment--is originally a Buddhist concept, and Kabat-Zinn is credited with integrating it into mainstream medicine and psychology.

MBSR is an 8-week group course. The group meets weekly and each class involves a discussion of mindfulness as applied to a particular topic (e.g., emotions, physical pain, relationships), in-class exercises, and a guided meditation. The goal of MBSR is for participants to develop a daily mindfulness meditation practice ("formal mindfulness") and to become more mindful in daily life ("informal mindfulness").

How does mindfulness reduce stress, improve mental health, and increase quality of life?

1) Appreciation of experience. When we function on automatic pilot, we miss out on many of the moments of our lives. Mindfulness means paying attention to the depth and richness of the present moment--really noticing what's happening, with all five senses. Many MBSR participants report that they now notice things they didn't notice before, like a pretty garden they walk by every day on the way to the bus, the pleasant drumming of warm water on their back in the shower, or how good food tastes when they aren't wolfing it down.

2) Fewer symptoms of anxiety and depression. Increased focus on the present moment prevents us from spending all of our time in the past, ruminating and regretting, or in the future, inventing anxiety-provoking scenarios. In this way, mindfulness cuts out a lot of symptoms of depression and anxiety, improving mental health. MBSR participants often report that they're now quicker to catch themselves ruminating or creating scenarios, which allows them to consciously bring their attention back to the present rather than getting carried away with their thoughts.

3) Responding rather than reacting. The more attention and awareness you bring to your behaviour, the more you can notice patterns and modify automatic reactions that aren't working for you. With greater mindfulness, you might start to notice that your post-dinner trips to the fridge aren't random but rather are almost always directly preceded by feelings of loneliness or sadness; you might realize that you automatically tense up every time your boss walks by your office door, making you constantly jumpy and on edge. One MBSR participant reported that greater mindfulness allowed him to realize that his first reaction to any request or proposal--at work or at home--was "No, I can't, I don't have time" and that he often missed out on opportunities because of this automatic reaction. He began consciously giving himself 24 hours to respond to requests, cutting out his automatic reaction and giving himself the chance to consider his availability and interest and respond accordingly.

4) Decreased avoidance. Mindfulness involves bringing a receptive curiosity to all experience (e.g., "Oh look, my stomach clenched the instant the phone rang, before I even saw who was calling. What's that about?"), whether pleasant or unpleasant. Conceptualizing all of our experiences as interesting phenomena means that even doing things we dislike, fear, or avoid can be fascinating. MBSR participants report that experiences that they formerly avoided, like one-on-one time with their in-laws, public speaking, or going out to eat alone became opportunities for mindfulness awareness; they used the experience to learn about themselves by observing their physical, cognitive, and emotional responses to the situation. 

NB: Mindfulness is effortful. In MBSR, we often say that mindfulness is easy, but that remembering to be mindful is hard. No matter how many hours we meditate, there are still times when we snap at someone automatically, avoid a painful-but-necessary experience, ruminate all day, or (ahem) stand at the front door for fifteen minutes freaking out because we think we left our keys at work, without noticing that they're actually hanging in the lock directly in front of us. The good news is that each time we become aware of how unmindful we're being, it creates a "mindful moment."

April 08, 2012

Acceptance versus Resignation

What does it mean when a friend, family member, or therapist tells you that you need to try to accept a situation you're struggling with? Is this reasonable advice, or is it just annoying and impossible?

Acceptance is a key concept and a good step toward effective coping with a tough situation, but it has to be properly explained. Friends and psychotherapy clients to whom I propose acceptance of their respective difficult situations say things like, "If I accept that I drink too much, if I accept my partner leaving, if I accept my chronic pain, doesn't that mean I'm just giving up--that I'll become an alcoholic, that I'll be alone forever, that my pain will take over my life?"


Acceptance does not mean passive resignation. Resignation means giving up because you've decided that there's nothing you can do about your situation, whereas acceptance simply means that you accept that your situation happened. It doesn't mean that you like what's happening or that you don't wish it were different, but once you give up the resistance and denial, you can take the energy you were spending on struggling and use it to decide how to respond or what to do next. In this way, acceptance can be liberating.


I had a client who had a problem with binge drinking at social gatherings. When he attended events with unlimited alcohol (e.g., his work Christmas party, a wedding with an open bar), he invariably drank way too much and either made social faux pas or became physically ill and left early, both outcomes that caused him significant distress. Friends had suggested various practical strategies to him, such as setting a number-of-drinks limit in advance, not sitting near the bar, and alternating each drink with a glass of water; the strategies worked well, but he rarely applied them. Why? Because applying a strategy required acknowledging to himself that he had a problem; instead, before a party, he would tell himself that he could handle it, that the open bar wouldn't be a problem for him this time. After some work on acceptance, my client was able to accept the fact that he had a binge drinking problem; he began using the strategies consistently, significantly decreasing his distress and effectively eliminating the problem behaviour.

I had a client whose partner left her. She was unable to accept that the relationship was over, and spent a ton of energy on begging and threatening phone calls, emails, and texts, trying to get her ex to come back. The months during which she couldn't or wouldn't accept the end of the relationship stalled the necessary grieving process and prevented her from moving forward. When she finally accepted that her relationship was over, she was still sad and disappointed, but she also felt some relief--the struggle to hold onto the relationship was over, freeing up mental space that she used to look for a new apartment, consider dating again, and start settling into her new circumstances.

Finally, acceptance is a big issue for chronic pain patients. Unfortunately, chronic pain can often only be managed, not cured, and at some point, most patients are told that some degree of pain will always be present and that they need to accept it and find ways to adapt. This is hard, and many patients continue to consult specialist after specialist, seeking a different diagnoses or new treatment options. Eventually, with or without psychological help, some patients come to accept the diagnosis of chronic pain; they are then able to take the time and energy spent on resistance and medical consultations and redirect it toward improving quality of life and learning to live well despite pain.

Acceptance sounds easy but isn't. It takes significant strength and motivation to let go of how you think things should be or how you wish they were, and to work wisely and effectively with your reality, especially when you don't like it. Accepting can be the hardest and bravest thing you can do.