January 31, 2013

A Recipe for Depression

It's pretty much fact that people who are clinically depressed demonstrate distorted thinking. Their reactions to negative events are skewed and they're more likely to make attribution errors--that is, to assign distorted meanings and causation to the things that happen to them.

Three specific attribution errors have been demonstrated to be typical in people who are depressed; my non-scientific guess is that they also show up in non-depressed people and contribute to feeling bad.

1) Internal versus external. People who are depressed blame themselves when things go wrong. In contrast, people who aren't depressed are more likely to attribute negative events to external factors like bad luck, chance, or others' actions. For example, a depressed person who doesn't receive a call back after a job interview assumes she made a gaffe during the interview or didn't prepare well enough. A non-depressed person is more likely to acknowledge that another candidate may have had more experience, or that the position could have been given to an internal applicant. A depressed person who gets hit by a car blames himself for not being more careful, even though the driver was running a red light; if his child gets bullied at school, he blames himself for poor parenting even though the bullies are targeting other kids too.   

2) Global versus specific: Non-depressed people typically view negative events as having only isolated or limited significance. In contrast, depressed people are more likely to conclude that a negative event has far-reaching or global implications. For example, a depressed person whose relationship didn't work out generalizes to other areas of his life and concludes that he has failed in every area; a non-depressed person is upset about the end of the relationship but can still acknowledge areas of his life where things are going well. A depressed person misses the bus in the morning and concludes that her whole day is shot; a non-depressed person acknowledges that the morning started poorly but figures that everything will be fine once she arrives at work.

3) Fixed versus changeable: Whereas non-depressed people often adopt a 'this too shall pass' attitude toward negative events or situations, people who are depressed view the same problems or situations as unlikely to change or improve. A depressed person feels lonely and believes she'll always be lonely; a non-depressed person acknowledges that she's going through a period of feeling alone but that it won't always be this way. A depressed person whose washer and dryer break in the same month that his cat gets sick and his transmission dies can't imagine a future wherein such things aren't happening to him; a non-depressed person knows that he's just having an unusually bad month. A depressed person who fails her exam because of poor study habits wonders if she should just give up on school altogether; a non-depressed person figures she can probably get help and learn new study habits.

In depressed people, attribution errors are problematic because they promote hopelessness and maintain depression. In non-depressed people, attribution errors just make us feel bad unnecessarily. In both cases, the first step is to realize that we're falling for these errors in thinking. The next time you're feeling down about some negative event, ask yourself if you're making an attribution error. If you think you might be, ask yourself: Is it really my fault? Am I overgeneralizing? What can I do about it?

NB: For other good questions to help you out of negative thought patterns, see here.

January 21, 2013

Enough is Enough

How's it going with your New Year's resolutions? If you're on track, good job! If you're less on track, read on:

Sometimes we're reluctant to take a baby step toward change or toward meeting a goal because the step seems too small. For example, say you resolved to quit smoking or to develop a regular meditation practice. And you decided to start by cutting back by two cigarettes per day or by meditating for five minutes every morning. Although these objectives are minor, you may find yourself not meeting them--because they feel almost too minor. 

Part of my job as a cognitive-behavioural therapist is to help people identify the thoughts that prevent them from moving forward. One thought that shows up repeatedly is "It's not enough." For example, a patient's goal might be to introduce regular exercise into his routine in order to counter anxiety and improve physical health. If his usual day involves no exercise at all, we'd probably plan to start with something like five minutes of walking every evening. My patient might express enthusiasm about the plan--but then end up going out walking once or twice, and then quitting. When asked what happened, he might reply that five minutes just didn't seem like enough. Similarly, severely depressed patients sometimes resist the validated strategy of planning small pleasurable activities, because it seems like calling a friend, taking a bubble bath, or going to the movies just isn't enough to counter depression.

The scourge of "enough" is not limited to the clinical setting. It comes up for me regarding writing. More than once, I've set the goal of writing for fifteen minutes every day, only to abandon it because it doesn't seem like enough. Similarly, I have a friend who has already abandoned her New Year's resolution to address her credit card debt with weekly payments of $15--because $15 is just not enough.

Here are a couple tips that might help when you're set to abandon your goals because your small steps seem inconsequential:
a) "Enough" is arbitrary. Why is cutting back by two cigarettes per day insufficient? Would three be enough? Four? Where credit card debt is concerned, would $20 per week be acceptable or would it have to be $25 to meet the enough threshold? Who decides? Recognizing that our thresholds for enough are arbitrary and idiosyncratic can help us adjust our expectations and commit to small steps

b) "Not enough" is how you get to "enough." Even if five minutes per day of walking isn't enough to immediately reduce my patient's anxiety or improve his physical health, it's a step toward enough. How will he get to twenty minutes per day if he doesn't start with five? Similarly, meditating five minutes per day may not seem like enough, but it's a step toward it. Recognizing that not enough is practically a required stop on the way to enough can help us persevere with small goals.

If the concept of enough is getting in your way, hopefully these tips will help you get back on track with your New Year's resolutions. Keep me posted!

January 16, 2013

Capacity for Empathy

How come sometimes you can listen to a colleague complain or to a friend vent for hours on end, never wavering in your sympathy, empathy, or active listening skills--but on other occasions, your patience wear thin after minutes?

Last fall, I posted about our capacity for composure, suggesting that composure is a limited and fluctuating resource dependent on physical comfort, mindfulness and the intensity of our stressors. Since then, I've been thinking about empathy--the often (but not necessarily) sympathetic identification with or experiencing of another person's thoughts, feelings and experiences. Empathy is a key component of friendships and of patient-therapist relationships, and a resource that may also be fluctuating and limited in nature.

For example, consider the time I lost my patience with my friend who kept repeating herself and unwisely retorted "I get it, already!" Not exactly empathetic! In retrospect, I can identify that it was the last week before the Christmas holidays and that we were spending the evening together after a long day of back-to-back therapy patients. That is, my capacity for empathy was low.

I was once on the receiving end of a breach in empathy on the part of my own therapist: I was complaining about something I wanted but felt was impossible to have and my therapist lost his patience and snapped something like "Can't you see that what you're looking for is right in front of you? Open your eyes!" I was pretty taken aback at the time but when I later learned that he had received some extremely distressing news about five minutes before our session, I understood a bit better. My therapist's capacity for empathy was very low during our session; otherwise impeccably appropriate, he slipped up and said something unhelpful and out of place.

For therapists and lay listeners alike, capacity for empathy seems to depend on a few things. First, similar to capacity for composure, having your basic physical needs met is key. It's hard to listen helpfully to someone else's problems when you're starving, exhausted, or have a raging headache. Second, capacity for empathy suffers when there's too much demand: if your best friend's marriage is breaking up and your sister just lost her job, you might not be a very good listener for your colleague who wants to discuss his toddler's bed-wetting. Third, it can be difficult to have empathy for others if you're having your own problems. If you were just diagnosed with a serious illness, your capacity to empathize with a friend's existential angst is probably pretty low.

Therapists need a pretty endless supply of empathy. To maintain capacity for empathy, in addition to attending to our basic physical needs, we need peer support (i.e., don't work all alone all week in your private office with no one to provide social interaction or peer support) and should avoid scheduling too many patients in one day, or too many patients in a row without a break. Further, awareness of how our personal lives are affecting us will allow us to monitor and minimize the impact on our work. Keeping these tips in mind can help us avoid exhausting our empathy reserves.

For non-therapists, the tips for maintaining the capacity for empathy are no different: in addition to making sure your basic physical needs are met, don't spread yourself too thin empathy-wise (e.g., if you spent the morning consoling your sister over her job loss and your friend calls to discuss his relationship woes, you might want to limit the length of the conversation or call him back later). Remember that your empathy reserves may be low if you're dealing with your own serious problems, and feel free to hoard most of your empathy for yourself during those times. Keeping these tips in mind can help you avoid breaches in empathy and maintain your reputation as an empathetic listener.

January 05, 2013

I Love Ya, Tomorrow

Last month, I went to see Annie on Broadway. Annie is the story of a plucky orphan living in New York City during the Great Depression. She escapes from the orphanage on a quest to find her birth parents and ends up adopting a dog, meeting then-president Roosevelt, and getting adopted by a billionaire.

One of the things that makes orphan Annie so beloved is her unshakable and infectious optimism; despite being destitute and having been abandoned by her parents, she always keeps her chin up. Several times during the show, Annie belts out her signature song, Tomorrow: "When I'm stuck with a day/that's gray/and lonely/I just stick out my chin/and grin/and say/tomorrow, tomorrow/I love ya, tomorrow/you're only a day away!"

Watching the 12-year-old actress playing Annie sing her heart out at centre stage, I was overwhelmed by emotion and optimism. I decided to adopt Annie's anthem as my personal theme song, convinced that the simple wisdom of Tomorrow could help me cope with everyday hassles and major life stresses. I sang the song in my head for days, confident in its optimistic message.

The following week, a friend who had been going through a tough time called me up for tips on using mindfulness to manage strong unpleasant feelings. She told me that her current strategy was to try not to think about it, to pretend the feelings weren't there, and to tell herself that tomorrow would be a better day--but that is wasn't working.

I put on my mindfulness teacher cap and suggested a new strategy: rather than ignoring or avoiding the unpleasant emotions, I proposed that my friend try to identify and acknowledge them, and even try to cultivate curiosity about her uncomfortable feelings. I reminded her that mindfulness means accepting and working with whatever's happening in the present moment--even when we don't like it.

After we hung up, though, I felt conflicted. What about Annie? What about "I love ya, tomorrow?"  Mindfulness explicitly advocates being in the present moment, and optimism is generally future-oriented. So on bad days, can you live mindfully in the present and still comfort yourself with the prospect of better days to come?

I had to think about it, but the answer is yes. While mindfulness means residing primarily in the present moment, it doesn't mean never thinking about or looking forward to brighter days. The key is to be optimistic about the future without avoiding the present.

Example: Say you wake up feeling anxious. You head to the office as usual and dive into your work, doing your best to ignore the continued roiling in your belly and tightness in your chest. If you avoid addressing the feelings and sensations and just tell yourself that tomorrow will be better, you're being optimistic, and you may be right--you probably will feel better tomorrow--but you're also avoiding experiencing your feelings. In contrast, say that rather than plowing through the day ignoring your symptoms, you decide to use half your lunch hour to sit quietly, identify what's going on, and practice experiencing your emotions. You can still be optimistic and remind yourself that tomorrow will probably be better, but you're not avoiding your emotional experience (a strategy that doesn't usually work it the long term).

Second example: Say you and your partner are going through a rough patch. And say you reassure yourself with vague optimism about the future of the relationship, rather than exploring your feelings and identifying the problems. With this blind optimism strategy, you can avoid uncomfortable or unpleasant feelings, but the relationship problem might remain. Say that instead you optimistically hypothesize that you and your partner love each other enough to make it through a rough patch, and decide to try to identify the problem, investigate your feelings about it, and discuss it with your partner. Such optimism combined with your mindful acceptance of the problem will probably lead to an open conversation, increasing the likeliness that your hypothesis will come true.

I was relieved to determine that Now this is happening and I love ya, tomorrow are not incompatible and that I can keep Tomorrow as my bad-day theme song without renouncing mindfulness. So if you're having a tough day, go ahead and remind yourself that you probably won't feel this way tomorrow. The only catch is to not use optimism about tomorrow to avoid experiencing today--unpleasantness, discomfort, and all.

January 01, 2013

At Your Service

If I had a friend who began every sentence with an apology, I might eventually point it out and ask her to knock it off. If a colleague told the same anecdote three times over the course of one lunch hour, I might tell him to quit repeating himself, or else intervene and change the subject.

But what if these things happened with my patients? What's the difference between conversations with friends and conversations with patients?

The difference is that with patients, everything I say or do should be in the service of the patient. With the friend and colleague in the examples above, I'd speak up to save myself from boredom and crankiness; with patients, my personal feelings are expressed if and only to the extent that expressing them would be helpful to the patient.

Example: Say I had a self-effacing patient who was driving me crazy by beginning every sentence with an apology. By the end of a session, I might want to snap "Quit apologizing!" but that would be a mistake. A better intervention would be to gently say something like "I've noticed that you frequently begin your sentences with an apology." Whereas the former comment expresses personal irritation, the latter is a simple and therapeutically relevant observation; the latter comment also allows for follow-up questions such as "Is apologizing something you also do with other people?" "How do you think your habit impacts your conversations?" and "How might you perceive someone who apologized all the time?" If later the patient and I were hypothesizing about how other people might perceive his constant apologizing, I could ask him for ideas (e.g. "People might think I have low confidence; they might think I'm being fake"), and then maybe add something like "Some people might find it endearing; others might find it frustrating." But my personal impatience would not be relevant.

Second example: Recently, I recently expressed frustration with a friend who kept repeating herself. She was struggling with the decision to move her elderly mother into residential care; despite my validation of the struggle and the decision, my friend continued to repeat just how much she loved and respected her mother, what a good parent her mother had been, etc. Finally I lost my patience and exclaimed "I get it, already--you love your mom!" This wasn't very helpful for my friend; a more helpful response would have been something like "Yes, you've mentioned that a few times. It must be really important for you to make that point clear."

With a patient, this kind of neutral comment is even more important, and often elicits useful information such as "I didn't know if you heard me the first time I said it because you just nodded but didn't say anything" or "I guess I feel guilty, like I'm just getting rid of my mom now that she's become a nuisance, or worried you'll think I'm a bad daughter" or "Really? I already said that?" With patients, these answers can prompt valuable conversations about validation, guilt, and social skills, respectively.

In therapy, comments like "Quit apologizing!" and "I get it!" are not appropriate because they imply a responsibility of the patient toward the therapist (e.g., to not be boring, to not waste my time), and because they express therapist feelings in a way that isn't relevant or helpful. But are there occasions when a therapist should express her true feelings? The answer is yes, but the same rule applies: only in the service of the patient.

Example: A depressed patient tells me he's bad at communicating and I respond that I've noticed that he's actually quite forthcoming and articulate in our sessions.

Example: A panic disorder patient tells me that he felt silly jogging on the spot in my office to try to induce panic symptoms for an exposure exercise, and I tell him that I was just thinking how brave he was to engage in an exercise designed to bring on symptoms that terrify him.

Example: A socially anxious patient reaches over in the middle of our session to pluck a stray hair off the arm of my sweater and then immediately asks, "Was that weird? Should I not have done that?" and I respond that her act didn't seem out of the realm of normal social behaviour, but that the timing was surprising and the gesture had taken me a bit off guard.

In each of these example, my comment is authentic and is designed to validate, bolster, and/or reflect reality to patients whose perspective may be unhelpfully distorted.