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.

Comments?

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!

Allowing

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!

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.

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.

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."

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?"

No.

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.

Examples:

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.

Saying No to Say Yes

Saying no isn't easy. Even if we already have a lot on our plate and already feel time-crunched, we say yes to supervising a new project at work, planning a friend's baby shower, organizing a camping trip, editing a colleague's grant proposal, teaching a weekly yoga class, joining a weekly pub trivia team, feeding the neighbour's cat, and volunteering at church. For various reasons--it's hard to say no to our boss and colleagues; we don't want to miss out on a cool opportunity; we don't want to disappoint our friends, partners, parents, or children--we often say yes to requests, opportunities, and activities when we might be happier or less stressed out if we said no.

I read a line a few days ago that I'm going to keep in mind the next time I'm having a hard time saying no:

Saying "yes" to more things that we can actually mange to be present for with integrity and ease of being is in effect saying "no" to all those things and people and places we have already said "yes" to.

This line (from Coming to Our Senses: Healing Ourselves and the World Though Mindfulness by Jon Kabat-Zinn) resonated with me because non-present is exactly how I feel on days when I've said yes to too many things. At the end of the day, even as I'm congratulating myself for being so efficient and productive, I usually realize that I missed something important that a client said, that I barely remember a conversation with a friend or colleague, or that I ate all three meals on the subway.

The idea that saying yes too often is really a way of saying no is great because it means that saying no is a way to say yes to established commitments and priorities. For example, say you and your partner have reserved Sundays for family time with the kids; when you're regretfully say no to brunch with friends, you can remind yourself that you're saying yes to your family. If you're supervising two projects at work or teaching two classes and you're receiving pressure to take on a third, you can remind yourself that saying no to a third class or project is a way of saying yes to the first two.

The next time you're having a hard time saying no to a request or opportunity, consider all of the things you'll be saying yes to. Let me know if if helps!

Mindfulness

Last January, I wrote about how mindfulness was taking the psychology world by storm. One year later, interest in mindfulness hasn't abated; if anything, it's grown--in my personal world, in the mental health field, and in Western culture at large.

What exactly is mindfulness again?

Mindfulness involves purposeful attention and awareness in the present moment, with acceptance and without judgment. Let's look more closely at the four key components of the definition, all of which overlap:

• Being in the present moment: Being mindful means being present no matter what you're doing. It means that when you talk with someone, you listen and actually hear and respond to what he or she says, rather than thinking about what you did earlier in the day, or only half paying attention while you smile and nod automatically. It means that when you eat dinner, you actually taste and appreciate your food, rather than reading while you eat or fantasizing about dessert or about what you're doing later.
• Awareness: Mindfulness means being aware of what's going on inside and around you, a kind of "waking up" to your life. The idea is that we sleepwalk through a lot of our days, without questioning our habits, routines, and reactions, and without noticing the impact they have on us and on the people around us. Mindful awareness means that when you find yourself doing something unusual or unhelpful, (e.g., eating when you're not hungry, drinking too much, overreacting to an innocent comment, avoiding your email inbox), you notice your behaviour and ask yourself "what's that about?"
• Attention: Being present and aware requires focused attention. You can't be in the present moment if your mind is off in the past or the future, and you can't be aware of yourself, others, or your environment if you aren't paying attention. Part of being mindful is cultivating the ability to focus your attention on what's happening now. Minds naturally drift away from the present, but with greater awareness and with meditation training, you develop the ability to notice when your mind drifts off and the discipline to bring your attention back to the present. These skills are cultivated by guided meditation exercises that use various anchors (e.g. the breath, body sensations, sounds in the environment) to increase your capacity for sustained and focused attention.
• Acceptance and non-judgment: In addition to being aware and attentive to what's happening as it's happening, mindfulness implies a kind of equanimity and acceptance of experience. The idea is that whatever's happening--pleasant or unpleasant--is already happening, and that struggling against the experience or labeling it as awful is unhelpful. We can develop equanimity in the face of any event or outcome by accepting the raw experience, rather than piling on layers of resistance and secondary emotions. Importantly, acceptance doesn't mean resignation; it doesn't mean that you have to accept everything that comes your way and never try to change or improve your circumstances. Rather, it means being aware and accepting of the facts. Accepting that your bus is late, that your partner forgot your birthday, or that you lost your job--rather than denying or resisting--frees up your energy and attention to decide what you want to do about it.

Mindfulness isn't a secret, special, or necessarily spiritual thing or something that happens only during meditation; rather, it's a way of being in everyday life, cultivated by daily meditation. An example of mindfulness meditation is sitting for fifteen minutes simply paying attention to your breathing or just observing sounds in your environment, without judging them or trying to change them. This type of exercise provides the opportunity to practice being aware, attentive, and accepting in the present moment, skills that sooner or later generalize into the rest of your moments, hours, and days.

Therapy Gold

Some clients come to psychotherapy because they are entirely non-functional and need help establishing the basics--routine eating and sleeping, and a reasonable degree of physical comfort, financial stability, and social support. Other psychotherapy clients are already highly functional and fairly content, but want help tweaking their life to achieve better relationships, a more meaningful career, or less stress.

Which type of client is more rewarding to work with? Is it better to slightly improve the already-good quality of life of high-functioning clients or to work with low-functioning clients who improve more slowly but whose progress, even if minimal, constitutes a huge improvement in quality of life?

I've always been partial to the idea of tweaking--of helping high-functioning clients meet their potential and achieve their stretch goals. But last week I had a therapy gold (term I made up in my post about friendship versus therapy) moment that changed my thinking somewhat:

I had a session with an extremely depressed client with a serious chronic medical condition. He was going through a flare-up in his condition and I expected him to report that his mood had plummeted correspondingly; however, when I asked him about mood, he replied that it was stable, good even. He reported that he had been using some of the strategies we had discussed in therapy and then said (and this is the therapy gold part), "I have more control over my situation than I thought I did."

After he left, I practically jumped up and clicked my heels! My singular therapy goal with this client been to improve his mood by instilling a modicum of hope and personal control; the serious joy I experienced at seeing this happen diminished my conviction that working with high-functioning clients is more rewarding.

NB: My cup of therapy joy ran over when, before the client left, I assigned him the What Went Well exercise.

Friendship versus Therapy

A friend called me today to ask for advice about a conflict in his relationship with a mutual friend. After listening for five minutes, I told him exactly how I thought he should handle it. He was grateful and I was pleased; I joked that I wish that I could do the same thing with my clients--that is, tell them what to do and make everyone happy. After we hung up, I started thinking about the difference between friendship and therapy. In both cases, I provide support, give advice, and, to varying degrees, facilitate insight and personal growth. So what's the difference?

One of the biggest differences is that, for two reasons, I rarely flat out tell a client what I think he or she should do. Why not?

1) It's risky. I know my clients in a very limited context. I've never been to their home or to their workplace and I haven't met their partners, children, friends, or colleagues. If I tell a client how she should, for example, discipline her daughter, handle her overbearing boss, or respond to learning that her partner reads her personal emails, it could easily backfire, causing significant distress for which I would be partly responsible. Further, my client and I may have very different values, and a solution that seems perfectly appropriate to me may be completely out of the question for her. I know most of my friends much better than I know my clients and we share a lot of the same values, making it less likely that I would give bad advice (and if I did, there would be no question of professional liability). 

And the more important reason:

2) It's kind of like "Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime." The goal of therapy is to render the therapist obsolete; I want clients to gain enough insight into their behaviour and develop enough new skills for problem-solving and for managing stress and distress that they no longer need a therapist. Telling clients what to do does not facilitate learning, and so a client who asks for straight-up advice will often get the answer-a-question-with-a-question technique. For example, if a client asks "Do you think I should take antidepressants?" I'll ask "What are some things that helped last time you were depressed?" If a client asks "Should I leave my partner?" I'll say "What are some of your options?" 

It can be challenging to not tell clients what I think they should do--especially if it seems obvious--but it's much more powerful if they figure it out on their own. And when clients surprise me by demonstrating that they learned exactly what I was hoping they'd learn (e.g., "None of my avoidance habits really work. I guess it's time to try something different," or "I notice that when I force myself to be active, even if I don't feel like it, my mood lifts"), it's therapy gold. 
 
NB: There are two situations in which I would tell a client exactly what to do. The first is if I have a tip the client can use to solve a practical problem (e.g., If you're suffering from insomnia, don't get into bed until you're tired; if you keep falling asleep during your relaxation exercises, try doing them before instead of after lunch). The second is a suicidal or other serious crisis (e.g., "When we hang up the phone, call your husband; if he doesn't answer, go to the ER").

What Went Well

Researchers in positive psychology study well-being, positive emotion, and quality of life. Investigating happy and unhappy people, they found that one thing that can make us unhappy is spending a lot of time thinking about what's going wrong in our lives, and very little time thinking about what's going right. Analyzing negative events is adaptive because we learn from our mistakes and avoid repeating them, but an exclusive focus on problems isn't helpful and can lead to rumination and depression.

What should we do instead? Positive psychology researchers have developed short exercises sometimes referred to as "positive activity interventions;" one exercise that's been consistently demonstrated to improve mood involves learning to notice when things go well, and to think about and savour the experience. Here's what to do:

1. Before you go to sleep each night, write down three things that went well that day.
2. Don't just think about them, but actually write them down; that way you'll have a physical record.
3. The events can be important (e.g., "I got a raise at work"), but don't have to be (e.g., "The bus pulled up just as I arrived at the bus stop this morning").
4. For each item, answer the question, “Why did this happen?”  For example, if you got a raise, you might write “I worked hard this year and my boss noticed." If you were perfectly on time for the bus, you might write "I checked the schedule and made sure to leave the house on time."

Research has demonstrated that people who stick with this exercise feel happier and less depressed after six months. I believe in positive psychology, so decided to try it for one month. It worked! I noticed that:

• I remembered and reflected upon positive experiences that I wouldn't otherwise have remembered or counted as positive, e.g., I re-potted my plant, I made a good dinner, I received the book I ordered online, I was invited to a dinner party.
• I started doing positive things on purpose so that I could put them on my list, e.g., going to the gym even if I didn't feel like it, taking care of an irritating but important errand, calling my mom to say hi, picking up a treat for dessert.
• I started noticing positive things in real time, including lots of things that I wouldn't have noticed before or wouldn't have counted as positive, e.g., I got a seat on the metro during rush hour, I was able to switch the date on my plane ticket without paying a penalty, there was no line at the drugstore when I went to pick up my prescription.
• I didn't always have an answer for "Why did this happen?" (e.g, why did I get a seat on the metro during rush hour?), but when I did (e.g., I was invited to a dinner party because my friends like my company, or I was able to change my plane ticket without paying the fee because I was patient and assertive with the customer service agent), it felt good. 

This exercise gave me a boost of positive emotion every night before I went to sleep. If you try it, let me know how it goes!

Public versus Private

Last September, I started a clinical internship at a chronic pain centre in one of Montreal's hospitals. A few weeks ago, I started a concurrent training program at a private psychology clinic. The differences between these two experiences are striking:

Physical environment and space. The pain centre is housed in a small wing of a large hospital, and there is a distinct lack of space. The clinic director and associate directors have their own offices, but the part-time doctors, visiting fellows, residents, and psychology interns shift around as needed, sharing offices and computers. The rooms in which we see patients are relatively barren, with fluorescent lighting and hospital beds; on busy days when no rooms are free, psychology staff have been known to see patients in the conference room and the kitchen.

In contrast, the office at the private clinic is lovely--exposed brick, plants, and tasteful, comfortable furniture. The handful of therapists all take turns using the office, but when I book it, it's mine and there's no risk of having to conduct psychotherapy in the kitchen.

Multidisciplinary collaboration. At the pain centre, we have biweekly meetings to discuss patients as a team; rheumatologists solicit advice from anesthesiologists, internists seek advice from psychologists, and I learn a lot. If during a session with me, a patient has a question about medication or another component of his medical treatment, I can usually snag a doctor in the hall and get him or her to join us for a few minutes. Sometimes pain centre doctors come into the psych office to see if one of the psychologists or interns is free to sit in on an appointment with a patient and provide an on-the-spot psych evaluation.

Private practice is much less multidisciplinary. At the private clinic, I'm by myself or with my supervisor, who is a psychologist. If I need to, I can (with the client's consent) contact his or her GP or psychiatrist, but it's not usually necessary.

Social support and interaction. At the pain centre, after my patient leaves, I usually go across the hall to discuss the session with my supervisor. I might get stopped on the way by the patient's doctor, wanting to know the result of my psych evaluation; by a anesthesiology resident who wants to know more about CBT; or by a fellow psych intern who wants me to read over a report she's written.

At the private clinic, when the client leaves, I'm by myself. I can call my supervisor at any time, but I'm physically alone and it's easy to see why some therapists find private practice lonely.

Patients versus clients. At the pain centre, we use the term patient rather than client. To me, this term fits because the pain centre is part of the public healthcare system (i.e., it's not for profit, services are free, and everyone has access) and because it's primarily a medical clinic. The advantage: many patients have been waiting months for an appointment and are therefore grateful to be seen and unfazed by an extra hour in the waiting room or by psychotherapy in the kitchen. The disadvantage: some patients aren't keen on seeing a psychologist, agreed to it only because their pain centre doctor insisted, and have no qualms about missing appointments without calling.

In private practice, I see clients--people who have researched and chosen the clinic where I work from among many options, and who are paying to see me. This creates a different dynamic, wherein the client is more of a consumer. A therapy hour is always fifty minutes, both client and therapist are expected to be on time, and clients are unlikely to miss sessions without calling. Unlike in the public system, all of my clients are people with the time, money, and motivation to seek psychotherapy.

Although I'm new to both positions, I suspect that the differences I've observed reflect global differences between working in a hospital or other public clinic and working in private practice. There are clear advantages and disadvantages to both milieux, and it's not hard to see why nearly every psychologist I know works in both.

Threat Perception Bias

Threat perception bias refers to the tendency to interpret ambiguous stimuli as threatening. This bias has been demonstrated to be stronger in people who are generally anxious. For example, in one study, a researcher read aloud a list of homophones to two groups--anxious people and a non-anxious control group--and participants in both groups were asked to write down the words. Participants in the anxiety group were more likely than were control participants to interpret the words in a threatening sense, writing down die, slay, and pain, rather than dye, sleigh, and pane.

How does threat perception bias manifest in the real world? Example: A man who suffers from social anxiety speaks to a friend on the phone, and notices that his friend seems aloof. He might automatically imagine that his friend is mad at him for some social gaffe, rather than assuming that his friend is upset or distracted by something unrelated to the friendship. The friend's coolness is the ambiguous stimulus and the anxious man shows a bias by making a personally threatening interpretation.

Threat perception bias is usually related to long-standing or trait anxiety, but two personal experiences have convinced me that it can be induced in the span of hours:

Last week, I was watching an extremely disturbing movie--a psychological thriller that involved, among other things, cabins in the woods and creepy cult members flashing lights through the trees at night. Partway through the movie, I got up to check my phone. When I reached into my purse, my hand felt something unfamiliar and came out holding a palm-sized piece of hardware that resembled a mini-canister. My immediate thought: Someone put a grenade or some kind of explosive in my bag! I felt a stab of true fear in my belly. One second later, I identified the foreign object as the light bulb holder for the paper lantern I had received as a gift earlier that evening.

Similarly: When I was 15, I flew on an airplane alone for the first time. It was a 50-minute flight on a 14-passenger plane, and there was severe turbulence. Air pockets caused the tiny plane to plunge dramatically over and over; food and books flew off tray tables and everyone screamed and clutched their companions. I was paralyzed in my seat, terrified; it was the only time in my life I've ever really thought I was going to die. Safe at home that night, I was reading on the sofa when I heard explosions in the sky. My immediate thought: We're being bombed. One second later, I realized it was a holiday and that the noise I was hearing was fireworks.

Both situations involved instant interpretations of an ambiguous stimulus as life-threatening. I don't usually go around making such wildly inaccurate and catastrophic interpretations, and I'm convinced that my threat interpretation was induced by the respective priming effects of the movie and the turbulent plane ride.

Has this ever happened to anyone else?

I'm Watching You

One of the best things I've learned in my clinical training is that everything is information. Everything a client does provides data, and I can use it to generate hypotheses, even before the first session. For example, it's telling when a client asks the receptionist four times how much longer he'll have to wait, even though I'm only ten minutes behind schedule. It's interesting and useful to notice that a middle-aged client is dressed like a teenager, or that a client keeps his coat and hat on when he sits down across from me. 

What can I hypothesize about these clients? The client who repeatedly checks with the receptionist might be anxious, entitled, or both. The middle-aged client dressed like an adolescent might be emotionally immature or fear aging. The client who keeps his coat and hat on might be emotionally guarded and unsure about seeing a psychologist. These are only possibilities, but they allow me to start generating a conceptualization of the client--one that will be reinforced or corrected during the interview.

Naturally, the habit of observation extends outside the therapy office. I notice if an acquaintance is usually on her phone when she enters a party, and I wonder if it's important to her to look busy or if she's socially anxious about greeting people. I notice if a colleague starts every sentence with an apology and try to guess if it's just a verbal tic or if he believes that his contributions to conversation have no value or that others aren't interested in his opinion.

You don't have to be a psychologist to notice behaviour and make hypotheses, and there are benefits to this kind of observation. Say a friend tells you that she's thrilled about her new job, but you notice that she's biting her nails and doesn't smile once during the conversation. You can gently point out that she seem more stressed out than thrilled, and give her a chance to reflect and to discuss her true feelings. If you notice that a friend often busies himself with drinks and hors d'oeuvres and spends most of his time in the kitchen during weekly games night, you can hypothesize that he's unsure of his place in the social group, and--without necessarily saying anything--make a particular effort to include him.

Next time a friend or stranger does something interesting or unusual, or you notice a pattern in a colleague's behaviour, make a hypothesis. You might learn something interesting!

Psychotherapy for Normal People: Therapy Poll Results

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

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

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

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

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

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

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

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

Too Much Empathy

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

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

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

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

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

What happened here?

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

Pain Psychology

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

Why do chronic pain patients need psychological help?

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

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

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

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

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

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

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

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

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

Learned Empathy

Is empathy an innate trait or a learnable skill?

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

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

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

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

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

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

Apology Rules

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

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

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

1) Figure out what you did wrong and take responsibility for it. This rule has two steps and is particularly important when we make a mistake that initiates a chain of unfortunate events. Example: your friend confides in you that he's dating someone new, but hasn't yet told his recent ex. You can't resist sharing this news with your work friend, who knows both parties. Unexpectedly, your work friend declares that your friend's ex has "the right to know" and calls her up. The next thing you know, your friend is livid with you because his ex confronted him in furious tears, and now won't speak to him and is refusing to share custody of their beloved cat. You are dumbfounded by this turn of events and your impulse is to apologize to your friend profusely and repeatedly, begging desperately for forgiveness for your awful sins. What do do instead:

• Identify your crime and apologize for it. You shouldn't have gossiped with your work friend; for that, you should apologize directly and genuinely.
• Don't apologize for the parts that aren't your fault. While it's true that your behaviour triggered the chain of events, you aren't accountable for your work friend's decision or for the ex-girlfriend's dramatic reaction. You can, and should, be sorry that your initial mistake prompted the whole mess, but you still aren't responsible for other people's behaviour and you don't need to apologize for it. 

2) Let the apology fit the crime. If it's hard for you to tolerate someone being upset with you, you may use the understandable but unhelpful strategy of "keep apologizing until you're forgiven." The problem with this strategy is that eventually, the apology no longer fits the crime. Example: you accidentally bump a guy on a crowded bus and he spills his coffee on the floor. You apologize sincerely, but rather than accepting your apology or your offer to buy him a fresh cup, the guy continues to berate you as though you had purposefully grabbed the coffee from his hand and thrown it in his face. Your impulse is to apologize even harder, but wait a minute--you didn't abduct his first-born child; you merely spilled his $1.25 cup of coffee. If he doesn't accept your first or even your second apology, it's time to stop apologizing and walk away.

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

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

Inside Out

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

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

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

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

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

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

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

If You Don't Understand, Ask

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

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

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

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

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

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

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

So far, so good.

Empathy

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

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

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

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

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

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

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

The Suicide Question

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

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

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

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

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

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

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

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

Decision and Will Power Fatigue

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

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

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

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

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

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

Stages of Change

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

There are six stages:

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

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

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

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

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

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

How is the Stages of Change model helpful?

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

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

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

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

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