Rain Check

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

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

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

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

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

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

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

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

Will Power versus Rules

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

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

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

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

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

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

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

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

What are your rules? Do they work?

Marsha Linehan

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

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

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

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

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

Criteria Controversy

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

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

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

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

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

Emotions About Emotions

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

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

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

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

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

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

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

Believe Me

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

Everyday Habits

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

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

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

Chronic Mental Health Problems

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

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

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

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

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

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

Few Good Men

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

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

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

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

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

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

Ask Yourself This

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

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

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

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

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

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

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

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

Up next: shorter blog posts.

Don't Believe Everything You Think

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What is CBT?

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

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

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

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

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

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

Up next: examples of specific CBT concepts and interventions.

Stages of Recovery

When you're pulling through any type of emotional crisis, psychological upheaval, or other difficult period, it can help to have some kind of scale to measure your progress. My best friend and I invented the Stages of Recovery model about ten years ago. You can use it to determine how you're doing on your way back to being all right, to being fine, to being yourself.

There are three stages:

1) Active member of society. At this stage, although you may not be doing much else, you've returned to work if you're an employee and to school if you're a student. You're no longer skipping class or calling in sick. Even if you don't wash your hair before going, you actually leave your house at some point during the day.

2) Active member of the household. At this stage, you start doing a couple things to help the household run smoothly. You probably don't repaint the bathroom, but you put your dishes in the dishwasher, feed the cat, and take out the recycling. (NB: this stage is often expedited by living with someone--it's much easier to not be an active member of the household if you live alone.)

3) Active member of yourself. This is the best part--the return of personal hygiene, personal projects, and social activity. You feel good enough to do the things that make you feel even better. You make actual meals, reintroduce yourself to your razor, return to the gym, and see your friends. You finish your book, bake banana bread, give your bike a tune-up, and buy a new pair of shoes. You start thinking about the future and making plans for what you might do now that the crisis is past.

I know that not everyone will go through all the stages or necessarily go through them in this order but I like the stages of recovery because even when you're at stage one, you can congratulate yourself for what you are doing rather than focus on what you aren't doing. At stage one, even if your work clothes aren't exactly ironed or clean, at least you're earning your living. At stage two, it might be only spaghetti with sauce from a jar, but at least you made dinner. Then when you get to stage three, you get the double pay-off of doing things that give you pleasure, and feeling pleased about how far you've come.

NB: These stages are also applicable to recovery from physical illness.

Mental Health Mantras

There are a few phrases that I find helpful to repeat to myself during difficult times. All of them are things my sisters have said to me at one time or another. I found myself sharing them with a friend recently and subsequently decided to share them here. 

1) This isn't your new life. This is for when your problem or situation is so hard or overwhelming or lingering or agonizing that you can't imagine that you'll ever not feel this bad. Well, that's just not true. Overwhelming and agonizing is not your new life; it's just right now and it inevitably won't be like this forever. There exists a place where you're not struggling and it's called the future.

2) You're just a person in the world trying to work something out. This is for when you're beating yourself up over your situation or thinking that your problem or struggle means that you're bad or wrong or dumb. It's to remind you that you're just a person, doing what people do--that is, make tough decisions, react to tough luck, manage stress. It's life and you're living it and you're probably doing the best that you can.

3) Look out the window. This is for when what's going on is so all-consuming that you're living 100% in your head, going around and around with your thoughts, and can't stop.  Looking out the window--literally--allows you to remember that there's a world out there beyond your problem.  Look! That woman walking by doesn't seem too concerned about your situation; in fact, she seems to be enjoying the sunny day.  This isn't a suggestion to just forget your worries and enjoy spring, but when your mind is simultaneously stuck on overload and repeat, looking out the window and noticing that the world is still turning can break the cycle.

4) No one decision can ruin your life. This is for when you have to make an impossible decision and are worried that the wrong choice will ruin everything. Yes, of course, decisions about whether or not to move, whether or not to get married, whether to take one career path or another, and other big choices are important. And yes, they will impact the direction your life takes. But no one decision can make or break your life. That's just not how it works.

These might not all work for everyone in every situation, but they're worth a try.

What Should I Call You?

When you see your doctor, you’re a patient. When you see your accountant, you’re a client. But what about when you see your psychologist? Are you a patient or a client?

Merriam-Webster says that a patient is an individual who is awaiting or under medical care and treatment or who is the recipient of personal services. A client, M-W says, is a person who engages the professional advice or services of another or a person served by or utilizing the services of a social agency.

‘Recipient’ and ‘engages’ are the key words here. The term patient invokes the medical model, implying that you’re sick or broken and that you’re seeing an expert in order to get fixed (i.e., receive care). I consider myself a patient when I visit the sports doctor, the dermatologist, or the surgeon, and I patiently wait over an hour in waiting rooms for these professionals. In contrast, client implies that I’m paying someone to do a service for me, that I shopped around and selected the lawyer, accountant, or psychologist I want to see, and that they have to listen to my needs and preferences (and not keep me waiting).  I have more power as a client than as a patient.

The choice of term by mental health professionals provides information about the professional’s view of the power differential in the relationship, and about whether or not the professional sees him or herself as working with or for or even on the client/patient. This distinction and the paying/non-paying distinction definitely apply in psychology, where you are more likely to hear the term patient in a hospital and the term client in a private setting. My default term is client, a choice that reflects a general trend in mental health away from the medical model.

Tu versus Vous

If you live and practice in Quebec, there’s a second question to consider regarding what to call your clients. French employs second-person pronouns that connote varying degrees of politeness, social distance, courtesy, and familiarity. Vous is the formal term, used in interactions with people you don’t know (e.g., the maitre d’ at a restaurant), people older than you (e.g., your partner’s grandparents), and people with whom you have a formal relationship (e.g., the VP of your company). Tu is the familiar term used with friends, peers, children, and people who asked you to please, call them tu (e.g., your boss, your friends’ parents).

What should you call your clients?

As an intern doing therapy in French, I was taught to a) always start by calling the client vous, b) if I feel comfortable and think the other person will be more comfortable, propose the switch to tu but c) don't switch without asking, d) and don’t switch back and forth. Of my seven internship clients, I maintained vous with four of them without broaching the topic, and switched fairly quickly to tu with the three others. The three I used tu with were my age or younger and I felt quite comfortable with them. Of the other four, one was someone I saw only briefly, one was someone I was uncomfortable with, and two were clearly older than me (NB: without any discussion, one of the latter four called me tu from the very beginning, something that irked me).

Which is appropriate? 

It depends. Vous maintains formality and distance. This can be a good: for example, if a client becomes overly familiar and starts asking personal questions or for special privileges, the use of vous is one method for maintaining a bit of distance in the therapeutic relationship. However, to a socially isolated client, the therapist’s use of vous could feel standoffish, whereas the use of tu could indicate warmth. Finally, depending on your age and on the client’s age and background, some clients may be just plain uncomfortable with one or the other term.

The choice to use patient or client implies a general attitude, whereas the choice of tu or vous is more of a case by case decision involving age, experience, and comfort level. Both can impact how psychologists think about their role, and how both parties see the relationship.

As the person receiving mental health services, what would you prefer? What does it depend on?

Just Don't Think About It

Last time, I described exposure therapy and how it can be used to successfully treat most common fears and phobias. But what if what you fear and avoid isn’t dogs, flying, or heights? What if you’re scared of and avoid your thoughts?

Some people get overwhelmed by worries—What if I can’t pay my rent next month? What if this lump is breast cancer? What if I marry the wrong person and one day get divorced?—and cope by pushing them out of their heads. Cognitive avoidance is the equivalent of putting your hands over your ears and singing “LA LA LALALA!” in order to not hear your scary thoughts. It’s things like distracting yourself with another activity, thinking about something pleasant instead, and avoiding places, people and situations that remind you of your worries.

The problem with cognitive avoidance is that it doesn’t work. Distracting yourself from worries provides short-term relief, but a) the relief you feel when you successfully avoid your thought reinforces the idea that the thought is scary and that you can’t deal with it, and b) thought suppression doesn’t work and your worry will come back. In the same way that crossing the street every time a dog approaches maintains and reinforces a dog phobia, avoidance of worries prolongs and reinforces worry.

The cure for cognitive avoidance is cognitive exposure. Cognitive exposure rests on the principle of habituation, that is, that with enough exposure to a feared stimulus, anxiety always fades naturally. In this case, the feared stimulus is your worry. Cognitive exposure requires you to choose one of your worries and compose a short text describing the worst-case scenario. You have to include all the thoughts and images that you associate with the worry, especially the most disturbing ones; you have to describe the situation in the present, as if it were happening right now, leaving out any reassurances or distractions. In other words, write out your worst nightmare in the simplest, scariest way. 

The exposure part is to interact with the scenario by listening to a recording of yourself reading it out loud. You have to close your eyes, vividly imagine yourself in the situation, and allow your anxiety to mount. Prolonged and repeated exposure (e.g., 45 minutes every day for a week) to your scenario will decrease your anxiety to the point that you’ll eventually be able to hold the worry in your mind without becoming overwhelmed or having to distract yourself.

NB: Cognitive exposure is primarily indicated to help with hypothetical worries (e.g., What if I get divorced one day?) whereas real and current worries (e.g., What if this lump is cancerous?) are managed through problem solving. However, I think that cognitive exposure can be used for both types of concerns. It’s true that if you have a lump (real and current problem), you need to see a doctor; however, if you’re too anxious to even think about the lump, let alone make an appointment, cognitive exposure can help you calm your fear enough to be able to begin the problem solving process.

Exposure Therapy

People say that the best way to overcome a fear or phobia is to bite the bullet and face it head on. Facing your fear is somehow supposed to make you less fearful.

Is this good advice?

Yes. Overcoming fears and phobias by facing them directly is the foundation of exposure therapy, a psychological intervention used when a person has a severe and debilitating reaction to a certain stimulus (object, animal, or context). Exposure requires the person to interact more and more closely with the feared stimulus until they’re no longer scared.

How does it work?

1) Exposure therapy is based on the tenet that fears and phobias are learned relationships. That is, the feared stimulus isn’t inherently scary, but is something that you learned was scary through a dramatic or traumatic experience. For example, I flew easily many times as a child, and wasn’t scared of flying until I was 15 and experienced severe turbulence on my very first plane trip alone. It only took five terrifying minutes of thinking I was about to die for me to learn a relationship between airplanes and danger, and for years subsequently, I cried in fear through every plane trip. Similarly, a 12-year-old with a dog phobia may have loved animals until she was ten and was bitten by a scary dog, requiring an ER visit and stitches. That one experience was enough for her to learn a relationship between dogs and danger, and now she feels automatic fear at the sight of any dog. Think similarly of someone who enjoyed driving, but became scared to drive following an accident.

Exposure therapy works by helping you unlearn the relationship between the feared stimulus and danger by repeatedly exposing you to the feared stimulus in the absence of danger. If the girl with the dog phobia interacts enough times with a dog without the dog doing anything menacing, the relationship between dog and fear will fade and will be replaced by an association between dog and neutral or maybe even dog and friendly. The person who had a car accident is encouraged to keep driving until he unlearns the association between driving and accidents. Sometimes exposure therapy happens naturally: In the past 15 years, I’ve taken many plane trips without incident. Through repeated exposure to flying in the absence of danger, I’ve largely unlearned the relationship (although whenever there’s turbulence, the old relationship is reinforced and I make strangers hold my hand).

2) Exposure therapy also rests on the principle of habituation. Habituation refers to the fact that it’s impossible to maintain an elevated level of anxiety for a prolonged period. That is, no matter how anxiety provoking the stimulus, your racing or pounding heart, sweaty palms, and dry mouth will always fade naturally if you wait long enough. For example: the girl who is scared of dogs sees a dog coming toward her on the sidewalk. Her heart races and she feels dizzy with fear so she crosses the street. Her symptoms abate, reinforcing her idea that the dog was dangerous. Through avoidance of the feared stimulus, she denied herself the opportunity to experience the physiological inevitable: that her heart rate, breathing, and blood pressure would have automatically returned to baseline even in the presence of the dog. Habituation to a feared stimulus decreases fear, whereas avoidance maintains it; exposure therapy forces habituation.

Final point: Exposure therapy is almost always gradual (e.g., looking at a picture of a dog, hearing the sound of a dog barking, being in the same room as a dog, approaching and petting the dog, letting the dog lick your hand). You may have heard of flooding, a type of non-graded exposure designed to stamp out your fear in one shot (e.g., a person with a snake phobia would be enclosed in a room with fifty slimy but benign snakes). Flooding is effective, but it can also be traumatic and there is a greater risk of spontaneous recovery of fears; graded exposure is appropriate for the large majority of phobias.

Resolutions Resolved

One month after New Year’s, a lot of us are assessing how we’re doing with our resolutions. If you’re happy with your progress, nice work. If not, two different psych concepts might help:

1)    Timing: A basic principle of behaviour change is that, to be effective, the reward or punishment for a given behaviour has to occur close in time to the behaviour. For example, giving the dog a treat an hour after it rolls over or sending your child to her room the day after she misbehaves is not effective. The timing principle explains why lifestyle-related behaviour changes like losing weight, getting fit, or quitting smoking can be hard. The delay between behaviours like skipping dessert or working out and the rewards of losing weight or seeing changes in your physique is too long. The same holds for punishment. Lung cancer 15 years from now is not an effective punishment; it would be much easier to quit if a cigarette this morning gave you cancer this afternoon.

What to do: close the distance between the behaviour and the reward or punishment by creating interim rewards or punishments. For example, decide that eating three healthy and balanced meals today means you can watch an extra episode of whatever show you’re hooked on before bed. Get your partner to agree to give you a half-hour massage on Saturday if you go to the gym three times this week and to hide your laptop (or crochet needles, chocolate, camera, other important item) for 24 hours if you smoke more than one cigarette per day.  Adjust the rewards and punishments until they work for you!

   

2)    Values: Why do you want to quit smoking, lose weight, or spend more time with friends this year? Values describe what’s meaningful to you, what you stand for, and how you want to relate to and interact with other people and with the world. Values provide direction and motivation; connecting with them can help you commit to behaviour change and give you the sense that your hard work is worth the effort (in fact, there exists an entire school of therapy based on mindfulness and commitment to taking action guided by values).  For example, remembering that I value my physical health will help me exercise and eat well even when I don’t feel like it; connecting with my value of close family ties will help me keep my resolution to spend more time with my family, even when it’s inconvenient or requires expensive travel.

Let me know if this helps!

Update

To date, no meetings have taken place between representatives of Quebec psychologists and representatives of the provincial Ministry of Health and Social Services.

Other things are happening, though.

1)   Even if the Ministry isn’t paying attention, the press is. In the past two weeks, articles about the issue have appeared in the Montreal Gazette and in La Presse. Rose-Marie Charest, president of the Ordre des Psychologues du Québec, and Marcel Courtemanche, president of the comité des chefs de service en psychologie en milieu hospitalier du Québec, were interviewed on Radio-Canada; both commented on the impact of the shortage of public sector psychologists on public accessibility to services, and on the roles of poor working conditions and of the disparity between educational requirements and compensation in perpetuating the shortage. 

2)   Students waiting for news about internships for next year were advised to expect letters from the sites we applied to, confirming receipt of our applications and advising us that they are keeping our unopened applications on file and will let us know when things change. Here’s the rub, though: not all internship sites are participating in the pressure tactic; even within hospitals that have announced their solidarity with the tactic, some clinics are offering applicants interviews as usual. This means that students who have applied to participating and non-participating sites may be in the awkward position of having to accept or reject an offer from one site before sites in which they are equally interested even review their application. To say nothing of the potential awkwardness of starting an internship as scheduled in September while your fellow students are forced to make other plans.

What to do? Although students are not obliged to support the Quebec psychologists’ position, those who plan to work in Quebec after graduation certainly have an interest in improved salary and working conditions.

Professional respect and decent pay are important. Supporting your future colleagues is important. But so is continuing your training and finishing your degree in a timely fashion.

I’ll keep you posted.

Winter of Discontent

In a pressure tactic designed to get the attention of the provincial Ministry of Health and Social Services, Quebec public sector psychologists announced in December 2010 that they are refusing to accept psychology interns for the 2011/2012 school year. Their problem: poor working conditions and lack of respect for their work, as demonstrated by remuneration not commensurate with the demands and the training requirements of the profession.

Yearly salary for a full-time psychologist in the public sector in Quebec is between $37,219 and $70,759 and comparisons with the salaries of psychologists in the rest of Canada ($57,000 to $130,000) and with other health care professionals in Quebec reveal significant discrepancies. For example, although Quebec social workers, nurses, and physiotherapists are eligible to practice as professionals after completing their undergraduate training and psychologists have to complete a PhD (i.e., a minimum of five more years of school, creating a corresponding five more years worth of student loans, and a five-year delay before starting to earn), the former professionals earn salaries that are equal to or higher than that of Quebec psychologists.

In response to the lack of respect and recognition, Quebec psychologists are leaving the public system en masse to work in private practice, where they can earn between $85 and $150 per one-hour session. The holes in the mental health care system mean that full-time psychologists are stretched extremely thin between clinical work (e.g., evaluation, psychometric testing, treatment, crisis management, consultation with other professionals), research, administrative tasks, and teaching and supervision, and that Quebeckers who can’t afford private services face long waiting lists for mental health care.

Refusing to train interns effectively stalls the education of new psychologists in the province, threatening to even further increase the number of vacant psychologist positions in the public system. For Quebec citizens, it means even less accessibility to services. For me, it means that my internship applications for next fall, mailed before Christmas, are being received but not opened, and that my degree—already long—risks being delayed by one year.

However, in the past few days, the Ministry acknowledged the pressure tactic, and a preliminary meeting between Ministry representatives and representatives of Quebec psychologists is in the works. Stay tuned.

Now This Is Happening

Mindfulness—a state of conscious awareness in the present moment—is a centuries-old Buddhist practice and one of the biggest trends in mental health right now. Mindfulness means full attention and presence in the now, on purpose and without judgment. It means being in tune with one’s self, and noticing and embracing the experience of each moment, good or bad. Mindfulness doesn’t necessarily imply formal meditation; it can simply mean a conscious effort to be present and aware during every moment. 

How is mindfulness related to mental health? 

1)   Proponents of mindfulness believe that much of what ails us stems from our habits of acting unconsciously and automatically, and of ignoring the present moment in favour of focusing on the past or the future. Lack of attention to the present leads to a poor understanding of our selves, our actions, and our perceptions, and promotes automatic reactions driven by insecurity or fear. Advocates suggest that practicing mindfulness improves mental health by increasing insight and understanding, and by helping us slow down and respond rather than react.

2)   Mindfulness implies not only observation and awareness of the present, but acceptance, too. I like to sum up the concepts of acceptance and mindfulness with the phrase “Now this is happening,” adopted from a funny scene with Jack Black in the non-mindfulness-related movie Anchorman. “Now this is happening” reminds me that what’s happening is indeed happening--whether or not I like it, approve of it, or am prepared for it--and that refusing to accept it won’t make it stop happening. The acceptance inherent to mindfulness is not an attitude of passivity, but rather a realization that the faster and the greater grace with which you accept that you are, for example, locked out of your house, not getting the job you wanted, or rejected romantically, the sooner you have a strong position from which to start dealing with it.

The mindfulness movement is everywhere right now in clinical and popular psychology. Psychology conferences are replete with symposia such as “Eat, Drink, and Be Mindful: Mindfulness Interventions for Binge Eating,” bookstore self-help sections boast titles like “Mind Your Manners: Teaching Children Respect Through Mindfulness,” and there doesn’t seem to be a single mental health problem that some clinician or researcher, somewhere, isn’t trying to treat through mindfulness.

For mental health professionals who don’t like it, don’t believe in it, or aren’t prepared for it: Now this is happening.

Multiple Personalities

Dissociative Identity Disorder (DID) is pretty much the most fascinating DSM diagnosis of all. Formerly called Multiple Personality Disorder, DID is a rare disorder diagnosed when a client presents more than one discrete identity or personality state that recurrently takes control of his or her behaviour. Each identity has a distinct and enduring way of behaving, perceiving, and interacting. Correspondingly, in addition to significant memory lapses and time unaccounted for, symptoms of DID include things like being told that one behaved extremely uncharacteristically, not responding to one's name, and being frequently accused of lying.

DID is associated with early traumatic experiences, particularly childhood physical or sexual abuse, often by a parent or other trusted caregiver. The hypothesis is that dissociation is an extreme response to severe trauma: the mind splits off the memory and awareness of the abuse; the memories go into the subconscious and eventually emerge in another personality, meanwhile allowing the original identity to exist as though untraumatized. 

Without forgetting the anguish and suffering inherent to DID, I can't help but be impressed by the brain's capacity to protect individuals from their own terrible experiences by creating a separate personality to whom the terrible experiences happened. Some research has even found evidence for differences between identities in handwriting, and in physiological variables like heart rate and blood pressure! 

Clinical psychology doesn't get more amazing than that. 

The Pursuit of Happiness

Psychologists and therapists have traditionally focused on alleviating misery–-making anxious people less anxious, angry people less angry, and psychotic people less psychotic–-and assumed that happiness was a byproduct. Researchers in a relatively new subfield of psychology believe that reducing suffering is not enough and that increasing happiness should be a separate and equally important objective.

Positive psychology is the study of positive emotion and human strengths, with the goal of identifying and building strengths, nurturing talent, and improving quality of life in relatively untroubled people. Positive psychology researchers study the traits and habits of happy people and, based on their findings, design interventions to increase happiness.

So what makes us happy?

·     Strong interpersonal relationships make us happy. The people in the highest percentiles of happiness are extremely social, have rich and meaningful friendships, are in a romantic relationship, and don’t spend a lot of time alone.

·     Knowing and using our personal strengths makes us happy. Positive psychology therapy clients complete questionnaires that identify their strengths and are assigned to, for example, use their key strengths in new ways three times per week. If your two greatest strengths are patience and teaching, things like helping your niece learn to read and showing your dad how to use HTML increase happiness. Likewise, couples in therapy with a positive psychologist are assigned to go on a “strengths date,” i.e., a date during which both partners get to use their strengths.

·     Meaning (using your strengths in the service of a greater good or to belong to a larger community) and engagement (the ability to get lost in what you’re doing, whether it’s stock trading, parenting, or making music) make us happy. Pleasure (the experience of positive emotion), on the other hand, is less relevant to happiness. 

The implications of positive psychology findings are considerable. People seeking happiness through pleasure can consider pursuing engagement and meaning instead. The known relationship between happiness and outcomes like better health and longer life can have a significant positive impact on larger systems such as health care and the economy. Finally, positive psychology is an exciting and validating option for future mental health professionals (ahem) who are less interested in severe mental illness and very interested in helping well people improve their quality of life.