Cognitive Behavioural Therapy dictates that what we feel is a product of your thinking. Depression and anxiety are therefore a consequence of negative thinking.
Free Association was a therapy technique of psychoanalysis. It encouraged people to express whatever came to mind without the usual mental censorship. Eventually the analysis could see the patterns of thinking, obsessions, and resistances that the analysand struggled with. When they were explored together the analysand could root out what were usually once useful thoughts but had outlived their value.
I have shared my own thoughts as a ‘writer’s journal’. This was the teaching of Julia Cameron in Artist’s Way. She recommended writer’s daily do ‘morning pages’ to free up their creativity.
“Journalling’ is a recognized therapy technique to help people in my words ’squeeze the pus out of their brains’. When I journal in the morning I record those things that are uppermost in my mind. In this way I tell my mind that I have acknowledged its concerns and recorded those matters most important to it. And just as when I make a list I don’t have to keep returning to remember it but can get on with other things till I need to review the list again, so with journalling I can quiet my mind. My mind no longer has to repeat the same concerns.
Fear and resentment are the major negative emotions and daily these primal emotions are triggered by recurrent negative thoughts.
Mostly fear and resentment resolve around security or money. Next they’re a response to interference with ambition or expectation. Something blocks our mental plan or interferes with our intention. Finally fear and resentment revolve around status, how we see ourselves in relationship to other, all the issues that are involved with shame.
Cognitive distortions are recurrent negative patterns of thinking like ‘catastrophizing’, jumping to conclusions and believing the worst. Black and white thinking is the ignoring of the possibilities of grey. Such binary thinking leads to paranoia and persecution delusions. Grandiose thinking is believing it’s all about you when it fact the play might not even have you as a lead. Not every theatre has you as the lead.
Logic is the study of thinking and the basis of philosophy. Rhetoric is the study of ‘sales’ thinking and politicking. Logic endeavours to reach the ‘truth’ whereas rhetoric endeavours to manipulate and ‘win arguments’. The fallacies are well recognized false arguments.
The one I notice most these days is the ‘ad hominem. When I say Justin Trudeau needs to be randomly drug tested others respond attempt to ‘kill the messenger’ and attack the arguer rather than address the thesis. Hence the standard ‘Facebook’ argument, “you’re an asshole to question Justin Trudeau’. This may be true but it’s quite irrelevant and ‘begging the question’.
Sadly most advertising a series of ‘fallacies’. Laboissiere teaches fallacy and sadly given the marketing and political nature of the world today it’s a topic that should be the basis of grade school just as scientific method should be taught that early. However the profound ignorance in the Canadian population reflects the propagandistic nature of the school system which fails to teach children ‘how to think’ by instead teaching them ‘what to think’.
Cognitive behavioural therapy with it’s tools of psychoeducation and logic includes journalling especially free association journalling as a means to allow us to review alone or with another what exactly is going on in our minds. If we can see and understand that then we can root out negative memes that are no longer useful or simply correct the fallacies and cognitive distortions that make life less joyful.
St. Paul taught us to ‘pray unceasingly’. My psychiatrist minister friend Dr. Willi Gutowski used to described the brain as a ‘radio’ which picked up all manner of stray frequencies from the world around us. He recommended taking two hands and turning the dial to the ‘god channel’ and holding it there.
Practicing the ‘presence of the Lord’ requires one to focus on being in the now. God is Omniscient, Omnipotent, Omnipotential so to know God and all Joy is to be in the present. As my army friend used to tell me when I talked to him, “Bill you have one foot in the future and one foot in the past and you’re pissing and shitting on the day. Get your head in the same room as your ass is.”
Mostly our mind is ranging out into the past where we have resentments or ranging out into the future where we have fears. Meditation is a means of focusing on the present. Mindfulness meditation as taught by Buddha is the means where by we see the thoughts as ‘creatures’. One identifies with the Self of Kohut’s “Self Psychology’. This has also been called the ‘Observer’. C.S. Lewis, the great Christian philosopher encouranged us to join with God and see that God was permanent and infinite and all else was finite and transient. This expression ‘this too shall pass’ refers to all but the essence of the flow, i.e. God.
Emmett Fox, author of Sermon on the Mount teaches that as we address the thinking disease we will find the underlying ‘spiritual laws’ of creation and be better able to live by them.
Selfishness and self centeredness is closed minded and fear based. It’s all the response to hurt. A child is like a fool all trusting until it learns from trial and error the dangers of the world around it. These leads to ruts of thinking, behaviour and attitudes. These had a value at the time and may be held onto for that very survival aspect but later may indeed impede further learning.
Showing posts with label Cognitive Behavioural Therapy. Show all posts
Showing posts with label Cognitive Behavioural Therapy. Show all posts
Sunday, April 24, 2016
Wednesday, July 29, 2015
Wednesday Morning Journal
I’m feeling a failure. It’s something that comes over me in waves. I’ve got this aging thing happening. Like I’ve had my time and blown it. There were so many dreams and they’ve gone past. The first was family. The decisions and abortions took those. The glass is half empty. I had this belief that I’d save the world in some way in medicine, make things better. I was a cog in the machine. I served my time. I did my part in a thousand little ways but I was plagued by the complaint that always comes to those who want to change something. The reformer is the enemy of all who benefit from the status quo. The corruption and deceit in the system is putrid to the max and yet others move along stepping around the cesspools. I waded right in and began with a bucket to no avail. There’s a cesspool swamp in every system. I learned that too late. I look back on years of frustration. There was always this really scummy dirty ignorant person in a position of leadership. They were killing people and I couldn’t stop them because there was always someone holding me back. Mostly that was to save my life. The amount of money in killing is amazing. Healing gets a fraction. The big boys and big girls dish out death like it was a fashion designer item.
Spirituality teaches me to look for the positive. Use both hands and pull my head out of my ass. Look back on your life and see the successes. You’re still alive. Others have died. You’ve been in multiple crashes and walked away. Others are missing limbs. You’ve known incredible stress especially dealing with the corruption of government and the lies of authorities and the theft of the finances meant for services but you’ve not had a heart attack. The stress has been countered by exercise and meditation, family and friends. Others are dying of chronic disease because they’ve had to deal with these same assholes in their own worlds. Cancers come from stress as do all the diseases. Acute stress is what our bodies are built for not the chronic debilitating stress of endless legal cases and beaurocratic miasma’s that go on for years.
Daily I’ve been required to make a decision , a diagnosis and a recommendation in less than a hour. I’m on the front line. Step back one leadership position and they form a committee to make a lesser decision. Step back one more leadership position and they have an enquiry. Step back another leadership position and they have a review. All of these ‘processes’ are to ensure that nothing gets done till maximum graft has been taken from the system and that the ones deepest in the shit have been able to get out and move to more lucrative grounds. I get paid x for making a decision. The next level gets 2 x and then 3x and 4 x. The longer one can delay making a decision in the courts and bureaucracy the more money and power one has. We’re living in a world of siege mentality.
And every year I’ve tried to stop someone killing some baby somewhere. And I’ve been punished and humiliated and shut up year after year. I feel like my life could be called one baby too far. I’ve just tried to save one life too many and someone a whole lot higher wanted that life killed. It’s the Morgentaller system. The whole abortion industry of our times. It’s a metaphor. Like Solyent Green.
And spirituality calls this my personal ‘black dog’. , my ‘depressive thinking’. I must daily struggle to focus on the positives. Today the worm of despair entered my mind when I read in the papers how a colleague I know as the most deceitful and psychopathic is being rewarded. It’s like the Aliens with a hidden head and no heart have a little gift ceremony for their cronies and this guys name comes up.
I see it with mixed envy and horror. It’s like Hitler getting the Nobel Prize. Who can want a Nobel Prize after Hitler gets it. I see this and wonder as always am I wrong. Was this fellow a good guy. He’s rich and famous now and I knew him as the liar and cheat. I personally know a fellow who let people die and ensured that others were seriously hurt, who sold out everyone and he got ahead.
So my cognitive behaviour therapy teaches me that I have to focus on those who are good people. I can’t let the drop of ink discolour all the water. I just heard a lovely woman I know won a beauty contest. A fellow I think is great got a job. My favourite person in academia got a professorship. Another friend’s book was awarded. There’s all manner of positives there if I can just focus on them.
I wake up now and drag myself out of bed. There’s a whole lot of aches.The dog is ecstatic. He bounces on me. When I get his leash he barks. He’s exuberant. He’s loving life. He’s showing me what we both should be doing. I walk him outside down to the park. He sniffs up a storm then has a marvellous bowel movement. I scoop it up and put it into the container. He’s happy to walk back with me pulling on the leash.
I think maybe I’d better stop reading the medical news in the morning. I’ve all but stopped listening to CBC. I feel like increasingly I’m becoming monastic turning away from the insanity of the world. I see that a whole lot of the folk I went to school with are hunkering down. They’re retired and kind of preparing for death. They’ve taken what ever crumbs they’ve been offered and have got out. They don’t plan to do more and are kind of like kids on summer vacation. They don’t think of the future. They don’t particularly care what’s happening in politics. They’re prepared for Armageddon and mostly just looking to their individual comfort. I remember dad began fishing seriously when he was my age. Fame is foolish. Fortune makes more sense but it’s pretty obvious most of the casinos are rigged in some way. The house always wins. Maybe next time around the karmic reincarnation cycle I’ll have more tools to win against the bank.
I read about St. John of the Cross in prison for 11 months being flogged every week or so for the entertainment of his fellow monks, the ones who didn’t like the reforms he’d tried to make. It’s in failure that we find Christ. If I had a room full of sex objects, cocaine and bags of money and a personal army and world leaders dropping by to give me prizes I’d not think of inward riches, those infinite glories that surpass death. Here it’s about the temporal. I’ve been given all manner of awards and made fortunes. I’ve delivered babies and had so many children treat me with love and respect. I’ve a full life. I’ve been blessed beyond my wildest dreams. If I measure my success from the bottom up. It’s success. But if I measure my success from the top down, from my not being an astronaut flying to Mars for instance, then yes my life is a failure. I haven’t written the great canadian novel, found the cure for all cancer or developed a faster than light space ship. I’ve been humbled by the reality of limitations. I’ve done my part. I’ve contributed. I’ve paid taxes. I’ve worked and been a good man when the temptations were overwhelming to be other. I’m not particularly wanting to be flogged every week so that I can compose the ‘long dark night of the soul’ to point the direction to the infinite. I’m kind of focussed on comfortable. Now I must get to work. Mid week. A few more days to go. The weekends are always down hill.
Thank you Jesus for opening an individual door of communication with the infinite.
Spirituality teaches me to look for the positive. Use both hands and pull my head out of my ass. Look back on your life and see the successes. You’re still alive. Others have died. You’ve been in multiple crashes and walked away. Others are missing limbs. You’ve known incredible stress especially dealing with the corruption of government and the lies of authorities and the theft of the finances meant for services but you’ve not had a heart attack. The stress has been countered by exercise and meditation, family and friends. Others are dying of chronic disease because they’ve had to deal with these same assholes in their own worlds. Cancers come from stress as do all the diseases. Acute stress is what our bodies are built for not the chronic debilitating stress of endless legal cases and beaurocratic miasma’s that go on for years.
Daily I’ve been required to make a decision , a diagnosis and a recommendation in less than a hour. I’m on the front line. Step back one leadership position and they form a committee to make a lesser decision. Step back one more leadership position and they have an enquiry. Step back another leadership position and they have a review. All of these ‘processes’ are to ensure that nothing gets done till maximum graft has been taken from the system and that the ones deepest in the shit have been able to get out and move to more lucrative grounds. I get paid x for making a decision. The next level gets 2 x and then 3x and 4 x. The longer one can delay making a decision in the courts and bureaucracy the more money and power one has. We’re living in a world of siege mentality.
And every year I’ve tried to stop someone killing some baby somewhere. And I’ve been punished and humiliated and shut up year after year. I feel like my life could be called one baby too far. I’ve just tried to save one life too many and someone a whole lot higher wanted that life killed. It’s the Morgentaller system. The whole abortion industry of our times. It’s a metaphor. Like Solyent Green.
And spirituality calls this my personal ‘black dog’. , my ‘depressive thinking’. I must daily struggle to focus on the positives. Today the worm of despair entered my mind when I read in the papers how a colleague I know as the most deceitful and psychopathic is being rewarded. It’s like the Aliens with a hidden head and no heart have a little gift ceremony for their cronies and this guys name comes up.
I see it with mixed envy and horror. It’s like Hitler getting the Nobel Prize. Who can want a Nobel Prize after Hitler gets it. I see this and wonder as always am I wrong. Was this fellow a good guy. He’s rich and famous now and I knew him as the liar and cheat. I personally know a fellow who let people die and ensured that others were seriously hurt, who sold out everyone and he got ahead.
So my cognitive behaviour therapy teaches me that I have to focus on those who are good people. I can’t let the drop of ink discolour all the water. I just heard a lovely woman I know won a beauty contest. A fellow I think is great got a job. My favourite person in academia got a professorship. Another friend’s book was awarded. There’s all manner of positives there if I can just focus on them.
I wake up now and drag myself out of bed. There’s a whole lot of aches.The dog is ecstatic. He bounces on me. When I get his leash he barks. He’s exuberant. He’s loving life. He’s showing me what we both should be doing. I walk him outside down to the park. He sniffs up a storm then has a marvellous bowel movement. I scoop it up and put it into the container. He’s happy to walk back with me pulling on the leash.
I think maybe I’d better stop reading the medical news in the morning. I’ve all but stopped listening to CBC. I feel like increasingly I’m becoming monastic turning away from the insanity of the world. I see that a whole lot of the folk I went to school with are hunkering down. They’re retired and kind of preparing for death. They’ve taken what ever crumbs they’ve been offered and have got out. They don’t plan to do more and are kind of like kids on summer vacation. They don’t think of the future. They don’t particularly care what’s happening in politics. They’re prepared for Armageddon and mostly just looking to their individual comfort. I remember dad began fishing seriously when he was my age. Fame is foolish. Fortune makes more sense but it’s pretty obvious most of the casinos are rigged in some way. The house always wins. Maybe next time around the karmic reincarnation cycle I’ll have more tools to win against the bank.
I read about St. John of the Cross in prison for 11 months being flogged every week or so for the entertainment of his fellow monks, the ones who didn’t like the reforms he’d tried to make. It’s in failure that we find Christ. If I had a room full of sex objects, cocaine and bags of money and a personal army and world leaders dropping by to give me prizes I’d not think of inward riches, those infinite glories that surpass death. Here it’s about the temporal. I’ve been given all manner of awards and made fortunes. I’ve delivered babies and had so many children treat me with love and respect. I’ve a full life. I’ve been blessed beyond my wildest dreams. If I measure my success from the bottom up. It’s success. But if I measure my success from the top down, from my not being an astronaut flying to Mars for instance, then yes my life is a failure. I haven’t written the great canadian novel, found the cure for all cancer or developed a faster than light space ship. I’ve been humbled by the reality of limitations. I’ve done my part. I’ve contributed. I’ve paid taxes. I’ve worked and been a good man when the temptations were overwhelming to be other. I’m not particularly wanting to be flogged every week so that I can compose the ‘long dark night of the soul’ to point the direction to the infinite. I’m kind of focussed on comfortable. Now I must get to work. Mid week. A few more days to go. The weekends are always down hill.
Thank you Jesus for opening an individual door of communication with the infinite.
Thursday, January 24, 2013
Behavioural, Cognitive and Emotional Concerns of Brain Injured Clients, TLABC, Mexco, 2013
The following are the rough notes I took of Dr. Lee's splendid compassionate and informative presentation at the Trial Lawyers Association of British Columbia Conference Mexico, 2013. He has doal specialization and certification in Cognitive Behaviour Therapy and Behavourial Analysis. His work proceeded as I've had the priviledge of seeing patients who his work has already helped significantly. A leader in the field, his presentation was fascinating to say the least. I'm only sorry I can only give this overview but share it as some idea of where the cutting edge in the field is going.
Effectively dealing with the behavioural, cognitive and emotional concerns of more seriously brain injured clients"
TLABC Conference, 11 th Annual Medical Legal Conference 2013 Mexico Conference
Dr. Douglas Lee, R. Psych, ABPP, BCBA-D
Registered Psychologist BC/AB
Clinical Faculty Department of Psychiatry, University of BC
Behavioural Solutions Inc - Surrey, North Vancouver, Lethbridge Alberta
Brain and Behaviour
Neuropsychology and Clnical Psychology and behavioural psychology overlap
- Behavioural Psychology - most of work is done in field, home, worksite, school with children
Academic areas of psychology - psychology has splintered into so many areas
Behavioural psychology is a very empirical area of Clinical Psychology
TBI and Behavioural psychology
Injury - demonstrable tissue damage - structural or functional
Impairment - loss of behavioural capacity that can be formally measured - loss of function that is related to the injury
Disability - measureable impact of an impairment on everyday skills and behaviour - type and level of interference the impairment causes in the person in their everyday life
Injury - mild , moderate, severe
Impairment - mild, moderate, severe
Disability - mild, moderate, severe
Neuropsych assessments may or may not match daily functioning
Behavioral assessments can assist in discovering why this may be the case
People who have a loss of function may find that mild loss of function on exam very difficult when they return to work, sometimes related to environment
- example returning to the 'pace' of workplace - patient might be able to do a previous task but no longer able to do them at the pace
Cognitive Behavioural Therapy (CBT) and /or Applied Behavioural Analysis (ABA) - Dr. Douglas Lee is certified in both
- to do cognitive therapy you need relatively normal cognitive functioning - need cbt therapist experienced in tbi
- if the injury is more mild, use the cbt model but if there is moderate injury, consider more aba - in latter make sure they bring somebody else so they can remember, but if it's severe, I need to work specifically with caregivers.
Discussion of anger management problems in a moderate severe brain injury group
The group identified the individual anger management events but the group of other brain injured patiients were able to identified all their episodes occurred 3 to 6 pm and related to whether or not they had a nap, something the individual hadn't been able to see.
Brain X Behaviour X Environoment
1)Small farming community in Alberta with long ties may allow someone with significant brain injury to function relatively independently
- his day was utterly structured
-all events scheduled
-as long as he was in grasslands he was fine
-happy as long as he could stay with schedule and people around understood
2) Man attempting to return to UBC pharmaceutical sciences program unsupported following Mild Concussion, attempted suicide - when having difficulties - refered for therapy with benefit
3) Demonstrating the actual effects of a 20 point IQ drop (140 to 120 results in a significantly larger settlement - this was a catastrophic loss - originally lawyer was going to settle for a small settlement - behavoioral analysis - showed difficulty at level of even filling puppy bowl
Outcome following traumatic brain injury , a comparison between 2 and 5 years after injury
Brain Injury 1996 10 841-848
Olver J, Ponsford,
List different
Brain Inury 1998 4 283-296 Catellani Lombardin
Disturbances at long term follow up
# children at e years
Baseline and 3 year follow up
With ortho injury in risk takers get better
In TBI get worse.
I deal with 3 forms of severity
-amt of physical damage done to the brain
-challenges unique to person achieing functional recovery outcomes
-impact of person's social and family support network
First type puts stres on other two types and biological limits to recovery
Translation of neuropsychological findings to the everyday contexts
Coordinating involvement of professionals and family towards meeting the cognitive behavioural and emotional rehabilitation goals.
Assisting specific professionals regarding presenting problems that are interferening with their rehabilitation activities
Consulting with caregiver gives
Long term consulting
- longest 17 years
Behavioural rehabilitation assistance
- for client with predominately cognitie and or behaviour problems
Input regarding cost of future care costs
Expert witness testimony
Questions
Dr. Armstrong - raised the issue of neuroplastic change after the brain injury can be positive or negative and this can result in change in behaviour in active
Question - re cogntive learning - Dr. Lee noted it can take longer and it's not good if it's stopped earlier since there's a longer period of learning - discussion of computer apps application and biofeedback techniques.
Thursday, January 3, 2013
Selective Negative Attention
All of our studies of memory and attention and cognitive behavioural therapy have taught me that I cannot trust my mind to give me a 'true' representative of even my little piece of the world. This 'information' that I experience is constantly being processed and edited by past prejudice and by emotional tone.
For example yesterday, I was driving to work, two seriously whacked out drivers nearly hit my car, one changing lanes without signalling and the other jumping a light in front of me at high speed but causing me to break with concern. Now there were hundreds of other cars on the road. All the other drivers were such model citizens and so thoroughly toilet trained as to drive with the group and be responsible motorists in all ways. In the 20 minute drive two yahoos stick out. I was unable to park because thieves working the parking meters with string and magnets had jammed the meters. It's a recurrent problem. I wanted to report it to the police. Instead of a brief encounter the police wanted me to describe the fellow in detail who had been casing these parking meters even though it might be a long shot that he was the one who was working this city block.
At work I saw some 40 people. The staff were amazing, truly amazing, wonderful competent, reliable delightful people. My colleagues were superb, pleasant, efficient reliable, knowledgeable, informed, courteous. The staff and colleagues and I chatted and exchanged New Years good wishes. The people I saw were all thoroughly pleasant and hard working trying each in their way to be compliant with treatment, making small progress here and there and greater progress in some cases. One person was typically obnoxious and belittling to me and staff and disrupting, loud and ultimately offensive. I asked them to leave. Even the person who had vpmitted in my office was upstaged by the loud person. The man who vomitted had said "I'm going to be sick, looked about, found the wastebasket, vomitted there, and then emptied the bag himself' saying he'd eaten something he thought off from his fridge just before coming, drunk a coke and now felt better with it gone, apologizing profusely for vomitting. Now there was a true gentleman considerate of others even in his distress and really a true contrast to the 'king baby' of addiction the attention seeking drama queen I'd seen earlier who plays the 'big shot' all the time and disdains others psychopathically looking for weak individuals to exploit.
At the end of the day I had a headache not from the thoroughly pleasant and enjoyable people I had to work with, My plan had been to drive to work. 2 yahoos threatened my vehicle en route. After that I was disrupted in my attempt to park by a criminal scheme. Then in the workplace while I had a man be sick in my office the Febreeze helped, there weren't windows as in my other office and by the end of the day the 'stuffiness' and sheer volume of work plus the always routinely offensive person ordering me to hurry up and stop wasting his time, had me exhausted at the end of the day wondering why I do this work and wishing to escape to work in the country or back on a polynesian island.
I was focussing on the frustration of city experience, the encounter with what I euphemistically call 'assholes' all the while my little dog simple loves assholes and sniffs any he can demonstrating that one's negative is another's positive. Or in this case, that I can choose to focus on the highs of my days or the lows and too often and too routinely I'm paying most of my attention to the negatives. In contrast I would like to remember the smiles of the staff. They are truly beautiful people with the greatest greeting manners, incredible love and tolerance for their fellow man, do a myriad of tasks all the while people like the most difficult person that day, "grind" and "grind" at them demanding preferential treatment and wanting to jump the queue and complaining and criticizing them endlessly all the while they're cordial and pleasant in return.
We all tolerate the greatest degree of abuse their daily with belligerence threats, swearing constantly, shouting and squabbling with everyone accepting that this is sickness and the emotional immaturity and social devolution that goes with the disease and the self centredness of people who often have been in jail, some live on the streets where the very traits that are so offensive in community and in waiting rooms actually may have some survival value. The staff and my colleagues smile. They are humorous. Someone had brought an arrangement. Everyone working there was dressed well and were clean. Some of the people I saw had clearly made an effort with their clothing and hygiene to appear as well as possible for the visit. In a way our mind doesn't register the masses of good people.
It's like the media that never reports 25 million Canadians today did not kill their neighbours. Thousands of schools did not have a mass murderer invade their doors today. No tsunami struck anywhere today and no hurricane hit a continental mass yesterday. There was no major new war offensive reported in BBC, just the smouldering old make work kind of wars that reflect the bad marriages of socially inept countries around the world. No one said Canada fed all it's people and provided shelter from the horrible weather conditions of winter for refugees and indigents alike. Elsewhere people are having trouble getting water and food but here at home we did that and kept the trains and planes flying and while more and more people are expecting more and more people to take care of them, frankly because of increasing entitlement and self centeredness, the vast majority of people in the country went to work and paid taxes and worked together with other to make this 2nd day of the year rather spectacular.
If I had the means to see 'truly' without the horrible filters I have I'd be setting off fire works at the end of the day. It realy was a historically great day though here in Vancouver but it's probably not going to show up in history text books. I also forgot that all the people I saw were pretty much dead men and women walking. Their conditions by all rights should have killed them years ago but despite the horrendous burden of disease they keep struggling to live in lives that are so chaotic and messed up that one really should celebrate any day they survive the level of abuse they experience through their own hands and the consequences of their society. I was given the miracle of this day. I was able to be a part of one of the greatest days the universe will ever give someone. I had food and shelter and friends and work and love and everything was truly sacred and amazing. Yet somehow rather than praising God and being eternally thankful that I was participating in the sheer wonder of creation I was focussing my attention on the negatives.
I can't trust my mind. Only my soul is truthful. My emotions are too often reflective of what I think and what I think is too often hijacked by any number of distractions. At the end of the day I need to remember the light. I slept through the night and today there is a new dawn. I sure hope I can see more clearly today. I must somehow ignore the misinformation of my mind and concentrate on the truth and wonder that God gives me. My soul knows better than my mind or sentiment. My soul is the very heart of the matter where wisdom resides and I can appreciate what is true. Please God let me see more truly today and know that truth even in the midst of the moment to moment reality of existence.
For example yesterday, I was driving to work, two seriously whacked out drivers nearly hit my car, one changing lanes without signalling and the other jumping a light in front of me at high speed but causing me to break with concern. Now there were hundreds of other cars on the road. All the other drivers were such model citizens and so thoroughly toilet trained as to drive with the group and be responsible motorists in all ways. In the 20 minute drive two yahoos stick out. I was unable to park because thieves working the parking meters with string and magnets had jammed the meters. It's a recurrent problem. I wanted to report it to the police. Instead of a brief encounter the police wanted me to describe the fellow in detail who had been casing these parking meters even though it might be a long shot that he was the one who was working this city block.
At work I saw some 40 people. The staff were amazing, truly amazing, wonderful competent, reliable delightful people. My colleagues were superb, pleasant, efficient reliable, knowledgeable, informed, courteous. The staff and colleagues and I chatted and exchanged New Years good wishes. The people I saw were all thoroughly pleasant and hard working trying each in their way to be compliant with treatment, making small progress here and there and greater progress in some cases. One person was typically obnoxious and belittling to me and staff and disrupting, loud and ultimately offensive. I asked them to leave. Even the person who had vpmitted in my office was upstaged by the loud person. The man who vomitted had said "I'm going to be sick, looked about, found the wastebasket, vomitted there, and then emptied the bag himself' saying he'd eaten something he thought off from his fridge just before coming, drunk a coke and now felt better with it gone, apologizing profusely for vomitting. Now there was a true gentleman considerate of others even in his distress and really a true contrast to the 'king baby' of addiction the attention seeking drama queen I'd seen earlier who plays the 'big shot' all the time and disdains others psychopathically looking for weak individuals to exploit.
At the end of the day I had a headache not from the thoroughly pleasant and enjoyable people I had to work with, My plan had been to drive to work. 2 yahoos threatened my vehicle en route. After that I was disrupted in my attempt to park by a criminal scheme. Then in the workplace while I had a man be sick in my office the Febreeze helped, there weren't windows as in my other office and by the end of the day the 'stuffiness' and sheer volume of work plus the always routinely offensive person ordering me to hurry up and stop wasting his time, had me exhausted at the end of the day wondering why I do this work and wishing to escape to work in the country or back on a polynesian island.
I was focussing on the frustration of city experience, the encounter with what I euphemistically call 'assholes' all the while my little dog simple loves assholes and sniffs any he can demonstrating that one's negative is another's positive. Or in this case, that I can choose to focus on the highs of my days or the lows and too often and too routinely I'm paying most of my attention to the negatives. In contrast I would like to remember the smiles of the staff. They are truly beautiful people with the greatest greeting manners, incredible love and tolerance for their fellow man, do a myriad of tasks all the while people like the most difficult person that day, "grind" and "grind" at them demanding preferential treatment and wanting to jump the queue and complaining and criticizing them endlessly all the while they're cordial and pleasant in return.
We all tolerate the greatest degree of abuse their daily with belligerence threats, swearing constantly, shouting and squabbling with everyone accepting that this is sickness and the emotional immaturity and social devolution that goes with the disease and the self centredness of people who often have been in jail, some live on the streets where the very traits that are so offensive in community and in waiting rooms actually may have some survival value. The staff and my colleagues smile. They are humorous. Someone had brought an arrangement. Everyone working there was dressed well and were clean. Some of the people I saw had clearly made an effort with their clothing and hygiene to appear as well as possible for the visit. In a way our mind doesn't register the masses of good people.
It's like the media that never reports 25 million Canadians today did not kill their neighbours. Thousands of schools did not have a mass murderer invade their doors today. No tsunami struck anywhere today and no hurricane hit a continental mass yesterday. There was no major new war offensive reported in BBC, just the smouldering old make work kind of wars that reflect the bad marriages of socially inept countries around the world. No one said Canada fed all it's people and provided shelter from the horrible weather conditions of winter for refugees and indigents alike. Elsewhere people are having trouble getting water and food but here at home we did that and kept the trains and planes flying and while more and more people are expecting more and more people to take care of them, frankly because of increasing entitlement and self centeredness, the vast majority of people in the country went to work and paid taxes and worked together with other to make this 2nd day of the year rather spectacular.
If I had the means to see 'truly' without the horrible filters I have I'd be setting off fire works at the end of the day. It realy was a historically great day though here in Vancouver but it's probably not going to show up in history text books. I also forgot that all the people I saw were pretty much dead men and women walking. Their conditions by all rights should have killed them years ago but despite the horrendous burden of disease they keep struggling to live in lives that are so chaotic and messed up that one really should celebrate any day they survive the level of abuse they experience through their own hands and the consequences of their society. I was given the miracle of this day. I was able to be a part of one of the greatest days the universe will ever give someone. I had food and shelter and friends and work and love and everything was truly sacred and amazing. Yet somehow rather than praising God and being eternally thankful that I was participating in the sheer wonder of creation I was focussing my attention on the negatives.
I can't trust my mind. Only my soul is truthful. My emotions are too often reflective of what I think and what I think is too often hijacked by any number of distractions. At the end of the day I need to remember the light. I slept through the night and today there is a new dawn. I sure hope I can see more clearly today. I must somehow ignore the misinformation of my mind and concentrate on the truth and wonder that God gives me. My soul knows better than my mind or sentiment. My soul is the very heart of the matter where wisdom resides and I can appreciate what is true. Please God let me see more truly today and know that truth even in the midst of the moment to moment reality of existence.
Wednesday, March 21, 2012
Therapies for Depression
Depression is a broad term to describe a psychiatric state of literally, unhappiness. So called Clinical Depression refers to some such state that persists for at least a couple of weeks. It's associated with a depressed mood, most of day, most every day. Sleep and motivation and cognitive function can all be affected. There have been a wide variety of terms over the year to describe this state. It's been called dysthymia, major affective disorder, mood disorder, major mood disorder, and at it's most extreme melancholia. It's differentiated from the blahs by being a bit more severe and lasting a bit longer. It's differentiated from Grief or Bereavement, the natural state of loss when a loved one is lost, by lasting much longer.
At the turn of the century a study in Pennsylvania at a farm when Quakers kept people who came with mental illness treating them with tender loving care but not much else, the length of 'untreated major depression' was approximately 9 months. Adjustment disorders, a reaction to a negative event in one's life such as the loss of a job or the break up of a dating realationship was considered to be about 6 months. The depth of suffering with an adjustment disorder could be as great as major mood disorder but if the disorder laster longer or was greater then the term major mood disorder or major affective disorder was used to describe the experience. There have been some who wrongly defined adjustment disorders as 'minor' depressions but adjustment referred to the presence of an identifiable stressor. In Major Mood Disorder alone a person might have a stressor or not.
Indeed there is a tendency in the pharmacological industry associated psychiatric diagnosis to described disorders independent of the causation. Hence the 'antidepressants' medication is likened to 'fever' medication, like Aspirin and Acetomenophen. People can have pain for a variety of reasons but aspirin or tylenol tend to treat the 'pain' regardless. There's this kind of non specific benefit noted with the antidepressant medications so that in association the term "major mood disorder' has by convention been likened to the condition a psychiatrist would use an antidepressant with.
That said depression and moods in general can be altered by a variety of factors in terms of the individual, their relationship or environment. A large number of physical medica conditions give rise to depression. Often the first presentation of an underlying major medical physical illness is depression. Cancer, Diabetes, Heart Disease, Chronic low grade infections, Anemia, Metabolic Diseases, all commonly present with depression as the first sympton of the disorder. For this reason people with persisting depression often benefit from seeing their family doctor who can readily rule out the major and more likely conditions that may present as depression.
Many of my patients have come to me after months of psychological treatments or counselling when they had an undiagnosed physical disease which was causing the person to have low mood, loss of energy and sleep problems and cognitive difficulties. The diagnosis of depression was correct. It's just that the cause and treatment had been wrong. I saw one poor gentleman after a year of weekly psychotherapy and all manner of discussion of his sex life when he had an anemic condition. When the anemia was treated his mood improved and he no longer had need for psychological treatment and certainly was disheartened by the year of therapy, the $10,000 of dollars cost and the loss of work and relationship which had occurred. In several cases depression was the way my patients breast cancer presented. I did an appropriate medical screening history and found that they had other symptons of concern. Hundreds of cases that have come to me for depression, even those who have seen family physicians before me have turned out to have a physical illness which when treated caused the patient to no longer need antidepressants or depression therapy.
The message there is 'screening'. Give a boy a hammer and everything is a nail. That's the problem with counsellors. They over diagnosis psychological depression and miss the other often common causes.
Psychosocial reasons for depression abound. Often people become depressed by lack of exercise. Scientific studies have shown that 1 half hour of aerobic exercise daily has the equivalent benefit on mood as taking prozac 10 mg daily has.
Often people who have eating disorders are depressed. Both obesity and anorexia are associated with depression.
All the addictions are associated with depressions. Alcohol is a 'depressive'. Cocaine is a 'stimulant' but it quickly depletes the bodies stimulant neurotransmitters and causes a depression as a result. Addictions are generally associated with a dramatic high followed by a low. Sex addicts get this and eventually the flogging of the dead horse phenomena in addiction leads to chronic depression and dysthymia. Bipolar II in the diagnosis associated with addiction until proven otherwise.
Chronic anxiety states lead to depression. Indeed the Seligman 'learned helplessness' studies suggest that depression is a chronic anxiety state. There's work with neuro implants that suggest that chronic anxiety may set up a derailed neurotransmitter pathway that requires a 'brain pacemaker' to disrupt and restore a person to having normal neurotransmitter release.
Electroshock therapy served to 'reset' this distrurbed neurotransmitter system. Serotonin deficiency was disagnosed in the cerebral spinal fluid of suicidals and the general pharmacalogical explanation for depression was a low serotonin or noradrenaline state. It's now recognised that there's more likely an imbalance between varying neuro pathways serving to maintain equilibrium.
All manner of therapies have therefore been scientifically shown to be beneficial in the treatment depression. Prevalence studies of depression show as much as 30% of a population base may have some form of depression at any time.
Talking therapies - counselling - psychotherapy -have all been shown to be beneficall. The is much competition between the various 'schools' of thought and the 'latest' brand of therapy but one very interesting study some years ago showed that psychiatrists with 10 years of clinical therapy experience regardless of their theoretical basis had the same general benefit.
The 'convention' is to use a 'cognitive behavioural therapy' today, mostly because it's so easy to train a person in and therefore costs less. Psychodynamic therapies have equal if not greater success in the treatment of depressive disorders but require more training and are more difficult to learn than 'cognitive behavioural therapy'.
Generally speaking 'relationship therapies' have been good with most depressions. Garden variety depressions were what we always gave the new residents as they tended to respond to any form of positive hopeful encounter.
Having branched out in to other areas of study I've seen that "pastoral counselling' has been effectively treating depression quietly for centuries because it combines cognitive behavioural therapies idea, with relationship therapy and even has the 'lending the ego' elements which were beneficial in psychoanalytic therapies.
The advantage of psychotherapies over doing nothing was the generally speaking it's been shown that therapy shortens the length of the dysfunction associated with depression and the risk of suicide. Considering untreated depression can last 9 months, most counselling therapies result in a depressive episode getting better in 6 to 10 weeks.
Indeed prozac the antidepressant was considered a success because it was shown to have relatively equivalent benefit to 10 weeks of psychotherapy. Combined psychotherapy and psychopharmacology, the person improved symptomatically but the potential for recurrence was also reduced.
Individual therapy is expensive as any labour intensive therapy is. Therefore there have been studies on group therapy especially with cognitive behaviour therapy which really lends itself to the class room. Indeed I might argue that individual therapy of the CBT nature should only be considered when group therapy had failed.
Misery loves company. A significant success of the self help movement has been it's ability to counteract the tendency to isolation.
Spiritual people as evidenced by a measurable variable such as church attendance have less likelihood of depression and respond to treatment better with greater success.
Seligman at his Authentic Happiness site has been doing research on improving the various traits that counteract depression, two specifically being hope and reslience.
While a lot of people think that depression should be a reason to not be working, not working can actually make depression worse. Clearly a pilot who has depression may present a risk for his passengers but if he is sent home 'to rest' , the isolation might indeed make the depression worse. A very effective therapeutic strategy employed by the British Columbia worksafe program was to have depressed patients attend a daily coffee house thereby ensuring that they had the occupation benefits associated with group therapy and socialization. People who isolate worsen their depression.
However depressives can run in 'packs'. Individually I've treated dozens of patients by encouraging them to reduce the contact with 'sick' people in their social network. It's the 'dosage' of the relationship that is sickening. One women became physically ill if she talked to her deeply mentally ill mother for more than a half hour a week. The mother was dependent and clinging and literallly what caloquially we'd call a soul sucker. In contrast one of my male patients had only to talk to his father for an hour and his father was constantly demeaning to him causing him to be literally suicidal. Again by limitting the dose of the relationship to 15 minute contacts the man was able to get better. I routinely ask depressed patients to avoid the news in whatever form since it's commonly old and depressing.
Music therapy has been shown to be a treatment for depression. It's especially beneificall if people are themselves participating in making the music.
Given the wide range of successful treatments available it's usually beneficial to consider the efficiency and cost effectiveness of a therapy.
Magnetic therapies have been shown to be very effective for therapy and equivalent in some patients as medication therapy however right now the cost is higher than electroconvulsive therapies.
Hypno therapy is an effective therapy for depression as is neurotherapy.
Often the therapy that is used is the one most available in the community. It's also is affected by what experience the therapists have. In eastern Canada it's common that there are a psychotherapeutically trained psychiatrist with extensive experience in a variety of non pharmacological treatments as well as pharmacalogical treatments and physical treatments. In western canada it's most common that the psychiatrists are only trained in psychopharmacology or if trained in other forms of therapy these are supported by the community financially or professionally.
Massage therapy is very attractive to patients. I once asked my heroin addicts if they had the choice of going to detox or massage therapy which would they choose. They'd naturally choose massage therapy. Unfortunately there's no evidence that massage therapy is an effective treatment for heroin addiction. Abstinence is and detox is not nearly as pleasant as doing heroin and getting a government funded massage.
No one ever questions what individuals do to treat their own depressions. This is in fact the 'right' to 'pursuit of happiness'. I personally find riding my Harley Davidson Electraglide an antidepressant but it's most unfortunate I can't convince an insurance body to pay for my motorcycle. Similiarly i personly think that if I were depressed I'd benefit from a year of high paid tropical therapy on a beach. I suspect I could devise a scientific study to show that this did work but the cost would be prohibitive for any insurance company.
Much of the failure in treatment of depression has been due to the failure of patients to follow medical regimens, such simple suggestions as don't drink alcohol or exercise a half hour a day, or get out of bed.
Dance therapy is an effective therapy for depression. I used dance and psychodrama to effectively treat depressed patients. There's just no support in the very conservative medical system for me to do these therapies. I'd need a larger office or space where I could do dance. I have a group therapy that helps depression but even to have a group therapy in my office I have to pay the higher overhead costs for the office that can hold 10 people at a time. Further the medical service plan discourages me from having group therapy because it's more time and effort for my staff to arrange and bill and yet there's no commiserate increase in the therapy cost.
So there's lots of therapies and lots work. The choice of therapy and indeed the choices available are numerous. People don't need to be depressed. Talk about it and get help.
When I started in psychiatry I commonly talked with patients and rather quickly they got better. Often just listening to people who had otherwise well established lives served to result in their mood improving. Later I would see more complex problems with less and less resources and more and more demands on my services. As a result I tended to use medications more often. Commonly I have the pleasure and benefit of working with a psychologist or occupational therapist who does the lions share of talk therapy. I'm a consultant and diagnostician and the the psychopharmacologist in these arrangements. The psychologists and counsellors and occupation therapists can't prescribe medications and aren't aware of the whole medical and neurological aspects of depression which can be an important part. A number of the psychologists I work with a specifically trained in a subset of patients and their experience and training makes them especially good with this group of patients. My experience and training is really broad based with some subspecialty areas so it's refreshing to work with psychologists who are subspecialists themselves. Increasingly family physicians are working psychologically with patients so that makes things easier all round.
I still come across alot of depressed negative people in my daily walk in life. It's like the number of addicts who actually access treatment. Very few. So commonly I'm treating an addict in the office but there are a dozen or so more who deny they have addiction and attribute their regular social and occupational problems to the 'other guy'. Similiarly depressive people often are the last to seek help which is unfortunate too.
When I consider psychiatric illness I often think it was akin to physical illness in the 30's. All manner of people had physical illness like heart disease or treatable infections or cancers but they never sought help for them. As a result the morbidity and mortality rate only one or two generations ago was so much higher. Today people have much more 'quantity' of life in general but the 'quality 'is still an issue.
Ironically alot of people think that they'd be happy if they were rich but wealth is not a cure for depression and not a guarantee against it. I used to think if I lived on a tropical island I d not see depression becuase I'd associated it more with the dreary winter months but when I worked on a tropical island I saw just as much depression. I have been thankful for the wide range of therapies that I've learned, the excellent psychopharmacologies and elegant psychotherapies.
At the turn of the century a study in Pennsylvania at a farm when Quakers kept people who came with mental illness treating them with tender loving care but not much else, the length of 'untreated major depression' was approximately 9 months. Adjustment disorders, a reaction to a negative event in one's life such as the loss of a job or the break up of a dating realationship was considered to be about 6 months. The depth of suffering with an adjustment disorder could be as great as major mood disorder but if the disorder laster longer or was greater then the term major mood disorder or major affective disorder was used to describe the experience. There have been some who wrongly defined adjustment disorders as 'minor' depressions but adjustment referred to the presence of an identifiable stressor. In Major Mood Disorder alone a person might have a stressor or not.
Indeed there is a tendency in the pharmacological industry associated psychiatric diagnosis to described disorders independent of the causation. Hence the 'antidepressants' medication is likened to 'fever' medication, like Aspirin and Acetomenophen. People can have pain for a variety of reasons but aspirin or tylenol tend to treat the 'pain' regardless. There's this kind of non specific benefit noted with the antidepressant medications so that in association the term "major mood disorder' has by convention been likened to the condition a psychiatrist would use an antidepressant with.
That said depression and moods in general can be altered by a variety of factors in terms of the individual, their relationship or environment. A large number of physical medica conditions give rise to depression. Often the first presentation of an underlying major medical physical illness is depression. Cancer, Diabetes, Heart Disease, Chronic low grade infections, Anemia, Metabolic Diseases, all commonly present with depression as the first sympton of the disorder. For this reason people with persisting depression often benefit from seeing their family doctor who can readily rule out the major and more likely conditions that may present as depression.
Many of my patients have come to me after months of psychological treatments or counselling when they had an undiagnosed physical disease which was causing the person to have low mood, loss of energy and sleep problems and cognitive difficulties. The diagnosis of depression was correct. It's just that the cause and treatment had been wrong. I saw one poor gentleman after a year of weekly psychotherapy and all manner of discussion of his sex life when he had an anemic condition. When the anemia was treated his mood improved and he no longer had need for psychological treatment and certainly was disheartened by the year of therapy, the $10,000 of dollars cost and the loss of work and relationship which had occurred. In several cases depression was the way my patients breast cancer presented. I did an appropriate medical screening history and found that they had other symptons of concern. Hundreds of cases that have come to me for depression, even those who have seen family physicians before me have turned out to have a physical illness which when treated caused the patient to no longer need antidepressants or depression therapy.
The message there is 'screening'. Give a boy a hammer and everything is a nail. That's the problem with counsellors. They over diagnosis psychological depression and miss the other often common causes.
Psychosocial reasons for depression abound. Often people become depressed by lack of exercise. Scientific studies have shown that 1 half hour of aerobic exercise daily has the equivalent benefit on mood as taking prozac 10 mg daily has.
Often people who have eating disorders are depressed. Both obesity and anorexia are associated with depression.
All the addictions are associated with depressions. Alcohol is a 'depressive'. Cocaine is a 'stimulant' but it quickly depletes the bodies stimulant neurotransmitters and causes a depression as a result. Addictions are generally associated with a dramatic high followed by a low. Sex addicts get this and eventually the flogging of the dead horse phenomena in addiction leads to chronic depression and dysthymia. Bipolar II in the diagnosis associated with addiction until proven otherwise.
Chronic anxiety states lead to depression. Indeed the Seligman 'learned helplessness' studies suggest that depression is a chronic anxiety state. There's work with neuro implants that suggest that chronic anxiety may set up a derailed neurotransmitter pathway that requires a 'brain pacemaker' to disrupt and restore a person to having normal neurotransmitter release.
Electroshock therapy served to 'reset' this distrurbed neurotransmitter system. Serotonin deficiency was disagnosed in the cerebral spinal fluid of suicidals and the general pharmacalogical explanation for depression was a low serotonin or noradrenaline state. It's now recognised that there's more likely an imbalance between varying neuro pathways serving to maintain equilibrium.
All manner of therapies have therefore been scientifically shown to be beneficial in the treatment depression. Prevalence studies of depression show as much as 30% of a population base may have some form of depression at any time.
Talking therapies - counselling - psychotherapy -have all been shown to be beneficall. The is much competition between the various 'schools' of thought and the 'latest' brand of therapy but one very interesting study some years ago showed that psychiatrists with 10 years of clinical therapy experience regardless of their theoretical basis had the same general benefit.
The 'convention' is to use a 'cognitive behavioural therapy' today, mostly because it's so easy to train a person in and therefore costs less. Psychodynamic therapies have equal if not greater success in the treatment of depressive disorders but require more training and are more difficult to learn than 'cognitive behavioural therapy'.
Generally speaking 'relationship therapies' have been good with most depressions. Garden variety depressions were what we always gave the new residents as they tended to respond to any form of positive hopeful encounter.
Having branched out in to other areas of study I've seen that "pastoral counselling' has been effectively treating depression quietly for centuries because it combines cognitive behavioural therapies idea, with relationship therapy and even has the 'lending the ego' elements which were beneficial in psychoanalytic therapies.
The advantage of psychotherapies over doing nothing was the generally speaking it's been shown that therapy shortens the length of the dysfunction associated with depression and the risk of suicide. Considering untreated depression can last 9 months, most counselling therapies result in a depressive episode getting better in 6 to 10 weeks.
Indeed prozac the antidepressant was considered a success because it was shown to have relatively equivalent benefit to 10 weeks of psychotherapy. Combined psychotherapy and psychopharmacology, the person improved symptomatically but the potential for recurrence was also reduced.
Individual therapy is expensive as any labour intensive therapy is. Therefore there have been studies on group therapy especially with cognitive behaviour therapy which really lends itself to the class room. Indeed I might argue that individual therapy of the CBT nature should only be considered when group therapy had failed.
Misery loves company. A significant success of the self help movement has been it's ability to counteract the tendency to isolation.
Spiritual people as evidenced by a measurable variable such as church attendance have less likelihood of depression and respond to treatment better with greater success.
Seligman at his Authentic Happiness site has been doing research on improving the various traits that counteract depression, two specifically being hope and reslience.
While a lot of people think that depression should be a reason to not be working, not working can actually make depression worse. Clearly a pilot who has depression may present a risk for his passengers but if he is sent home 'to rest' , the isolation might indeed make the depression worse. A very effective therapeutic strategy employed by the British Columbia worksafe program was to have depressed patients attend a daily coffee house thereby ensuring that they had the occupation benefits associated with group therapy and socialization. People who isolate worsen their depression.
However depressives can run in 'packs'. Individually I've treated dozens of patients by encouraging them to reduce the contact with 'sick' people in their social network. It's the 'dosage' of the relationship that is sickening. One women became physically ill if she talked to her deeply mentally ill mother for more than a half hour a week. The mother was dependent and clinging and literallly what caloquially we'd call a soul sucker. In contrast one of my male patients had only to talk to his father for an hour and his father was constantly demeaning to him causing him to be literally suicidal. Again by limitting the dose of the relationship to 15 minute contacts the man was able to get better. I routinely ask depressed patients to avoid the news in whatever form since it's commonly old and depressing.
Music therapy has been shown to be a treatment for depression. It's especially beneificall if people are themselves participating in making the music.
Given the wide range of successful treatments available it's usually beneficial to consider the efficiency and cost effectiveness of a therapy.
Magnetic therapies have been shown to be very effective for therapy and equivalent in some patients as medication therapy however right now the cost is higher than electroconvulsive therapies.
Hypno therapy is an effective therapy for depression as is neurotherapy.
Often the therapy that is used is the one most available in the community. It's also is affected by what experience the therapists have. In eastern Canada it's common that there are a psychotherapeutically trained psychiatrist with extensive experience in a variety of non pharmacological treatments as well as pharmacalogical treatments and physical treatments. In western canada it's most common that the psychiatrists are only trained in psychopharmacology or if trained in other forms of therapy these are supported by the community financially or professionally.
Massage therapy is very attractive to patients. I once asked my heroin addicts if they had the choice of going to detox or massage therapy which would they choose. They'd naturally choose massage therapy. Unfortunately there's no evidence that massage therapy is an effective treatment for heroin addiction. Abstinence is and detox is not nearly as pleasant as doing heroin and getting a government funded massage.
No one ever questions what individuals do to treat their own depressions. This is in fact the 'right' to 'pursuit of happiness'. I personally find riding my Harley Davidson Electraglide an antidepressant but it's most unfortunate I can't convince an insurance body to pay for my motorcycle. Similiarly i personly think that if I were depressed I'd benefit from a year of high paid tropical therapy on a beach. I suspect I could devise a scientific study to show that this did work but the cost would be prohibitive for any insurance company.
Much of the failure in treatment of depression has been due to the failure of patients to follow medical regimens, such simple suggestions as don't drink alcohol or exercise a half hour a day, or get out of bed.
Dance therapy is an effective therapy for depression. I used dance and psychodrama to effectively treat depressed patients. There's just no support in the very conservative medical system for me to do these therapies. I'd need a larger office or space where I could do dance. I have a group therapy that helps depression but even to have a group therapy in my office I have to pay the higher overhead costs for the office that can hold 10 people at a time. Further the medical service plan discourages me from having group therapy because it's more time and effort for my staff to arrange and bill and yet there's no commiserate increase in the therapy cost.
So there's lots of therapies and lots work. The choice of therapy and indeed the choices available are numerous. People don't need to be depressed. Talk about it and get help.
When I started in psychiatry I commonly talked with patients and rather quickly they got better. Often just listening to people who had otherwise well established lives served to result in their mood improving. Later I would see more complex problems with less and less resources and more and more demands on my services. As a result I tended to use medications more often. Commonly I have the pleasure and benefit of working with a psychologist or occupational therapist who does the lions share of talk therapy. I'm a consultant and diagnostician and the the psychopharmacologist in these arrangements. The psychologists and counsellors and occupation therapists can't prescribe medications and aren't aware of the whole medical and neurological aspects of depression which can be an important part. A number of the psychologists I work with a specifically trained in a subset of patients and their experience and training makes them especially good with this group of patients. My experience and training is really broad based with some subspecialty areas so it's refreshing to work with psychologists who are subspecialists themselves. Increasingly family physicians are working psychologically with patients so that makes things easier all round.
I still come across alot of depressed negative people in my daily walk in life. It's like the number of addicts who actually access treatment. Very few. So commonly I'm treating an addict in the office but there are a dozen or so more who deny they have addiction and attribute their regular social and occupational problems to the 'other guy'. Similiarly depressive people often are the last to seek help which is unfortunate too.
When I consider psychiatric illness I often think it was akin to physical illness in the 30's. All manner of people had physical illness like heart disease or treatable infections or cancers but they never sought help for them. As a result the morbidity and mortality rate only one or two generations ago was so much higher. Today people have much more 'quantity' of life in general but the 'quality 'is still an issue.
Ironically alot of people think that they'd be happy if they were rich but wealth is not a cure for depression and not a guarantee against it. I used to think if I lived on a tropical island I d not see depression becuase I'd associated it more with the dreary winter months but when I worked on a tropical island I saw just as much depression. I have been thankful for the wide range of therapies that I've learned, the excellent psychopharmacologies and elegant psychotherapies.
Thursday, December 29, 2011
Cognitive Behavioural Therapy
Cognitive Behavioural Therapy, CBT, is not new. It was developed by Aaron Beck. I did 6 months of formal weekly training in this psychotherapy approach in my psychiatry residency in the mid 1980's. At that time it was not a standard part of the psychiatry residency. Psychoanalytic psychotherapy was the dominant form of therapy in my training program. CBT training was an 'elective' then whereas today it's fairly mainstream.
The principal behind CBT is that 'mood disorders' and other psychiatric dysfunctional states are a product of 'cognitive' internal process. Simplified it says 'we feel what we think and behave what we feel.' Therefore if you change your 'thinking' then feeling and behaviour will change accordingly. Though the actual techniques that Beck developped were fairly original the idea of the effect of thinking on mood and behaviour was in fact ancient. It's part of the standard teaching of Christianity and Buddhist so heralds back thousands of years. Beck himself acknowledged the origins of his work in the Stoic philosophers of the ancient world. In psychology 'positive thinking' therapy had turn of the century application in the early hypnotists proponents. Mesner's 'Everyday in everyway I'm getting better and better" self affirmation may as well have been early CBT.
Beck's real genius was in the development of a particular strategy of positive thinking and teaching of this that could be replicated and reproduced to allow for scientific study of the basic premise. His methodology was such that with CBT alone there was an approximate 75% cure in the treatment of depression in a roughly a few months.. Without treatment depressions commonly lasted a year. CBT was equal then to the response rates of patients treated with antidepressant medications. When the two forms of treatment were combined the response was enhanced even more.
In contrast to psychoanalytic psychotherapy which on a weekly basis similiarly administered resulted in relatively equivalent response rates, practitioners in CBT could be trained in shorter periods of time with great effectiveness. My own training in psychoanalytic psychotherapy as a psychiatrist took place over 4 years and was quite intensive whereas I learned CBT in a matter of months. Further CBT could be given to groups whereas psychoanalytic therapy was much more labour intensive and effective one on one. Even better CBT could be self administered. Burns, a student of Aaron Beck, wrote the best seller 'Feeling Good' which today still stands as a terrific text for patients to be given suffering from mood disorders.
Being relatively cheap and easy to learn, it has also leant itself to being used as part of research, it's value shown to be beneficial far beyond just 'depression' and having benefit in anxiety disorders, thought disorders, and addictive processes.
In contrast to psychoanalytic therapy that worked to 'weed' out misinformation acquired in childhood, CBT focussed on the 'present' and didn't really consider it that important how a person had become 'misinformed' about how to think effectively.
For example 'catastrophizing', is seen as a 'cognitive distortion' in CBT. It is recognised that people who tend to catastrophise in crisis are being 'irrational' and less 'effective'. Individually, with a therapist or in a group one learns to 'identify' this trait, see it , in fact, as an 'error' and bypass it or work around it. The techniques that Dr. Beck developped for this included 'talking back' to the 'misinformation'. As an example, "I don't get paid today because the mail doesn't arrive, I think, I'm not going to be able to pay the rent and am going to be homeless." Instead I should think, 'it's not the end of the world', I will contact the people who expect me to pay them that day and advise them that the mail has been delayed and I will pay them tomorrow. " This is 'normal reality' unless one is dealing with the mafia or government beaurocrats. Government beaurocrats actually respond humanly if you give them the same information in triplicate with a witness of a lawyer or doctor or prime minister as notary. The world doesn't need to end.
Interestingly these 'irrational tendencies' were common and formed the basis of the development of the 'fallacies' in the study of 'logic'. Beck's contribution was to simplify these 'fallacies' for the lay person, counselloers,r psychologists and others by putting a memorable spin on them. An example from Dr. Burn's list of Cognitive Distoritions in Feeling Good was 'disqualifying the positive". In this situation the person says it doesn't matter if I have the money in the bank to cover the rent, I didn't get the cheque in the mail so I'm going to be homeless. The nature of the focus here is to 'disqualify' the assets one has.
My mother used to say 'count your blessings' because frankly depressed and angry people commonly focus on the negatives and as long as they do commonly create a 'self fulfilling' prophecy. "CBT has been used in sports training athletes not to 'psych themselves out' but rather to 'psych themselves up'
Ironically, the business psychology world had been using many variations on CBT in their 'inspirational' talks and 'motivational' sales training. If anything the academic world in this case was commonly playing catch up to the business world and refining what worked. Scientific study has proven what often common sense already knew.
Maslow, developped the term 'self actualization' in his study of highly successful people. He wasn't a CBT therapist but rather his approach was to study 'well people' and then suggest that the very strategies that made them well be applied to helping the sick. Freud had originally in the early years of the study of mental illness only treated 'sick' people and learned their differences. Today therapists have learned many 'effective' ways of thinking from those leaders in society and are taking these strategies into psychiatry. Not surprisingly Thessalonians of the New Testatment of the Bible had CBT recommendations telling people to 'think on positive things'.
In addiction work Hal Morley, now deceased, always encouraged an 'attitude of gratitude'. He said with an 'attitude of gratitude' one simply could not remain depressed and negative.
In CBT work the relationship with the 'client' or 'patient' is much more like a 'teacher' student relationship than the traditional psychoanalytic psychotherapy relationship where transference and counter transference, the 'process' and the 'relationship' itself were the focus of therapy. In CBT patients are given 'home work.' They are encouraged to 'journal' and it's accepted that 'success' in therapy is no different than one would expect for 'success' in geometry'. The more one does, the better one gets at 'changing' one's negative thinking to 'positive thinking' and 'purposeful and effective' living.
I commonly ask patients with depression to avoid daily news since it's commonly negative and fear mongering. In this way I'm not acting at all like a traditional psychoanalytic psychotherapist but am being very directive and drawing from my experience as a family physician addressing allergies in children. In that world I'd remove those things that caused sneezing and today in the process of CBT I help the patient remove daily news for instance from their daily repetoire and not uncommonly see patient's moods improve immediately. I also tell the depressed to stop listening Sylvia Plath. An analytically oriented session in constrast would encourage a patient to reflect on the meaning of their listening to, say Kurt Cobain, when they were insisting they wanted to live not die. I might simply tell a person to listen to Bach or Sarah McLaughlan or Bare Naked Ladies.
Going over a particular stress we would look at what the person was thinking and how they could think more effectively. The questions asked are 'what could you have done differently? What would you have liked to have said." What were you thinking?. What would be a better way of thinking given those events?."
Indeed in the Christian community there seems to be a bit of CBT going on when people ask 'What Would Jesus Think/Say/or Do?"
CBT has been called physiotherapy for the mind because it's done in much a way as a person with a physical injury goes to a physical therapist to learn how to walk or move an arm in recovery. In CBT people are trained to think differently about situations, people and relationships. Often pen and paper examples are used much as teachers do in the class room. In group therapy, examples of difficulty are shared and other members are asked how one could think better about such an experience.
It's not 'rocket science'. It's common sense, mostly. However in day to day reality people rarely are exposed to what others are thinking. They just see that a person is 'acting' poorly and rarely know how 'odd' and 'different' their thinking may be.
As CBT therapists can themselves 'think' their 'thinking' is 'superior' and come across unknowingly as terribly arrogant, I encourage everyone who has studied CBT to read Job in the Old Testament. Job is a character who is blameless, thinks well indeed, and accurately but his friends faced with his difficulties do their own version of CBT without any benefit and far too much judgement and arrogance.
That said, CBT is a tremendous asset for anyone and worth the learning. There are superior therapies and ones which are better for specific conditions and individualized therapy is usually better than any of the 'off the rack' therapies. I'm an 'eclectic psychotherapist' so I've been formally trained in several of the major modalities of psychotherapy so am least at risk of the criticism of 'give a boy a hammer and everything is a nail." That said I'm very thankful for my training CBT a quarter century ago and the advances I've acquired in this modality over the intervening years. I doubt a day goes by I don't get to use some aspect of this therapy.
For anyone interested in CBT I strongly recommend Feeling Good, by Dr. Burns. I still remains a classic and can often be bought cheaply at a second hand store. The first copy written circa 1980 was probably better than later editions anyway. It's bright yellow, like sunshine. Go Figure!
The principal behind CBT is that 'mood disorders' and other psychiatric dysfunctional states are a product of 'cognitive' internal process. Simplified it says 'we feel what we think and behave what we feel.' Therefore if you change your 'thinking' then feeling and behaviour will change accordingly. Though the actual techniques that Beck developped were fairly original the idea of the effect of thinking on mood and behaviour was in fact ancient. It's part of the standard teaching of Christianity and Buddhist so heralds back thousands of years. Beck himself acknowledged the origins of his work in the Stoic philosophers of the ancient world. In psychology 'positive thinking' therapy had turn of the century application in the early hypnotists proponents. Mesner's 'Everyday in everyway I'm getting better and better" self affirmation may as well have been early CBT.
Beck's real genius was in the development of a particular strategy of positive thinking and teaching of this that could be replicated and reproduced to allow for scientific study of the basic premise. His methodology was such that with CBT alone there was an approximate 75% cure in the treatment of depression in a roughly a few months.. Without treatment depressions commonly lasted a year. CBT was equal then to the response rates of patients treated with antidepressant medications. When the two forms of treatment were combined the response was enhanced even more.
In contrast to psychoanalytic psychotherapy which on a weekly basis similiarly administered resulted in relatively equivalent response rates, practitioners in CBT could be trained in shorter periods of time with great effectiveness. My own training in psychoanalytic psychotherapy as a psychiatrist took place over 4 years and was quite intensive whereas I learned CBT in a matter of months. Further CBT could be given to groups whereas psychoanalytic therapy was much more labour intensive and effective one on one. Even better CBT could be self administered. Burns, a student of Aaron Beck, wrote the best seller 'Feeling Good' which today still stands as a terrific text for patients to be given suffering from mood disorders.
Being relatively cheap and easy to learn, it has also leant itself to being used as part of research, it's value shown to be beneficial far beyond just 'depression' and having benefit in anxiety disorders, thought disorders, and addictive processes.
In contrast to psychoanalytic therapy that worked to 'weed' out misinformation acquired in childhood, CBT focussed on the 'present' and didn't really consider it that important how a person had become 'misinformed' about how to think effectively.
For example 'catastrophizing', is seen as a 'cognitive distortion' in CBT. It is recognised that people who tend to catastrophise in crisis are being 'irrational' and less 'effective'. Individually, with a therapist or in a group one learns to 'identify' this trait, see it , in fact, as an 'error' and bypass it or work around it. The techniques that Dr. Beck developped for this included 'talking back' to the 'misinformation'. As an example, "I don't get paid today because the mail doesn't arrive, I think, I'm not going to be able to pay the rent and am going to be homeless." Instead I should think, 'it's not the end of the world', I will contact the people who expect me to pay them that day and advise them that the mail has been delayed and I will pay them tomorrow. " This is 'normal reality' unless one is dealing with the mafia or government beaurocrats. Government beaurocrats actually respond humanly if you give them the same information in triplicate with a witness of a lawyer or doctor or prime minister as notary. The world doesn't need to end.
Interestingly these 'irrational tendencies' were common and formed the basis of the development of the 'fallacies' in the study of 'logic'. Beck's contribution was to simplify these 'fallacies' for the lay person, counselloers,r psychologists and others by putting a memorable spin on them. An example from Dr. Burn's list of Cognitive Distoritions in Feeling Good was 'disqualifying the positive". In this situation the person says it doesn't matter if I have the money in the bank to cover the rent, I didn't get the cheque in the mail so I'm going to be homeless. The nature of the focus here is to 'disqualify' the assets one has.
My mother used to say 'count your blessings' because frankly depressed and angry people commonly focus on the negatives and as long as they do commonly create a 'self fulfilling' prophecy. "CBT has been used in sports training athletes not to 'psych themselves out' but rather to 'psych themselves up'
Ironically, the business psychology world had been using many variations on CBT in their 'inspirational' talks and 'motivational' sales training. If anything the academic world in this case was commonly playing catch up to the business world and refining what worked. Scientific study has proven what often common sense already knew.
Maslow, developped the term 'self actualization' in his study of highly successful people. He wasn't a CBT therapist but rather his approach was to study 'well people' and then suggest that the very strategies that made them well be applied to helping the sick. Freud had originally in the early years of the study of mental illness only treated 'sick' people and learned their differences. Today therapists have learned many 'effective' ways of thinking from those leaders in society and are taking these strategies into psychiatry. Not surprisingly Thessalonians of the New Testatment of the Bible had CBT recommendations telling people to 'think on positive things'.
In addiction work Hal Morley, now deceased, always encouraged an 'attitude of gratitude'. He said with an 'attitude of gratitude' one simply could not remain depressed and negative.
In CBT work the relationship with the 'client' or 'patient' is much more like a 'teacher' student relationship than the traditional psychoanalytic psychotherapy relationship where transference and counter transference, the 'process' and the 'relationship' itself were the focus of therapy. In CBT patients are given 'home work.' They are encouraged to 'journal' and it's accepted that 'success' in therapy is no different than one would expect for 'success' in geometry'. The more one does, the better one gets at 'changing' one's negative thinking to 'positive thinking' and 'purposeful and effective' living.
I commonly ask patients with depression to avoid daily news since it's commonly negative and fear mongering. In this way I'm not acting at all like a traditional psychoanalytic psychotherapist but am being very directive and drawing from my experience as a family physician addressing allergies in children. In that world I'd remove those things that caused sneezing and today in the process of CBT I help the patient remove daily news for instance from their daily repetoire and not uncommonly see patient's moods improve immediately. I also tell the depressed to stop listening Sylvia Plath. An analytically oriented session in constrast would encourage a patient to reflect on the meaning of their listening to, say Kurt Cobain, when they were insisting they wanted to live not die. I might simply tell a person to listen to Bach or Sarah McLaughlan or Bare Naked Ladies.
Going over a particular stress we would look at what the person was thinking and how they could think more effectively. The questions asked are 'what could you have done differently? What would you have liked to have said." What were you thinking?. What would be a better way of thinking given those events?."
Indeed in the Christian community there seems to be a bit of CBT going on when people ask 'What Would Jesus Think/Say/or Do?"
CBT has been called physiotherapy for the mind because it's done in much a way as a person with a physical injury goes to a physical therapist to learn how to walk or move an arm in recovery. In CBT people are trained to think differently about situations, people and relationships. Often pen and paper examples are used much as teachers do in the class room. In group therapy, examples of difficulty are shared and other members are asked how one could think better about such an experience.
It's not 'rocket science'. It's common sense, mostly. However in day to day reality people rarely are exposed to what others are thinking. They just see that a person is 'acting' poorly and rarely know how 'odd' and 'different' their thinking may be.
As CBT therapists can themselves 'think' their 'thinking' is 'superior' and come across unknowingly as terribly arrogant, I encourage everyone who has studied CBT to read Job in the Old Testament. Job is a character who is blameless, thinks well indeed, and accurately but his friends faced with his difficulties do their own version of CBT without any benefit and far too much judgement and arrogance.
That said, CBT is a tremendous asset for anyone and worth the learning. There are superior therapies and ones which are better for specific conditions and individualized therapy is usually better than any of the 'off the rack' therapies. I'm an 'eclectic psychotherapist' so I've been formally trained in several of the major modalities of psychotherapy so am least at risk of the criticism of 'give a boy a hammer and everything is a nail." That said I'm very thankful for my training CBT a quarter century ago and the advances I've acquired in this modality over the intervening years. I doubt a day goes by I don't get to use some aspect of this therapy.
For anyone interested in CBT I strongly recommend Feeling Good, by Dr. Burns. I still remains a classic and can often be bought cheaply at a second hand store. The first copy written circa 1980 was probably better than later editions anyway. It's bright yellow, like sunshine. Go Figure!
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