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Saturday, March 29, 2014

Holistic Therapy--Yes But I Won't Be Using That Word

Well, I feel as if I have been drug kicking and screaming into the holistic revolution.

After years of resisting it, I just have to give in.

But outside of the title of this article, I still won't be using the word.  Why?  Because it is a buzzword.  It means so many different things that it means nothing.  It is a way of saying, "I'm with you; I'm with the modern IN crowd."  But the word means so many things it starts to mean nothing.

But what I do want to do is be comprehensive in the way I approach depression.  Cognitive therapy is not the only way.  Behavior therapy is not the only way.  Medication is not the only way.  Even electroconvulsive therapy may have its place.  Exercise is definitely a factor in recovery, and I believe that for some people nutrition may be important.

I did not reach this conclusion because of a desire to be part of a feel good movement.  I reached it out of pure practicality and what works.  Or what doesn't work would be a better description.  What doesn't work as well as we wished it worked.  And that would include pretty much every treatment that we know of now.

When I started learning cognitive therapy, in 1980, it was relatively new.  It was not inconceivable that cognitive therapy, or cognitive therapy combined with behavioral therapy, or cognitive therapy combined with medication, etc. just might cure most people.  Sadly, that has not been the case.  The ultimate solution to the riddle of depression lies a ways off--perhaps fifty years, perhaps a century.  Talking therapy has proved to be just as limited as medication.  Cognitive therapy has more research evidence behind it than psychoanalytic therapy.  But that doesn't mean it is much more effective.

However, there are a variety of interventions and coping techniques which can help depression:
exercise
nutrition
spiritual techniques
mindfulness techniques, e.g. meditation
positive psychology techniques (such as altruism and volunteering)

These are just a few.

Why did I resist the idea of a comprehensive "holistic" approach?  It seemed just too much of a catchphrase, better at making authors money and being part of a feel good movement than really helping people.  The research for holistic approaches was often flimsy when one actually looked into it.  That is beginning to change.  Research into alternative techniques (alternative to medication and talking therapy) is growing in amount and in quality.

Also, I was simply overly focused on pure psychotherapy research and too much of a true believer.  Perhaps I can be forgiven for being a "true believer" in a technique which had really quality research showing that it worked.  What the research also showed, however, was that it worked only up to a point.  It worked for certain people and not others.  Or it worked partially for some people.  For awhile it seemed that there must be a moderator variable in there somewhere.  If we gave it for 40 sessions instead of 20, maybe that would make it much better  If we combined it with other treatments, or if we used it only for certain patients, or if patients would only do their homework, etc. then maybe it would work for almost everyone.  And each of these was a legitimate issue, but it never solved the whole puzzle. 

It's not that I have quit believing in cognitive psychotherapy.  It is still the main treatment I would recommend for someone who has mild to moderate depression.  If I had a family member with depression, I would want them to have cognitive behavioral therapy, and maybe medication.

It's just that it is now clear that no matter how you slice and dice psychotherapy, it will have limited results.  The same is true of antidepressants.

I have been reacquainting myself with the new biological research into the underlying brain issues associated with depression.  It is clear that for some types of depression, and maybe all severe depressions, there is a biological substratum.  We now believe that chronic stress releases so much cortisol over such a long period of time that it damages certain parts of the brain.  There is evidence for this as a possible cause of depression.

The brain can regenerate cells in some areas.  One of those areas is the critical hippocampus.  It is involved in memory and also in controlling our anxiety/fight or flight mechanism (HPA axis).  Regeneration of hippocampal cells is stimulated by brain derived neurotrophic hormone (BDNH), which in turn is released after exercise.  Outcome studies are pointing to excellent treatment effects for depression with exercise.

Thus, theoretical and basic science findings such as this are encouraging me to think more broadly.

Secondly, outcome studies of exercise and other techniques such as medication are showing good effects.  Cognitive therapy has a lot of good research behind it, but now we are starting to see some really good research outcomes for exercise and positive psychotherapy.

Thirdly, as I have improved my own healthy behaviors, I feel less hypocritical asking my patients to work on theirs.  I am more comfortable now advocating that other people do things which I used to avoid working on for myself.

Just how helpful are some of these alternative therapies?  Exercise has been shown to be quite helpful, perhaps yielding as large an antidepressant effect as current medications on the market.  Nutrition has not been as well studied as exercise.  However, one Australian study published in the prestigious journal Lancet, found that there was a correlation between fish consumption and a lowered risk of depression.  (Correlation studies such as this have to be followed by experimental studies to be fully interpretable, however).  Omega 3 fatty acids are thought to be very important in proper brain function.  Other foods, such as protein, are important because they provide a good supply of all the necessary amino acids.

Well, that's enough for now.  I hope to write more about this later.

Monday, March 10, 2014

Deilberate Mind

This state of mind is about living life in a consciously deliberate fashion. It may seem strange that this would have anything to do with mindfulness, since mindfulness generally incorporates a form of meditation which involves no thinking at all.  However, to meditate in this way is actually very deliberate and focused.

In a sense, deliberate mind takes away blame.  We oftentimes blame others because we see our lives as stimulus and response.  You do something, and I react.  Therefore, my reactions are your fault.  To live life with full consciousness on the other hand, or at least as full consciousness as possible, would involve living life so that less blame shunted onto other people for our negative feelings.

To live deliberately is to take responsibility for my actions and feelings.  And if, as sometimes happens, someone has harmed me and made life difficult for me, then deliberate mind is more focused on finding a solution than on my anger or blame at the other person.

To live life deliberately is also to live life consciously--conscious of what I am doing and why I am doing it.  To live unconsciously is to live without a knowledge of what is truly driving me.  We may never understand all of our feelings, but at least we can live in such a way that we can take considerable responsibility for what we think, do, and feel.

Thursday, February 06, 2014

Games, Belonging, and Avoiding Depression in Retirement

I am no expert in game theory, but there is something which is now so clear to me that I just need to write something about it on this blog.

Many people, when they retire, become depressed because they no longer play a role in society.  They are no longer part of the "big game."  (This is a phrase I picked up from a Harrison Ford movie.  I'll figure out which one later.)

For each of us, the "game" involves reaching a goal.  It often involves gaining something, which gives us some satisfaction.  What we gain could be a game of checkers, a smile from someone we like, or status within a group.  The kind of game I am talking about generally does not involve "winning" in any all or nothing fashion.  To win is simply to participate and to achieve some kind of goal.

In this kind of participation, we are "known" by others. They see us as part of their circle.  They expect something from us.  They may expect us to do our part and pull our weight.  We may be seen as doing something particularly well, such as playing checkers, scrapbooking, or giving political opinions.  If we are "in the game" others may seek to have us as an ally when there is conflict.  Or they may expect us to be an enemy, but either way we are known to them.  If we do not show up, our absence is noted.

In this way, we have "self objects" (see Heinz Kohut on self objects).  And we are a self object to them.

People retiring may look forward to having nothing that they have to do.  But they are no longer part of the "big game."  In a worst case scenario, they go into a state of deprivation for face to face contact, which can lead to depression.  Many persons who retire do not quickly go on to develop dementia.  Their minds are still capable of analysis and decision making, but they no longer have a role to play.  They are no longer a part of the "game."

In a best case scenario, people still have a role to play at church, at the VFW, or at the country club.  They can still run for an office.  It may not be earth shaking in importance, but it's just as good.  They are not irrelevant to the people around them.  There is a reason to make an effort, to strive, to think, and to progress.

Unfortunately, for some people no such "game" is available.  They are shut ins, or there are no available groups in which they can participate in any meaningful way.  If elderly people are not seen as desirable participants, then they are shut out of the "game."  One cannot easily barge into a system.

I believe that to some degree elderly participants can form their own groups.  But I also believe that it is even better when younger groups (people younger than retirement age) can find value and purpose in including older persons.

This issue is not limited only to retired persons, however.  It can also apply to disabled persons.  It can also apply to newly divorced persons.  It can apply to people who have been dislocated and/or have moved to a new geographic area.

Well, I've said my peace for now.  More on this later.

Monday, April 15, 2013

State of Mind: Observing Mind


The ability to observe ourselves is a distinctly human ability (as far as we know) and is associated with the frontal lobes of the brains.  It is one of the executive functions.

As far as we know, we are the only animal capable of observing ourselves and contemplating what is going on within us, and also about how we are affecting others by our actions.

This ability can keep us out of trouble by warning us about how we are coming across to others before we go too far and damage relationships. It therefore can help us to know what not to do.

The ability to observe outselves dispassionately gives us a means of coping.  It means that we don't always have to be fully immersed in our emotions.  We don't always have to participate in situations from a self-centered, me, me, me point of view.  We are not our emotions.  There is a person, an "I" or a soul, behind my emotions. 

We use observing mind in cognitive therapy.  There are two major steps in cognitive therapy: thought distancing and thought evaluation.  Observing mind is used in the thought distancing step.  We realize that we are having thoughts.  More than that, we can realize that these thoughts are not necessarily the same thing as reality.

I would also include here the concept of what I might refer to as "transcendent mind."  The transcendent, observing mind is capable of looking at ourselves and at our situation philosophically.  Philosophers call this "sub specie aeternitatis."  For a better understanding of this concept, see http://en.wikipedia.org/wiki/Sub_specie_aeternitatis in Wikipedia.  We have the ability, as it were, not only to stand aside and look ourselves from the ceiling in the present moment, but we also have the capacity to imagine how out situation and behavior might look from a vantage point decades later or even centuries hence.  And the result is that we begin to see our problems, our needs, and our behavior in a different light.  In transcendent mind, our problems might seem quite small, just as looking through the wrong end of a telescope.  Instead of things looking exceptionally large, as when we look through the eyepiece of a telescope, they can look smaller when considered from the vantage point of eternity.  Emotional mind tends to make problems look larger than they might otherwise seem; transcendent mind tends to make them look smaller.

Tuesday, March 19, 2013

Sensing Mind

(Part of an ongoing series on mindfulness.)

Sensing mind is the part of us which is pure experiencing.  We see, we hear, we feel, but we don't judge.  At the moment that we are in sensing mind, we are not judging.  We are probably not worrying.  We are probably not feeling despair.  We are just in touch with our senses.

Sometimes with patients, as I am trying to get them to focus on the present, I will ask them, "How does that chair feel?"  (I have two green wingback chairs in my office.)  Usually, the client will say that it feels soft and comfortable.  I then go on to ask them to notice other sensory stimuli in the room at that moment--the lighting, the air temperature, and so on.  When focusing on these, we are not focused on whether we will be able to pay the taxes six months from now.  We are not focused on what our lab tests will show next Friday.  We are just sensing.

I want to oversimplify a little here.  Pure sensing is direct and bypasses the emotional centers of the brain.  It is in someway a focussing process based on the occipital cortex, the auditory cortex, and the sensory motor strip of the brain.  It is not focussed on the limbic system.

What are some of the things which I might sense directly?
Blue sky
Green grass
The color red on a car or anywhere else
Yellow traffic lines
The colors of flowers
The color of my wife's eyes
The smell of roses, or of food
The taste of food or drink
The soft feeling of a chair
The feeling of acceleration in a fast car.
A cool breeze.
And so on.

Mindfulness therapy teaches people to do things, sense things, see things, etc. in a deliberate way.  All too often we lives our lives on autopilot.  We don't slow down to really taste our food or to really see our environment.

The value of sensing mind is in part how it can distract us from painful emotions.  In addition, it produces pleasure.  There is pleasure in sound, in light, in color, in contrast, in texture, in smell, in taste, and so on.  Our autopilot selves know little of this.  Our autopilot selves live in an abstract world: turn left, take care of that letter to insurance, see 9 AM patient, return telephone call, and so on, as we tick off a list of things to do.  I'm not saying that such a list may not necessary or helpful; it just produces little pleasure.  Yesterday, as I walked my dog, I saw one of the most beautiful sunsets I have seen in a long time.  It looked like the sky above the horizon was on fire.  I tried to take it all in.  I just focused on the color, and the variations of colors.  It was quite enjoyable.

Related to Sensing Mind is what I would refer to as "Aesthetic Mind." There is a major difference between just seeing colors and seeing a Renaissance Botticelli of a Madonna and Child. Much more is coming into play in the mind besides color or even color and form.  When we see or listen to something which is complex, then a whole new level of beauty is added.

Music can range from the relatively simple delights of the sensing mind (the sound of birds, or a simple but pleasant childrens' song) to something quite complex and aesthetic.  I would suggest for example, listening to Barber's Adagio for Strings as an example.  Experiencing such a piece of music goes beyond pure sensing to something more, something transcendent.  And again, there is pleasure, and there is distraction from unpleasant emotions.

Note: In addition to seeing, hearing, touching, smelling, and tasting, there are internal sense states--proprioceptive and kinesthetic sense states. I want to acknowledge that there are some situations where paying attention to stimuli, particularly internal stimuli, might actually make things worse. For example, being aware of our internal sensations (such as heart racing, stomach churning, heavy breathing) can actually heighten anxiety during panic attacks. Being aware of some external stimuli (e.g., hearing people talking) might heighten anxiety or paranoia. I will deal with this problem a little later on in a different blog.

Sunday, March 10, 2013

State of Mind: Emotional Mind

I'm going to start by talking about emotional mind.  Why?  Because that is the place where many of my patients start.  They are wrestling with depression, anxiety, or anger.

In emotional mind we are taken hostage by our limbic systems and midbrain.  We ARE our anger; we ARE our anxiety, our depression, and so on.  It has taken us over lock, stock, and barrel.  We are now thinking through a primitive part of our brain.  We can be taken hostage by our anger, by our depression, by our fear, and so on.  These are all built into us for good reason.  But many of the original primal situations from "cave man" days, which required these feeling states, are rarely present.

Emotional reasoning is not advanced.  It is very instinctual and primitive.  It does not think rationally.  It may generate thoughts, e.g., "I'm going to fail this test," but the thoughts are not being generated logically.  The thoughts are being generated by the emotion, or more accurately, the thoughts are being generated by the emotional part of the brain.  They are thoughts in bondage to emotion, rather than emotions being subservient to logical thinking.

The experience of strong emotion is somewhat like a spasm.  Indeed, panic attacks have been likened to an anxiety spasm.  When we become enraged, we don't want to be calmed down.  In fact, telling someone who is enraged to calm down may be a sure way to make them angrier.  They don't want to calm down.  They often want to take out their rage on someone or on something. 

When we are in a panic state, we may not want to stay in a panic state, but we may feel absolutely frozen and stuck in it.

When we are mired in depression, we may want to get out of it, but we can be constantly bombarded by more and more negative thoughts which seem to prevent escape.  Even the thought of getting help may be batted down with a negative thought that "getting treatment won't help; my case is hopeless."

Emotions lead to negative thoughts, which lead to more painful emotions, which lead to more negative thoughts, and so on.  In negative emotional states, it is easier to remember incidences of shame and failure from our past.  It is harder to remember positive events from our past when we are depressed, and it is harder to anticipate positive events in our future.

When we are engaged in emotional mind, we believe that we are being realistic.  There is a feeling of certainty which comes from our emotions.   If we are angry, we believe that we are justified in our anger.  If we are panicked, we are sure that there is catastrophic danger.  If we are depressed, we believe that we are only being realistic.  Emotional mind does not want to "yield the floor" to other aspects of mind.  It does not want to admit to other possible ways of looking at situations.

Of course, not all emotions are negative.  There are very positive emotions, and joy is a positive aspect of mental health.  Joy does not coexist well with anger, depression, or anxiety.  Enhancing joy in our lives is one way of dealing with our negative emotions.  I have not included a mental state of "joyful mind,"  although that would certainly make sense.  It would make sense because we know that it exists.  We know that it is distinct from our negative emotions.  It is also relativelydistinct from our logical mind state and our observing mind state, although I would tend to associate it somewhat with sensing mind.  I will write more about joy in the blog on sensing mind.

Monday, March 04, 2013

Mindfulness: Wise Mind and Monkey Mind

Traditional mindfulness concepts include about "monkey mind" and "wise mind."  I cannot pretend to understand all that is meant by these two terms because my training is in cognitive therapy and not mindfulness therapy.

However, I believe that "monkey mind" involves much of the ceaseless, annoying chatter which can bubble up in our brains when we try to achieve calm, deliberative silence.  (Think of the jabber of monkeys in the trees.)  Wise mind is a compassionate, observing mind which can learn to ignore monkey mind.  There.  That ends my knowledge about the concepts.

However, in my work with clients I have come to understand that there are at more important states of mind that my clients need to understand--probably several more.  But let's start with the most important four.

First of all, there is emotional mind.  This state of mind occurs when we are dominated by our emotions: sadness, anger, grief, fear, panic, anxiety, jealousy, envy, and so on.  It is not all bad.  Grief is normal.  In fact, most emotions have some important place in life.  However, many patients consult with me because they are overwhelmed by their emotions and they need some new way of coping with them.  They want an alternative to emotional mind.

Emotional mind is probably associated most with the limbic system.  This is the midbrain, sometimes called reptilian brain.

What are the other three types of mind which can compete with "emotional mind?" They are observing mind, logical mind, and sensing mind.  Each of these provides an alternative to being submerged in our emotions.

Let's start here with observing mind.  This would most likely be associated with the pre-frontal cortex.  It is associated with the executive function of self-awareness.  When we are in the state of observing mind, we are aware of what is going on within us.  We can observe, in a somewhat detached way.  We can become aware that our anger is rising, or that we are feeling panicky.  We can be aware of our negative thinking, and we can watch it come and go.  We can see how our negative thinking is producing painful feelings, and vic versa.  We can also detach ourselves from our emotions.  When we are observing them, they do not have to stick to us.  They are simply clouds passing in the sky.  They come, and they go. 

Then there is logical mind.  This is the part of the mind which is trained the most by cognitive therapy.  If I fear that I am going to lose my job because the boss has been in a bad mood recently, my logical mind can realize that I am personalizing my boss's behavior and seeing it as aimed toward me.  Logical mind can realize that there is a very low rate of people being let go.  Logical mind can think about all of the written counseling procedures and safeguards which have to be accomplished before someone can be let go.

Finally, there is sensing mind.  No matter what I think may happen tomorrow, I am currently sitting at my computer.  I can feel the chair beneath me.  This morning, from where I was sitting, I could look up and see the colored spot lights.  Then later, I noticed the blue sky, and even the yellow stripes on the road.  My center shifted from logic and from emotions to heightening my awareness of what was coming in through my senses.  I became aware that I was hardly aware of the colors around me and that it was actually quite enjoyable to look at the colors of the world, even the man made world.

When we are submerged in emotional mind, these other three states of mind offer us alternatives.  We can observe the coming and going of our thoughts and feelings.  We can logically challenge any irrational negative thoughts which lead to the negative feelings.  Or we can simply focus on our senses and enjoy the world around us.