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Tuesday, March 27, 2018

Is There Such a Thing as Positive Denial?

Positive denial

Denial is considered one of the most primitive of the defense mechanisms.  It is usually thought of as a distortion of reality, and therefore as being very unhealthy.  To put it bluntly, denial sometimes involves a person lying to themselves.

But I am now wondering if there is a healthy form of denial.  Or another way of putting it is, maybe there is a role for extreme optimism which is not fully justified by the evidence.

The issue came up with a patient of mine with Parkinsons.  (I have permission to share this.)  This patient is aware of all of the statistics about the disease's progression.  He is seeing all the appropriate doctors and taking all of the appropriate treatments.  Therefore, the denial in question is not the same as ignoring the warning signs of a disease; this is quite different.

An article came out in JAMA Neurology which suggested that some persons with Parkinson's remain stable, or even get better, over a six month period of time when they have sufficient vigorous exercise.  My patient has seized on this as a touchstone, figuring that he, too, will remain stable, or even get better, as long as he exercises enough.  This may be denial because Parkinson's is always a progressive disease; it's just that sometimes it progresses very slowly.  This person's "denial" is helping him to exercise 75 minutes a day, which will almost undoubtedly help the Parkinson's.  Without this optimism, he might crater, go into depression, and hence might give in to the disease.

Is there a down side to the denial in this situation?  Or is it even denial?  Maybe it's just taking optimism to its ultimate lengths, extrapolating in a very hopeful way on some of the research available.

Now, it could be argued that a slightly toned down optimism might be just as useful.  That is, believing that vigorous exercise will slow the disease rather than keeping it totally stable, might be more realistic and still motivate the required level of exercise.  However, for this particular person I'm not so sure that a toned down level of optimism would be nearly as effective in motivating him.

Moreover, we can't overlook the role of the placebo effect.  If you believe a medicine is extremely powerful, then it is more likely to be.  Placebo effects have been demonstrated even in the treatment of cancer.

So, it is still true that some forms of denial are destructive and prevent growth.  However, I am now seeing that extreme optimism (even up to involving some denial) may be just what the doctor ordered in some situations.

Thursday, March 22, 2018

States of Mind: Active versus Passive, and Doing Versus Being

Many of us like to be doing things.  America was built on doing things.  Getting things done and accomplished is usually a good thing.  But there are other useful--and pleasant--states of mind as well.

Primarily I want to talk about "doing" versus "being."  Another way of thinking about this would be active versus passive mental activity.

First, let's start with what is positive about "doing."  The "doing mind" is active.  I sometimes refer to it as "active ego" (as opposed to passive ego).  Passive ego occurs when we are aware of thoughts and feelings, but they just wash over us.  We may be overwhelmed with good feelings (as on the beach) or worry (as when a family member is sick).  We just worry and worry and worry.  I sometimes see passive ego manifested as a neutral emotional state in the state of hypnosis (which I used to do, but hardly do anymore).  In hypnosis, the patient is not actively directing their own thinking, and the mind is in a receptive state to suggestion.   The opposite then is what I refer to as "active ego."  In active ego state, the mind is ready to solve problems and is actively considering options.  In this state, it appears to be less susceptible to worry and rumination.  That can be very helpful when there is anxiety.  The thoughts associated with this mental state may be, "What can I do about this situation?  I can do something to fix it!"

There is also an in between state--neither clear passive or clearly active.  When we appreciate what is around us (nature, people, even the feel of the air in the room), there is a kind of activity, but it is not visible to  others.  We are making a choice to focus our minds.  While we do not appear on the outside to others to be doing anything, we are actually expending mental energy.

Is there anything negative or self defeating about the active/doing mind?  On the negative side, the "doing" frame of mind can become overly habitual, and maybe even addictive.  We "do" out of habit, or because we are afraid to be alone with ourselves and our feelings.

Mindfulness therapy generally points out the value of the opposite of doing, which is learning to simply "be" or to appreciate what is around us.  Mindfulness tends to play down the role of actively achieving goals.  To the degree that it promotes doing, mindfulness therapy creates an awareness of the thoughts and feelings associated with it, so that the person is not "doing" purely out of habit.

I think that Americans sometimes get into "doing" mind so much that they miss out on some of the other aspects of reality. Back in the sixties and seventies there was a clash of cultures in America, between the "establishment" and the "hippies."  One aspect of this clash was the disagreement about the value of turning inward and meditating.  This was disparagingly called by some "navel gazing."  This pejorative term implied that people would focus too much on themselves and their feelings, to the exclusion of taking positive action in their lives or helping others around them.  Fortunately, we have progressed beyond that dichotomy.  We no longer see life as either/or in that regard.  We can be energized by our times of quiet and reflection to go out of our own personal sphere and accomplish goals.

So, let's summarize.  Here are some different states of mind that we have available as human beings:

Doing mind--planning and getting ready to cope or to execute a plan of action

Active (but not doing) mind--focusing intentionally on what is around oneself, or maybe focusing intentionally on clearing the mind.  An example would be some forms of meditation or prayer.

Passive mind--Letting ideas wash over  you.  This can be good, such as on vacation and in creative states of mind; but it can also be negative as when we succumb to runaway rumination and uncontrolled worry.

You may want to reflect on which of these three states occurs the most with you.  Do you need to ruminate less and be more actively in problem solving?  Do you need some calm down times when you are more focused (meditating and/or praying)?  Or is it even possible that you need some more time for thoughts just to wash over you, when you can be open to creative states of mind?

States of Mind: Gratitude and Thankfulness

In the past, psychology has been very focused on what was wrong with people.  It was not unusual to hear terms such as "overly dependent," or even more negative terms such as "orally fixated," "anal," and so on.

Fortunately, now, clinical psychology can talk about people's strengths as well.  Being educated in my Ph.D. program in the seventies, I can throw around negative terms with the best of them.  But I usually don't find that to be useful (except sometimes in psychological testing, but that is a different matter).

Many times issues bring with them to therapy can be normalized to a great degree.  For example, instead of saying to a person in therapy that they have a dependent personality, I might say that they simply are not in a good balance between depending on themselves and depending on others.  It is in fact somewhat normal to have difficulty finding just the right balance in life.

But that is off the point.

Focusing on the positive can mean focusing on growth.  Many situations that bring people into counseling are crisis situations.  Crisis doesn't feel good; but it does one positive thing: it breaks up  old, ensconced behavior patterns and potentially allows for new growth.  It is like breaking up hard, parched ground and letting new seedlings come through.

Early counseling sessions often focus on putting out fires; but often there is often eventually an opportunity in therapy to start looking for new directions in life.  One new direction can be bringing new positives into our lives--looking for what is good, looking for where we have been fortunate.  Gratitude is easier when we have a lot to be thankful for.  But that doesn't always have to be the case.  Even in bad situations, there may be persons who have given us a helping hand, or fortunate turns of events.  When we look for the positives we are likely to find them.

There is a school of therapy that focuses a great deal on reframing.  For example, in losing a job where one was subjected to a tyrannical boss, a reframing interpretation might focus on the possibility that the client has been unconsciously wanting an impetus to move on to something better.  A child who is being "bad" in their behavior may actually be wanting attention to deal with grief or anxiety.  And so on.  There are almost a limitless number of different counseling situations and possible reframes.  The interesting thing to me is that when I work out a reframe with a patient, even if it doesn't seem too plausible at first, I often eventually see it as very plausible.  Reality is a very slippery thing.  We think we have it well in hand until we begin to look at situations from different angles; and then we may begin to realize that we were overly committed to one particular view (e.g., the "bad" kid) and closed off to wider views of reality.

So even in tough situations, they may not be the pure calamity that we think they are.  They may offer the opportunity for growth, and that is something to be thankful for.

With other clients, there is no particular calamity they are facing.  They suffer from depression, anxiety, or perhaps some other emotional state.  But their lives are just normal otherwise.  With these types of clients, there is no struggle to find something for which to be grateful.  But there may be a lack of gratitude simply because that faculty of the mind has not been used  much.

Think it over.  How would it feel to be thankful today?  Are there negative thoughts and emotions that you could set aside for a little while and replace with gratitude?  And if so, why not?  What do you have to lose?

Saturday, February 13, 2016

The Statute of Lmiitations

In the legal field there is such a thing as a statute of limitations.  I think this applies to just about everything except murder.  After a certain length of time, a person can no longer be legally prosecuted.

I was thinking it would be great if the same applied to people, that is, for people who are psychologically punishing themselves. Sometimes people do this not just for months, but for years and decades.

If the law eventually quits chasing a person, and they can no longer be prosecuted, why don't we give ourselves the same break?  This would be a psychological statute of limitations.  After a certain length of time, it would be healthy for people to quit punishing themselves and to let go.  If society does this for us, can't we do it for ourselves?

Friday, March 20, 2015

What Happens When We Avoid Life?

Much of what psychologists work on with patients is the way that they try to avoid aspects of their lives.

What do they avoid, or attempt to avoid?
  • Unpleasant thoughts or feelings.
  • What they consider to be unacceptable thoughts.
  • Situations and stimuli which make them feel uncomfortable.
  • New experiences which might cause some tension in them.
How do they attempt to avoid them?
  • drugs
  • alcohol
  • sex
  • overwork
  • very strict, straightjacketed ways of thinking
  • substituting one feeling for another
  • high stimulation activities
  • staying constantly busy

While not all of these are bad in themselves (high stimulation activities such as skydiving are sometimes positive in themselves), taken to an extreme they suggest that the person is trying to avoid something.

I work with my clients to truly encounter their lives.  However, recently, working with my jazz piano teacher, I realized that I was rushing through exercises.  And by rushing through them, I was not  getting the learning out of them which I could.

Some psychologists would go further, and would say that experiential avoidance is one of the root causes of human suffering.  (This was be true of therapists in the school called Acceptance and Commitment Therapy; however, it was also true of the older school called Getstalt Therapy.)

My clients might find this hard to believe.  They might point to the fact that they ARE experiencing depression, in fact too much of it.  Or they ARE experiencing too much anxiety.  They might say that they are not experiencing too little feeling but too much.

The paradox would be resolved by the idea that anxiety or depression may be the result of not really encountering or digesting the original feeling.  If something is digested, everything tends to work out alright.  However, if we are not digesting something, then bad things happen.  In the same way, if we encounter life's experiences one by one, and deal upfront with each one by one, then they tend to get digested, absorbed, and so on.  We learn from them.  We solve problems.  We can even desensitize to certain types of negative situations.  But when we avoid feelings and situations, we can't do any of these, and things just go from bad to worse.

Another way to think of this is that there are primary feelings and secondary feelings.  A primary feeling might be the hurt of someone breaking up with us.  We might feel sadness and anger.  If we allow ourselves to feel those feelings, then they have a good chance of getting digested, and we can go on.  If we do not deal with those primary feelings, then we may be left with a residue which is not directly attached to any particular situation, a residue of depression or anxiety which is more free floating, and which tends to linger and stay on.  It tends to linger because we are not fully aware of what is causing it or how to solve it.  It may be a free floating residue.

Or here is another way of thinking of it.  If we deal with situations and feelings up front, then our stress levels may decrease, and any underlying genetic biological tendency towards a mental disorder may not be triggered.

Now, I don't want to claim that it is always easy to face our situations and feelings.  Sometimes we may need professional help if situational stress is overwhelming to us.  BUT, I do believe that it always better (with help or without help) to face issues and try to solve them within a reasonable period of time.  Feelings can be faced but not exactly SOLVED.  We can't solve a feeling.  But by facing it, it will often go away.

That doesn't mean that it hurts anything to go home at night and have a glass of wine, saying to yourself that you will tackle the problem tomorrow (assuming you are not an alcoholic).  That is avoidance, yes,  but very temporary avoidance.  We do not have to tackle problems 24/7.  But if we put off dealing with problems day after day, then that is when the problem and feelings we face may transform themselves into something even worse.

Friday, March 06, 2015

Language as a Two Edged Sword

A news article came out the other day about research indicating that dogs are able to remember what happened the day before.  This made me reflect once again regarding the value of language and the problems that come with it.  I would guess that lack of language is one contributing factor to dogs not being able to remember recent events.  Words and phrases such as "family get together," "football," "Saturday," and so on, aid our memory.  Dogs don't have those words.  In addition to helping our memory, words make us more capable of conceptualizing problems and solving them.

It just may be that dogs may be a little happier than humans, or put another way, that they may be less miserable. If their basic needs are met, they probably are content. Human beings can worry about tomorrow, remember the past, and berate themselves interminably.  And much of those thoughts involve words.

Words are a two edged sword.  It would be much harder to be neurotic without words.  Many of the negative events and effects of childhood are stored in words.  Negative messages from our parents, e.g., "You can't sing,"  "You'll never amount to anything," and so on, take abuse to a whole new level.  Physical and sexual abuse certainly harm a lot of people, but words add an entirely new layer of negativity.  We can rehearse and remember those negative statements over and over, until our own demise.  Moreover, our own negative thoughts about our abuse, e.g, "I must have deserved it," "I caused it," and so on, make it even worse.

Much of the therapy I do with clients is aimed at helping them to rid themselves of irrational negative thoughts.  I have written about that many times in this blog and elsewhere.

Sometimes the negative thoughts come so fast and furious in therapy, that it is hard to keep up with them.  Consider the following dialog:

     Patient:  So I screwed up once again--just like my parents said.

     Therapist:  That would seem to be the same type of negative thought we discussed just a few minutes ago.

     Patient: Oh, you're right.  I'm so stupid.  I can't do anything right.

In this example, even before the therapist is able to assist the patient with dealing with one negative thought, two more have been added.

That is one reason why cognitive therapy for depression can take 10-20 sessions.  Eventually, however, most persons can get a handle on their negative thinking and make progress with their thoughts.

I could say a lot more about this, but I will make this short and leave you with the moral of this story:  Use language wisely.  Use it to describe thoughts, events, and behaviors accurately.  Use it to conceptualize problems and conceptualize solutions.  But remember that thoughts can sometimes be produced by the brain which are very unhelpful.  In that situation, they neither lead to better conceptualization of problems, nor better solutions.  Sometimes rampant, unbridled words and thoughts in our heads are the problem.

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:
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.