One of my long-standing puzzles as a therapist has been how CBT (Cognitive Behavioral Therapy) has gained more popularity than REBT as the go-to therapy. There are indeed many books by many authors on each technique. Does CBT work better? Does it have better press? Are there more practitioners? is it easier to teach to therapists in training? Is it easier to teach to clients?
My take on the above questions is quite the opposite. I find REBT to be easier to learn, easier to teach, and more effective than CBT. I am trained in both, and, while I learned CBT in school and learned it first, when I studied REBT (Albert Ellis was one of my instructors), I was immediately stuck by how easy it was to learn, to teach, and to put into effect in my own life not to mention those of my clients. So is it the press? Perhaps.
I was reading _Animals in Translation_ by Temple Grandin with Catherine Johnson, and an interesting point about how humans think and process versus how animals or autistic people think and process was made. Humans want a narrative. They prefer complexity and big picture thinking. They see the forest more than the trees. When Dr. Grandin was looking at the treatment of animals in slaughter facilities (regardless of your moral stance on this, she improved animal handling by light-years), she created SIMPLE, ELEGANT checklists for plants to use to determine if the animals were handled appropriately. Grandin notes that the more items on the old lists, the easier it was for a plant to pass if one critical item was missed. The more items on the list, the more difficult it was to get things right, but the easier it was to pass. The less clear and objective the criteria, the more questions arose and the less clear passing versus failing became, which caused less safety rather than more at the plants. "Most language-based thinkers find it difficult to believe that such a simple audit really works." (Grandin & Johnson, p 268). Substitute "form of therapy" for "audit" and there you have it! Sometimes simple is best.
Rational Emotive Therapy is so easy to learn that Michael Edelstein has an REBT-based website (and a book) called "Three-Minute Therapy". Now, he is not saying someone will be cured of his depression nor anxiety in three minutes, but rather, that there is a three-minute exercise you can learn that, with practice, CAN teach you to overcome your unpleasant and less-than-useful emotions. I love this. What CBT has done is to add complexity--to add more narrative, more layers, more paperwork, more words, to REBT. It works, but it has lost some of the elegant simplicity of REBT.
My clients know me as a very paperwork-adverse therapist. I keep my practice simple. I keep my intake forms simple. I love simplicity. If it is simple, I can keep track of it, and they can understand it. I learned to do CBT from many trainings and many books. It advises a lot of papers to be filled out and has a lot of diagrams for demonstration to clients. I copied all of them and prepared to use them according to my instructors. When I learned REBT, the lightbulb went off. THIS, said I to myself, is more for me. It is simple. It is elegant. It contains ONE simple homework sheet to be filled out. Clients can keep the responses as simple or complex as THEY desire. They can make REBT their own, and they can all learn it.
Maybe I lean a little in that direction of animal intelligence, where I like simplicity and clear statements and short, operationalizable lists, and I hate piles of paper. For me, REBT helps me to teach my clients what they come to learn, and this helps people to feel better faster, and be independent of therapy sooner.
Edelstein, M. & Steele, D.R. (1997) _Three Minute Therapy_. Glenbridge.
Ellis, A. (2016). _How to Stubbornly Refuse to Make Yourself Miserable About Anything
--Yes, Anything!_ Citadel.
Grandin, T. & Johnson, C. (2005). _Animals in Translation_ Scribner.
You already knew that, right? If you have been paying attention, you did. The various news media these days have more competition for your attention, and they have long known that to get your attention, they have to produce an emotion in you. They get more attention by producing a negative emotion. So the news is no longer JUST THE NEWS. It is a concoction of events developed into a story in language carefully crafted to get your attention. Even the weather is no longer just "here's what to expect." Today's weather reporters are also competing for your attention. So rather than, "We are expecting 5" of snow before 6PM ," now it is, "This is shaping up to the the worst snow in 52.5 years, so be very scared."
We know that most of what has changed is competition for your attention. But something more subtle has changed along with that. The news is no longer "just the facts, m'am." Today's reporters want to grab you with negative emotions: fear, anger, outrage. But we tend to assume that the news and weather types are still reporting facts, so we respond as they have guided us. This affects our lives in very real ways.
What is the difference between "Today the temperature will be -13" and "today there is a wind-chill advisory in effect and you are advised to dress warmly"? One aspect is the assumption that we are all too stupid to wear warm clothes; that we do not know what -13 means, that we need it to be painted in scarier terms so we pay attention. I don't know about you, but I am insulted by weather reporters on a daily basis. Yep, -13 is cold. Yep, I need a coat. Yep, I will cover my face and hands. This barrage of insults is bad enough for me to have stopped paying attention to them altogether. I want the facts, and I will decide how to behave, thanks.
But the more sinister aspect is that when people are continually subjected to such emergency tactics, they tend to feel fear. It comes on gradually as we are inundated daily with this and that emergency. From weather to climate to politics to foreign affairs, there is a reported emergency around every corner. Thus, my attempt to avoid all forms of media reporting.
As a society, however, trends become obvious. First is that more people demand to be kept totally safe from reality. We become more fearful of things that once were considered normal. This week, it is tornadoes. I have actually looked at the historical data on tornadoes. Every year, the midwest suffers A LOT of them. There is no evidence that they are worse than ever. In fact, my memory contains some crazy fragments of walking (admittedly, a little fear on the part of the school officials who sent us out the door would have been wise) home from school because of a tornado warning, watching a tornado out the window, another of walking to school the day after a tornado, surrounded by uprooted trees, broken back porches, and the school bleachers in the middle of the street! School closures? Nope, never. Well, once, in '67, after a blizzard totally shut down Chicago. We might have sometimes been stupid, but we did not live in fear of basic facts of reality. There is weather every day. Sometimes it is inclement. It is wise to plan accordingly rather than demanding better weather or blaming something for bad weather or refusing to plan for bad weather and getting into trouble.
The question is, are we better off now that we, as a society, are so much more cautious? Admittedly, there are times when this caution is well-placed. No, I ought not to have walked three miles to a movie in a short skirt in -15 weather when I was 13! But I did learn a lot about cold and frostbite and never did anything like that again. Are your kids better off if they do not have an after-school job, so they can focus more time on studying? If they get 12 vaccinations rather than the 3 we used to get or the 4 my kids got? If their playgrounds have short slides and soft landings? If they stay home from school when it snows more than an inch?
Alternatively, were we better off when we played outside all day and came home with bumps, bruises, and probably a cold? When we walked to school in every sort of weather? When a job was required if we wanted spending money? When we left the occasional kid in the car while we ran into the store? When, if our home lacked air conditioning, we found a way to stay cool that did not involve a public "cooling center" (yes, it did used to get over 100 degrees regularly in Chicago when I was growing up)?
Trust me, there has always been weather. There will always be germs. Bad people exist, and do harm, though not in the numbers the media would have you believe. Kids fall and need stitches. Life is not always safe.
So what am I getting at with all of this? Missing in many people today is resilience. Resilience is when a bad thing happens and you dust yourself off and try again. If we protect our kids from all forms of adversity, if we avoid adversity at all cost, if we deny adversity ought to exist, we do not develop the ability to deal with it. Adversities will occur. Often. There is more power in having the skill to deal with whatever happens than in demanding that it not happen or that it ought next time to be prevented by someone somehow.
Resilience is what kids demonstrate when they fall off the monkey bars, scrape a knee, and get right back on. Resilience is also what a kid demonstrates when he can fail a test or lose a ball game, feel sorry, recover, and work harder next time and do better. Resilience is what we show when we hear that it is going to rain all week where we are planning to go camping and either we still go and make the best of it or revamp our plans and have a great time even though we did not get to do exactly what we wanted.
Resilience does not develop when we protect kids from adversity. I see this time and again: A kid who is shocked when he is hospitalized and cannot cope with being away from home, and what's worse, feels betrayed by reality that he was injured at all, can indeed feel traumatized by normal life events! Another who receives a bad grade, goes home and complains, and a parent calls the school to complain (and I am a person who does not believe in traditional schooling nor traditional systems of grading--see other blog entries, but if you are part of that system, then you play by those rules). What did the child learn from that interaction? That he does not have to do the work to get the grade if he can get a parent to make enough noise. Is that going to work when he has a boss?
Lack of resilience has many consequences. Why do we see more anxiety and depression than we used to? Why are more kids struggling to adjust to college? Why are so many young people either on prescription medication or self-medicating with psychoactive (I am including nicotine, alcohol, cannabis, and all illegal drugs here) substances?
The answer to these societal ills is not more drugs. It is not getting society to change and remove all adversity from our lives. It is also not going back several decades to when life was more full of obstacles. It is good that humans can make life safer and easier. What is not good is when people then learn to demand even more degrees of safety and ease and lose the ability to cope with reality.
The answer here is learning when not to listen to scare stories from the media. It is learning that adversity is what helps us gain resilience. It is accepting that often life will be difficult, and we can learn to cope with these difficulties. It is also making sure the next generation, while gaining many advantages through technology that we do not yet have, and thus having an easier life, does not thus lose the ability to tolerate things that do not go as expected.
Challenges, or stressors, are what motivate us to act, to change, to improve. Without them, we become lifelong dependents upon others to save us from every twist of fate and every shift in our reality. This is not life; it is slavery.
I have said it many times and shall say it for as long as I can: there is not a pill for that. Make no mistake, your brain is a biological entity--YOU are a biological entity--thus distress of the mind and emotions are also biological entities, but this does not imply that the only or even the best or even a viable way to solve problems of the mind and emotions is with a pill. The overused "chemical imbalance" theory is dead. On the contrary, psychoactive pills cause chemical imbalances--they change your brain in ways science does not understand, sometimes they alleviate symptoms, but they do not CURE distress.
Thus one danger of calling mental distress a "disease" is that it is then treated as such--you become a patient and you look to a doctor to fix something. This works with appendicitis and broken legs and cancer. It is a fact, however, that not all things clearly within the realm of medical disorders are treatable by medical doctors. In general, there is no treatment for the flu or even the common cold, and physicians are stymied by irritable bowel and migraine. Medical science certainly does not work with depression, anxiety, phobia, PTSD, and the many variations of psychological distress delineated in the various manuals of disease such as the DSM and the ICD, because these are not diseases in the once-commonly understood meaning of the term. These problems do not show demonstrable tissue damage such as a cancer or a stroke, nor do they have symptoms that represent the body fighting a foreign invader, such as cough, fever, runny nose. Rather they have emotions and behaviors as their hallmarks.
How weird is it that one way of diagnosing ADHD is to try a pill and if that works, then the diagnosis fits? What this really means is that there is a behavior someone (not necessarily the individual in question) wants changed, and there is a pill to reduce that behavior, and someone thinks the reduction of that behavior will be beneficial to the individual. It is debatable whether there is always benefit in reducing the cluster of behaviors we have called ADHD. It also turns out that while it may be the case that for some individuals, reducing the behaviors we have come to label "ADHD" is indeed of benefit, this can be done via psychotherapy and biofeedback, both of which lack the potentially serious side-effects of commonly prescribed ADHD medication (lack of appetite, depressed mood, sleeplessness, loss of creativity, failure to maintain growth patterns compatible with age). By simply calling ADHD a disease in need of medication, we fail to account for individual differences, and potentially do harm to the individuals so labelled.
A similar paradigm applies to anxiety--anxiety is a signal that something is wrong. It is not the case that all anxiety must always be removed via medication. I submit that it is vitally important to understand the root of this anxiety and assist the individual in achieving a reduction in his discomfort via understanding and changing thoughts and behaviors in such as way as to feel calmer. Anxiety is basically a subset of fear. While in modern times we are rarely in actual fear for our lives, modern life has many stressors--job stress, school stress, health stress, financial stress, traumatic stress. Applying a pill to the results of these stressful situations is not a solution, and it is certainly not a cure. You are anxious for a reason, and you need to learn about this reason and either remove the distress or change yourself accordingly--which might mean anything from thinking differently to moving out of a dangerous environment. When we diagnose anxiety as if it is a disease, we neglect the vital information about the state of the individual struggling with the anxiety.
The answer thus to the title question is yes, these diagnostic labels speak to something very real. On the other hand, the use of such labels leads us down the wrong path to helping you, the client, feel better. So they are not "just" another label; rather any one of them is a misleading and potentially dangerous and stigmatizing label. It is all too easy to become trapped in the language of illness; "I have depression" or "I am depressed" rather than, "I feel depressed" or even "I have been feeling depressed for a long time".
Describing your distress as a temporary state rather than a fact of your existence can be very liberating and allows you to focus on the potential for change. Remember that stress is a motivator to change. It is hard to change when you are feeling anxious or depressed or in pain, but that is the time when even a small change in how you think or act can make a significant difference. Try something silly right now--pull your face into the biggest smile you can and observe what happens. Change your posture--sit up straighter if you are slouched--slouch if you were sitting straight--observe your inner state. Small changes can easily lead to bigger ones.
Taking mental distress out of the realm of illness and disease is not meant to belittle or disregard your very real pain. The point is to empower you to take control of your discomfort and regain control of your life, rather than submitting yourself as a patient to the experiment that is modern psychiatry.
Szasz, T.E. (2011). The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. Harper Collins.
As humans, we have long memories. Our memories vary in their accuracy, but to us, memory is a big part of who and what we are. Each of us is largely the product of the many experiences that we have had and the many people we have known.
The problem with being formed of memories is that it is easy to get stuck in regrets. What if I had not done this or that? What if he or she had not died, left, said that? What if........ And, of course, there is no answer.
When we have erred, hurt someone, suffered a loss, or missed an opportunity, there is an opportunity for growth and learning, but there is rarely a do-over.
It turns out that such difficulties are motivators to change, and are overall a good thing. If nothing ever goes wrong, we are never driven to grow.
Psychologists distinguish eustress from distress. Both are meant to stimulate action. Eustress like the birth of a baby certainly triggers many behavioral changes in new parents, but is nonetheless stressful! Distress also triggers activity, from eating when you are hungry to apologizing to a co-worker you have hurt. What we commonly call stress is really when we are overwhelmingly distressed; when life and work get out of balance, when too much goes wrong, or when something goes wrong that feels like more than you can cope with.
This is a good time to talk to someone, whether in your social network, or professionally, to gain some perspective on what you can do to reduce your perceived distress. When you remain overwhelmed, it can lead to depression, anxiety, or even physical illnesses caused by too many stress chemicals in the body, so it is important to keep your daily stress under control, but that is a topic for another day.
The problem we are focusing on here arises when you cannot fix an old wrong or get over an old hurt, and it reaches out from the past to haunt your thoughts. People whom you loved dearly have died, and you miss them. Friends have inadvertently been offended by something you said that you did not get a chance to right or vice versa, someone has done something to hurt you. Things from your past seem to creep into your attention and distract you from the present and upset you. It is difficult to ignore these persistent thoughts. They seem important. They seem to carry lessons. You have to fight to put them out of your mind and focus on work or get to sleep.
It turns out that trying to ignore persistent, bothersome thoughts from the past is not a good tactic, despite well-meaning people telling you it will get better with time. Often, that is true. But what do you do when it does not? Sometimes your thoughts seem to get bigger and harder to live with each time they resurface. A more successful approach is to confront these thoughts head on--to figure out the fallacy and deal with them when they surface.
If you miss a dead loved one, focus on positive remembrances. Death is, for better or worse, something inevitable in life. Some deaths seem more unfair and untimely than others, but healing is always possible. There are strategies that work to ease your pain. They are positive strategies--facing the thoughts that plague you, and dealing with their meanings. We all have regrets when a loved one dies, but regrets do not move us forward, and that particular issue cannot be repaired. It can, however, be reframed. Was that particular regret the focus of the relationship, or did it have good points? Death leaves us with sadness, but life is full of joy as well, and the time you shared with a loved one is irreplaceable--what does it take to focus on the positive thoughts about him or her? Is there a benefit to focusing on regret or loss? Which tactic has the best outcome? Perhaps even speculate as to which memories your friend or relation would prefer you to maintain.
Let's say you did something wrong--broke a friend's favorite vase; you apologized, but it is irreplaceable. The friend knows you did not break it deliberately. However, you find yourself agonizing day after day, night after night, about what a bad thing this was. Will this agony replace your friend's item? Will it prevent clumsiness in future? Will it make you a better person? The answer to each of these, is, of course, no. And the value in this is that if we are to learn from our mistakes, then it is important to know where the lesson lies. It does not lie in self-abuse and regret, but in self-improvement and constructive thinking. Obviously, the breaking of a piece of pottery is not a life and death mistake, but it is used here as a symbol for things that we might do in life that we feel are irreversibly harmful to someone. The important thing is remembering that nothing positive is achieved by tormenting yourself forever.
It is very human to get stuck in recurring unpleasant thoughts about past problems and losses. Our thoughts run our lives; they tell us what to do and how to do it. It turns out, however, that our thoughts are often repetitive and uninformative. By refusing to follow such destructive thoughts yet again to their inevitable, painful conclusions, you take control of your mind and of your feelings. It is weird to dismiss a thought in your own mind as harmful, but it is also liberating. What if the four-hundredth time you fret about that broken vase is still not going to restore it or make you a better person? Then it is high time you let yourself off the hook and move on.
You, I, and all of us, are fallible humans. We make mistakes. We suffer losses. We handle things poorly. Sometimes. But these issues do not define you. How you choose to deal with pain and regret is what defines you--what choice you make when you have a choice. It is not a deliberate choice to hurt a friend nor fall down a flight of stairs, but what happens next is. How you think about bad incidents and how you act on those thoughts affects your mood, your self-image, and thus your quality of life.
It often goes against your intuition to deliberately control your thoughts. It is natural to run with the thoughts as they pop into your head. But it can lead to rethinking the same destructive thoughts, getting stuck in unhappy thought patterns, and generally being less happy than if you take that odd-seeming step to say no to depressing, negative, self-effacing thoughts and choose to ponder uplifting and positive things instead. This does not mean go off into the distance in a fantasy where nothing ever goes wrong. To the contrary, what it means is avoiding being unrealistically negative in favor of being realistically positive.
Try it. You'll like it.
Ellis, A. & Doyle, K. (2016). How to Stubbornly Refuse to Make Yourself Miserable About Anything--Yes, Anything! Citadel.
Hello Ashland! Up here in the woods, amazingly only 15 minutes from town, clients will be invited to see me in a private space, with the sounds of nature to add to the ambiance. It was gratifying to see our garden immediately begin to thrive as it never had in Bend, and I know the beautiful environment will enhance the healing that occurs for my clients. In-person sessions will begin Sept. 1 in this new space.
I also welcome intensive clients starting Sept. 1: Medford is 30 minutes away and Ashland less than 15, and both have a variety of hotels, motels, B&Bs, and hostels, as well as a fine selection of eateries and groceries. We are 30 minutes from the Medford airport. While a therapy intensive is hardly a vacation, traveling to a beautiful spot far from your daily environment offers a unique opportunity to break old patterns and create new ones. Follow-up in person or via video-chat assists you in maintaining your new learnings in your home environment.
It has been stressful to move many miles for the second time in 2 years, and perhaps I have learned some new things about managing stress and the ways in which change affects me and others as well. Stress is always both good and bad: it forces new ways of seeing things and behaving, but it can cause strain on the system. Moving changes one's relationship to others, to resources, and to oneself. Out with the old, in with the new, to coin a phrase!
The new incarnation of the Center for Conscious Living will offer individual and family therapy, Rational Emotive Therapy, which is the elegant, effective precursor to CBT, Sensorimotor Trauma Therapy, and clinical hypnosis. I will continue to focus on physical symptoms that bridge the mind-body gap such as gut issues (irritable bowel, cyclic vomiting), headache (migraine, cluster headache), and chronic pain (RSD, CRPS 1, fibromyalgia); those difficult-to-treat issues that often defy medical treatment. Call for a free phone consultation.
Meanwhile, I shall be learning about my new environment and preparing a new space for seeing clients.
In the years since I have been practicing psychology, I have seen a startling number of serious, damaging reactions to medications. In addition, I have also seen no small number of similarly bad reactions to street drugs. Years of observing and reading have thus led me to a very conservative stance regarding attempts to pharmaceutically solve health problems, both physical and psychological, as well as the ones sitting on the border thereof. Some examples follow, after which I'll provide some details about how I work with my clients in light of my observations.
A man called me for help with a serious problem--one that had nearly landed him in jail. He was a peeping tom. Suddenly. The long story was that he had Parkinson's disease and was being treated with L-dopa. In those days, it was not yet firmly established that, due to its effects on the dopaminergic pathways, L-dopa can cause obsessive-compulsive problems. Some time soon after this, the news began to surface--something that ought to have been pretty obvious, that when you alter a neurotransmitter system, since neurotransmitters serve more than one function in the body, you have to expect some serious changes beyond the hoped-for effect. As good a therapist as I fancy myself, nothing I did would completely break this man's obsessive preoccupations, until the drug was stopped. He made therapeutic progress and stopped violating people's rights, but that was not the same as overcoming his obsessive thoughts. So here we have an example of a drug prescribed for a medical condition causing a serious psychological symptom for many years before he came to me and we figured it out. Did that drug help his other problem? Indeed, but the solution caused a more serious issue.
A friend of mine complained of sudden pain and cramping in his muscles during his thrice-weekly jog. He had to stop exercising, which caused him great distress, not to mention weight gain, depression, and other problems. It did not take him much longer to stop his statin medication, change his diet to control his blood chemistry, and get back to normal. Not everyone is this lucky--for some, statins cause permanent alterations in muscle and nerve tissue. For others, lifestyle changes do not make the needed change in cholesterol. The caution here is to read those scary leaflets that come with every prescription and pay attention to your own responses. If you are the unlucky one to experience severe side effects, often there is an alternative to the medication that is causing harm. Talk to your physician.
For several years, my office saw quite a few clients with anxiety that had developed after a course of steroid treatment was ended. These anxiety problems turned out to be much tougher to treat than other forms of anxiety. Eventually steroid treatments began to be tapered carefully and used with more caution, and that problem decreased dramatically. Score one for pharmacology. But, again, proceed with caution when taking steroids. While they can be lifesavers, nothing comes without a cost.
The same caution applies as well to acne medications; while some sorts of acne can be severe and disfiguring, and I would not want a suffering individual to go untreated, the internal medications that have been developed to help sufferers are known to cause anxiety. This can be very hard on the target patient, who is a teenager struggling with a difficult issue. Parents--be willing to monitor your teen and seek psychological help when needed. This is no small matter.
Proceeding to the other end of the equation, we can peek at medications prescribed for psychological issues. And we can find both sorts of side effects; the physical and the psychological. Anti-psychotic medications can cause movement disorders and perceptual problems, not always reversible. Antidepressants have been know to cause anxiety, manic episodes, lethargy, and sleep issues, to name a few. And research shows very little demonstrable mood-enhancing effect. Stimulant medications for attention problems can cause depression, appetite suppression, and sleep problems. These medications are most often given to growing children, for whom such side effects are non-trivial. Again, the message here is to approach psychoactive medications with caution, particularly for children.
I have seen several young adults who either were or had been taking several psychotropic medications. In each case, the psychological symptom that had sent them to the doctor was easily treatable with psychotherapy. In each case, the youth in question suffered suicidal thoughts that struck them as out of the blue until their parents brought them to me. One young woman had taken herself off of all of her pills without medical supervision. Another was simply following doctor's prescriptions when she thought of self-harm. The scary thing for me and for them and their parents was that in each case, the young person had a mild depression, some life stress, or some other life problem that once we got to work at it, was readily treatable.
In another vein, a long, long time ago, a patient, my first actual client, in fact, appeared before me at a rehabilitation hospital. I nearly fainted, being a psychology trainee and not expecting massive quantities of blood. This incredible man was in fact, a high-functioning heroin addict, or had been. His last dose of his drug of choice had caused a massive event depriving his brainstem of oxygen and nearly killing him. He had, indeed, been comatose in a hospital for months, without the normal precautions having been taken to maintain skeletal function, as it was expected that he would not survive. Clearly, they were wrong. So, several surgeries later, finally able to walk a little, I met my patient in a hallway, covered in bloody bandages. My job was to learn about his cognitive functions and help him rehabilitate. He would never again rise to the top of his profession. In fact, he would never work again, but he could think, and he could understand that even an addict with perceived control over his use could have a devastating reaction to a non-prescription drug.
Two other clients, both college students, had bad responses to relatively small experiments with hallucinogens. One, salvia, not even illegal at the time, and the other, psilocybin. The first developed bipolar disorder and disorders of thought, which have not remitted 10 years later; the other developed depersonalization. I do not know his long-term outcome. Again, buyer beware--street drugs develop a mystique, and are often purported to be harmless--just a good time, but not everyone gets away with that. For some, putting such powerful, reality-changing chemicals into the brain makes frightening and sometimes permanent changes in perception and functioning. How do you know if you will be the unlucky one whose brain does not recover?
My reaction to the sum of these and other anecdotes, is to approach all chemicals that work on a neurotransmitter system or a hormone system with a great deal of caution. After all, even antibiotics can be misused and cause harm, and they work directly on the offending microbe. These drugs that affect our complex, multi-functional, interwoven system of chemical information can change us in many interconnected ways. They ought never to be taken lightly.
It worries me daily that so many people worldwide take such medications as if they are relatively harmless. I learned on my first day as a psychology student: First do no harm. Rarely is a medication completely harmless. Physicians, patients, and pharmacologists must always weigh benefits against risks. The problem is that when the problem seems dire, you, the patient, are afraid to risk not taking the medication and often therefore, blind yourself to the harm it is doing.
I run into this often with chronic pain. Many types of chronic pain do not respond to opioid medications, but patients in pain are terrified to stop taking a medication even when they cannot in truth tell me that their pain changes a jot when taking it. Pain is scary, and chronic, unceasing pain is really scary. But that is not a good reason to take a potentially dangerous drug that is not helping, nor the chorus line of subsequent medications to enhance mood, reduce the side effects from the first two, aid sleep, and then, of course, get the gut to work again after the effects of all of the nervous system suppressants.
Now let's look at how I approach clients who come to my office. First, I make sure to get a complete health picture, as well as a decent lifestyle snapshot for each client. This way I can get an idea of their overall self-care, major health issues, and what other treatments they are receiving. Even though I am a psychologist, I often discover an important datum about my client from such information. Is my client eating? sleeping? attending to hygiene? able to work? People come to me for such problems as depression, anxiety, phobias, gut issues, chronic pain, headache, and trauma.
I do not differentiate the mind from the body except insofar as I need a medical review when there are physical symptoms to make sure nothing important has been overlooked, because, of course, I never treat a broken leg nor a brain tumor primarily with psychotherapy, though after medical treatment has been undertaken, I can safely offer pain reduction and immune enhancement via clinical hypnosis, which has been demonstrated to improve patient outcome. On the other hand, I will treat an irritable bowel or a migraine with psychological methodology, after that physical exam, because it is effective and can lead to a cure, which medications have not been shown to do.
What about drugs, then? In acute pain situations such as that broken leg, pain meds can be of great benefit. Hypnosis can be very useful with acute pain as well, but not everyone is in a situation to take advantage of hypnosis in the ER. On the other hand, in chronic pain, hypnosis surpasses medication on many occasions, especially when the pain persists despite many attempts to medicate, and the doses seem to be abnormally high with little effect. There is new evidence that chronic pain that lacks a current medical source or is in excess of what the medical issue accounts for, does not respond to medications, but it does respond to appropriate psychotherapy.
When we get to high cholesterol, diabetes, hypertension, and other clearly medical ailments, I ask my clients to have clear discussions with their physicians. All of the medications to treat these issues have side effects. For some, behavioral change and psychological counseling will rebalance the body's systems and restore health. For others, either the imbalance is too severe or the behavioral changes will not help enough, or you, the patient, really prefer the medication, which is your choice to make. But, again, it is always good to have a frank discussion with your prescriber as to potential for harm, alternative treatments, and what the drug research indicates a far as safety and effectiveness.
In the realm of depression, the modern tendency to immediately prescribe medications worries me. Research does not really support the use of medications with most depressions. Good (GOOD!) psychotherapy is more effective, and medications carry known side effects which are often worse than the offered symptom relief, and they are notoriously difficult to wean off.
As far as anxiety, we have a completely different issue. Anti-anxiety medications are less side-effect prone than antidepressants, but highly addictive, with the added issue that taking a pill rather than dealing with the cause of anxiety often leads to long-term psychological dependence as well as lifestyle restrictions to avoid feeling anxious. Anxiolytics are indeed effective, but not quite safe, as far as the dependence they can create. Psychotherapy is known to be effective for anxiety and phobias.
This issue of understanding psychiatric medications and other medications that are not serving a clear purpose is vital to how I practice psychology. I see many individuals with physical symptoms, taking several medications, and not able to identify any particular improvement from the drugs, yet afraid to stop or taper any of them. These same clients might also complain of poor sleep, lack of appetite, grogginess, or gut problems. The fact that this individual is in my office means that the medical approach is somehow not helping, or not helping enough, but because nothing better has been tried, the medications linger.
When a psychological approach is shown to be effective, working with my client's physician to taper medications is part of the process. We are able not only to work on the original problem, but also the new fear of stopping the medications.
When there is a psychological diagnosis such as anxiety, depression, phobia, or trauma, once again, if the client is sitting in my office, it is often because medications have not worked. In these cases, research bears out my own conclusion that psychotherapy is the approach most likely to help. Once again, when my client experiences an improvement in symptoms, he then needs to confer with the prescribing physician to assist in the tapering of any drugs that have not shown positive effects, but in this case, psychotherapy can proceed and the potential for cure rather than symptom reduction is real.
One of the problems here is that is can be very difficult to distinguish, as a consumer, good psychotherapy from just having a pleasant chat. Many supportive, empathic conversations help you to feel calmer and happier. Psychotherapy ought to be aimed higher than that. Not a short-term relief from psychological or physical pain, but a long-term learning process in which you acquire new knowledge and new behaviors that lead to a better mood and a calmer frame of mind. It is okay to hold your psychotherapist to a higher standard; you ought to see improvement. While this can be difficult to measure, it is less vague than some might think. Set goals with your therapist, and go over whether they are being met. Ask for assignments. The completion of assignments is a major predictor of therapeutic success; it means both you and the therapist are engaged in a learning process.
Psychotherapy has been shown to be effective in treating depression, anxiety, phobias, PTSD, and many other problems with life. Specialized psychological approaches have been shown to be helpful with chronic pain, migraines, functional gut issues, and problems with the immune system. Please discuss all medications with your physician at length, and if medication is not the answer, there are a variety of alternatives depending upon your issue, including, perhaps, a visit to a psychologist.
Ananth, J: Pharmacotherapy of Obsessive-Compulsive Disorder, (1985) in ed: M. Mavissakalian, L, Michelson, S.M., Turner: Obsessive-Compulsive Disorder: Psychological and Pharmacological Treatment : Springer Science, NY. Chapter 5, p 177.
Antonuccio, D.O.; Danton, W.G. & DeNelsky, G.Y. Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, Vol 26(6), Dec 1995, 574-585.
Kirsch, I. (2010 ) The Emperor’s New Drugs: Exploding the Antidepressant Myth. Basic Books.
Sarno, J. (1990) Healing Back Pain: The Mind-Body Connection Warner Books.
Whitaker, R. (2010)Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, Random House.
For me professionally, understanding memory is important in the process of doing psychotherapy. After all, it is with people's memories that I work all day. Early in my career, I learned that with psychotherapy the validity of a memory is less important than its impact. A client might recall an event as a painful experience, and that memory can have a present-day effect on his mood. That effect does not affirm the accuracy of the memory, just its impact. The impact is what I work with, as I can never know, minus sources of corroboration, whether my client's memory is precise.
How accurate is memory? The answer overall is "not very". Research demonstrates time and again how easily our memories are misled by simple suggestions. Asking, "what color was the traffic light before the accident?" will tend to elicit a response--regardless of whether there was a traffic light at the intersection in question. This is not because the witness is a fool, but because controlled intersections are common and, thus, an existing memory is elicited by the question and conflated with the memory being probed. What is not easy is to implant a totally foreign memory, such as suggesting that someone was injured in a crash, molested, or committed a crime. The fact that memory can be altered does not mean that it is completely unreliable and vulnerable to alteration.
The truth is that memories are malleable. It is thought that each time you access a memory, it is somewhat altered by the you who accessed it, who is not identical to the you who formed it. This makes for small changes over time in frequently retrieved memories, which are also affected by the conditions of retrieval and your mental state when remembering. Memory is not a simply thing.
Another aspect of the accuracy of memory is the strength of the attached emotions. Traumatic incidents tend to produce what are anachronistically termed "flashbulb memories," which tend to be stored differently, in fact, highly accurately, with a lot of highly charged emotional content. These memories tend not to be altered over time, as they are rarely retrieved deliberately (versus as flashbacks, because who wants to purposely recall the worst thing ever?) and the means of storage has been shown to be different. This, however, brings me to a point of contention. If flashbulb memories are so clear and unforgettable, how can some people claim to be missing memories for traumatic events?
Whether you term these "repressed" (which implies unconsciously hidden from awareness), "suppressed"(actively hidden from awareness), or simply missing, not everyone remembers everything bad, or even really bad, that happened to them. Our minds have ways to secrete memories that are too painful to process. This effect is not necessarily common, but occurs under certain circumstances that seem to involve the capability of the mind to handle the trauma, the capability of the mind to hide the memory, the age of the victim, and the type of event.
I'd like to add that trauma therapy is NOT focused primarily on recovering or clarifying memories. Trauma therapy at its best is focused on improving functioning, using whatever tools and skills this entails. If someone claims to be doing "recovered memory therapy," their focus is wrong, and it would be inadvisable to proceed.
As conscious beings, our identity is the sum of our memories; which can make it scary to think that perhaps you did not ride in that convertible in the picture from 40 years ago, or perhaps you did not make that trip to Vermont, and perhaps you did get lost at camp that summer. Be aware that most of those memories are close enough to reality to remain a good representation of where you have been, but some are just enough different to be startling.
If something seems to be pricking at you from the past, it is wise to look into it. But in most cases, it is unwise to assume that every aspect of the memory picture is absolutely accurate. Competent, respectful psychotherapy can help you function better despite painful memories, understand and reframe old hurts, and live more fully in the here and now.
Science tries, year after year, to isolate specific markers for mental illness. Tests come and go, but the construct remains elusive. We can objectively test for the flu or cancer or diabetes or a broken leg, but we cannot test in a way that never changes, for depression, schizophrenia, or anxiety. This does not mean that you are not suffering with your problem. It only means in this context, that your problem is mislabeled by being lumped in with physical illness. This is important for many reasons. I hope you are still with me as I elucidate why I, and others like me, believe calling mental problems "diseases" hurts those who suffer with them.
Despite years of using these new labels and making depression and alcoholism diseases, we are no closer to a solution. I do not say "cure", only because that word is used to refer to the removal of a disease. I like the word cure, as it implies a final exorcism of the problem, but I do not like that it then throws the problem back into the language of disease. If depression is like flu, then you can either wait until it gets better, and it ought to run a pretty specific course, or you can perhaps get vaccinated at a young age and never become depressed. This, of course, does not make sense. Depressions often do remit over time, but it can be too difficult to handle the suffering meanwhile, and, despite pharmaceutical advertising to the contrary, there are no medications developed to alleviate symptoms while you wait.
You can indeed take one of many antidepressant medications, but there are a couple of problems with this approach. One is that they tend to have bad side effects. This is one reason drug trials with antidepressants are mostly unreliable--people can tell if they are on the placebo or the medication due to side effects, and in comes the placebo effect and they feel better. A second problem is that the theory of why they work is patently false. We do not know enough about neurotransmitters in the human brain to make direct cause-and-effect claims like "when you take a selective serotonin re-uptake inhibitor your brain is normalized by keeping more serotonin available". The brain compensates for the presence of excess serotonin, making this claim false on one end, and we actually have no proof that depression is causally linked to a lack of serotonin, making it false on the other.
This does not mean you are crazy if you take one and feel better, just that the evidence that these medications cure something is not really there. For some, the symptoms do remit for a while while taking such drugs. That, unfortunately, is not a "cure"; it is a respite from a part of your symptoms; an aberration from your normal brain chemistry that is tough to repair later.
What about alcoholism? One thing that becomes increasingly clear over time is that addictions often co-vary with other mental problems such as depression, trauma history, or anxiety. While there is often a genetic component to these problems, some of which is metabolic, a complicating factor is that we can learn how to use a substance to escape from problems from those around us, making sorting genetics from environment very tricky. There are medications that can help you avoid using your substance of choice, but are there any for the symptoms, so that you can wait patiently, feeling okay while your disease remits? Thus, the first reason to avoid calling depression or addiction diseases is that calling them that and treating them as such does not help you get better.
A second reason to avoid labeling mental issues or symptoms as diseases is that this removes your feeling of owning the power to improve. If you have a genetic problem or a chemical imbalance in your brain, it could be impossible for you to effect change by some action you take. If, on the other hand, mental problems have a variety of causes, you can begin to root out those causes and make changes in your personal experience. For some, having a guiding therapist helps, but many people use books, seminars, articles, or simply self-awareness to help themselves.
What about problems in childhood? ADHD--Attention Deficit Hyperactivity Disorder, prevents kids from doing well in school, makes them difficult to handle, and prevents them from living successful lives, right? So the only solution is to medicate them and help them to fit in and do what they're told. Maybe. What if ADHD is not one thing, but many things, and some of them are normal. Children are supposed to play and explore and misbehave and test limits. The environments in which we place them at very young ages tend to discourage such behaviors. This is not to say that no child is an outlier who is more active or less attentive than her peers, just that fidgeting and impulsivity are hallmarks of childhood, and we ought to be less eager to call them symptoms. Additionally, given the rampant side-effects from stimulant medications, we as a culture ought to be more flexible in learning how to help such children without chemical assistance. We ought to be differentiating the symptoms of lead poisoning, head injury, or severe trauma and anxiety from behaviors that annoy us. Just because a child does not fit the public school model does not mean he is ill.
What if you have suffered a terrible trauma or a neglectful childhood? You have genuinely suffered from injuries to the psyche, and you are in emotional, or even physical, pain. Why would I not count the symptoms you have, from PTSD (Post-Traumatic Stress disorder) to dissociation to depression, as illnesses? My reasoning remains the same. There is no disputing the fact that trauma, early or late, can lead to debilitating symptoms, but when I call it a disease, you might feel trapped by your past experiences and unable to help yourself heal. This is in no way meant to diminish the damage caused by abuse or neglect or trauma, but to call the results by another name in an attempt to empower those who have suffered to learn the path to healing.
Disorders of the brain such as Parkinson's disease, stroke, and tumors exist, but these are not my subject today. Such physical ailments of the brain can also cause emotional or behavioral symptoms, but not all behaviors we do not like are symptoms of disease. The trouble with the label of mental illness is that calling everything a disease distorts both the construct of disease and the process of getting help.
Because what I do under the label of psychotherapy is to empower clients to solve problems, the language of "mental Illness" is contrary to my intent. I do not have the power to heal you with a drug or a surgery; there is no magic bullet. What competent psychotherapy can do is to guide you to help yourself feel better with empathy, information, skills practice, and occasional sound advice. To me, the question is whether you wish to be a patient with a mental illness or a client with a desire to solve your own problems. Getting help to solve a problems is just as logical as having someone else repair your car or your plumbing--You are ultimately getting the work done, but you may require expert assistance. Do not discount your own power to solve problems and feel better.
References: Kirsch, I., The Emperor's New Drugs: Exploding the Antidepressant Myth Basic Books, 2010
Szasz, T. S., The Myth of Mental Illness: Foundations of a Theory of Personal Conduct , Harper Collins, HarperCollins 1960.
Whitaker, R., Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill Basic Bookis, 2001
These extreme examples of the intricate mindbody connection led me to view my clients with a much more open mind. Things I had diligently learned in graduate school held less sway versus the real experiences of my clients. Medications did not appear to work miracles despite being used in ways even our textbooks said were dangerous. Diagnostic criteria and diagnosible disorders from the _DSM_ changed over time, which confused me if those listed problems were diseases. Does the definition of influenza or diabetes change with each new edition of a manual? Do they sometimes disappear from the text? And despite modern times labeling many problems as diseases in what appeared to be both an attempt to put them in the bailiwick of physicians and to remove the stigma of causality from patients and their families, suffering seemed to be getting worse, not better, and reliance on medications increasing as well. Additionally, the number of clients coming to me already taking three or more psychoactive medications appalled me. Why, after all, were they still suffering if these medications work? I began to wonder about many things I had been taught and to question common treatment practices of people seeking mental health treatment as well as physical medical treatment.
Too often when you get referred to a psychologist with an ache or pain or other physical manifestation of illness, it feels like a put-down. “There is no physical explanation for this; perhaps CBT would help”, “I cannot figure out why this is going on; here is a referral to a psychiatrist”. If instead, we eliminate the dichotomy between the mental and the physical, human health and illness make more sense. It turns out that the brain can and does cause physical symptoms.
The simplest example of this interconnection is pain. And this makes sense at its very core, because nearly all pain is generated in the brain, Sure, a signal may have arisen in your foot or arm, but the pain percept comes from your brain; which means, conversely, that a pain percept can be generated in your brain without any help from the foot or arm that SEEMS to hurt. That is not the same as faking. It is a fact that pain is a signal that something needs attention, but the something might or might not be an injury or tissue damage at the spot that seems to hurt. Enter psychology. It is important to learn why your brain is doing that and what you can do to stop it.
Turning to a problem that seems, you might say, more physical, like irritable bowel syndrome; physicians are often willing to prescribe psychotropic medications for this problem and put you on a weird and not very nutritious diet. So here are two questions: first: why use psychotropic medications if the problem is strictly in the gut and, second, why do different sufferers have such vastly different trigger foods? We know that the gut has even more neurotransmitters than the brain, so a gut-emotion connection actually makes a lot of sense. And it might not matter whether the gut issue came first, as when IBS arises soon after food poisoning, or second, as when it arises after a huge and important test in school. In both instances, the mindbody connection is pointing to a need for some learning in order to change a problem with how the body is functioning.
What about the flu, you may ask? My mind certainly does not impact the flu; it is caused by a specific microbe, and has a specific set of symptoms, and I either get a shot or hope for the best, and lie there until I get better if I am unlucky enough to catch it. That is correct as far as it goes. What we do know, however, is that over and above differences in exposure to germs and basic immune system functioning, stress has a huge impact on whether you succumb to a bug and how long it takes you to recover. So while I would not suggest you run to the psychologist with a cold or flu, it is a good time to examine both physical and mental stress in your life, and slow down.
Your mind and body are part of an inseparable, indivisible, and delicately balanced whole that is you. When something is wrong, the balance is disturbed. If you have sought medical treatment, and it has not worked, the problem might have its roots in stress. Remember that stress can be both physical and emotional, and both sorts can cause illness. In these cases, psychological treatment may be the answer. Whether you have chronic pain that does not respond to medication, a functional gut disorder, or an autoimmune disorder that responds to medication, but still has a negative impact on your life, psychological treatment can help.
Rossi, Ernest L., Ph.D. & Rossi, Kathryn L. Ph. D.
The New Neuroscience of Psychotherapy Therapeutic Hypnosis & Rehabilitation : A Creative Dialogue with Our Genes