Coping with Uncertainty

These are challenging times.  Who would have thought that almost overnight, our everyday lives would have so drastically changed?  While not all of the changes have been negative, take the environment, for example, but the stress on our working lives and the economy cannot be denied.  As human beings, we tend to react negatively to the unknown.  Uncertainty is hard to adapt to in an evolutionary sense because it is hard for us to know how best to prepare.  Do I need supplies for two weeks or six months?  Will my job be there when this all over?  Such uncertainty is experienced as a threat and activates primitive emotional systems in our brains that evolved over time to keep us safe.  In a sense, we are operating in the modern world with antiquated hardware. We are no longer scanning for tigers in the savannas (generally speaking) but coping with a rapidly changing modern environment saturated with information designed to activate the fear signaling circuits in our mammalian brains.

So, given that we are living through an event that may as well have designed to create anxiety, how best to cope?  Here are some suggestions for effectively weather uncertainty:

•     Try to maintain some kind of regular schedule.  Eat breakfast, exercise, read, etc. following a predictable routine. Routines make the unpredictable more predictable, and thus safer.  When children experience a disaster, for example, they are comforted by a return to predictable behavior.  You don’t have to pretend you are at the office, but having a loose structure can help.
•     Reach out to social contacts and friends.  Call family members and reconnect with people you haven’t talked to in a while.  Humans are social animals and benefit from interaction with other humans.  We are essentially “wired for social connection.”  This does not mean that you have to become a social butterfly but try to avoid isolation.
•    Limit your exposure to news and commentary about the pandemic.  Like in the aftermath of 9/11, the 24-hour news industry has filled the airways with information of varying quality.  Remember that news producers know full well that engaging their audience through activation of the primitive fear/alert systems in our brains is a sure way to keep us engaged.
•    Engage in moderate cardiovascular exercise.  There is a lot of research that suggests that moderate cardiovascular exercise is related to lower levels of stress and a greater sense of self-efficacy.  You don’t have to train for a marathon, but 15-30 minutes of exercise that elevates your heart rate can be an excellent strategy assuming that your doctor has not limited your activity for health reasons.  Bodyweight routines or walking are good examples and there are many free workouts posted on line. 
•  Take up mindfulness meditation.  Again, there is an emerging body of research linking mindfulness meditation to decreased stress, improved focus, and increased self-efficacy.  Smartphone apps such as Headspace, Calm, and Mindfulness Coach (which is available for free from the Veterans Administration) can walk you through the process of learning to meditate.
• Finally, exercise self-compassion.  Accept that you may be under a great deal of stress and that a wide range of feelings are normal and acceptable

I hope some of these suggestions are helpful.  As always, I am happy to consult with you if you have questions or would like support.  Be safe and well.

Embracing Change

As temperatures finally begin to moderate here in the Northeast it becomes clear that the seasons are changing.  Our relationship to change is a complex one.  In depth of winter it was easy to fall into the belief that the cold and discomfort would go on forever. This leads to a feeling of helplessness and depression as we embrace what Daniel Gilbert termed the "death of History."  By this Gilbert refers to the idea that we forget the world around us is always changing.  When we are sad (or anxious or any other unpleasant experience) it seems that this is all there will ever be even though history (experience) tells us that this moment too shall pass.

Change is hard for us because it poses a challenge to our equilibrium.  We are forced to adapt to change and this can cause stress and discomfort.  Resilience is all about being able to adapt to changing circumstances and in fact there is really no escaping change.

People often hold on to ways of being that are rigid and not adaptive because they are familiar.  By doing what we have always done we avoid the discomfort of change but we also deny ourselves the opportunity for growth offered by changing our habits.

In therapy I help patients become more comfortable with all of their feelings, including discomfort, so that they can choose to try out new ways of being.  This can be hard but rewarding work.

So as Winter gives way to Spring embrace the inevitability of change and accept that all things are transient.

My Experience Starting Meditation

I have recommended that my patients give meditation a try for a while now and decided that I should take some of my own medicine.  There is a lot of good empirical evidence supporting the efficacy of meditation and mindfulness practices in the treatment of depression and anxiety, among many conditions.  In addition there are really no side effects to balance against the benefits of meditation as there are with medications.

So with that in mind I decided to embark on my meditation journey.  First I did some reading.  I strongly recommend Jon Kabat-Zinn's work (especially Full Catastrophe Living), Mark Epstein's Thoughts Without a Thinker, and Rick Hanson's Buddha's Brain.  Each of these authors make a strong case for meditation and for accepting suffering as a given rather than something to waste effort avoiding.  Epstein and Hanson also make connections between meditation and neuroscience highlighting the scientific evidence for meditation's efficacy.

Once I had convinced myself that meditation had empirical support and was not just a new-age trend, I needed some help getting started.  Because I like technology I turned to smartphone apps that could guide me through some basic exercises.  I ended up using the headspace app and have been using it now for several months.  I really like the integrated approach used in this app. Each meditation builds on the last.  The first two series are shorter, ten and fifteen minutes respectively, and lead you to twenty minute meditations which is where the benefits really start to accrue. There is a subscription fee for the app after the first ten meditations but I have found it worthwhile.  Note, I have no connection or business arrangement with Headspace folks.

So what was it like to get started?  I found it difficult at first to make myself sit quietly for fifteen or twenty minutes (ten minutes was quite easy though).  There always seemed to be something else I thought I needed to do.  Weekends were especially difficult because my schedule was less predictable and I had trouble isolating myself from my family to meditate.  I suppose I felt a little self conscious, what I later discovered was ego imposing itself.  The key, I found, was not to let a few missed meditations scuttle the whole enterprise.  I got back to it when I could and gradually came to value the experience enough to prioritize it in my day.

Somewhere in the Take-20 series I had a powerful experience of relishing the time I was taking for myself.  I felt relaxed and joyful just to sit back and focus on my breath, doing nothing but settling the mind and being present in the moment; what a wonderful feeling!

At this point I miss a day here and there but for the most part I have established a pattern.  I highly recommend the practice, especially if you suffer from depression, anxiety or a sense that you cannot tolerate a feeling you have.

You Don't Have to be Sick to Talk to Psychologist

For some reason we have equated talking to a psychologist with a medical visit. We think that there has to be a problem for the doctor to fix to make it worthwhile to visit a psychologist. Where did this idea come from?  Why do we have to be in emotional pain or completely overwhelmed before we decide to talk to someone?  And when did all of this become a medical specialty?

Talking to a psychologist helps

There are lots of studies that document the effectiveness of psychotherapy for all sorts of issues including smoking cessation, anxiety, career burnout, depression, and many more.  I wrote about some of this evidence in my posting Does Therapy Really Work?  Furthermore, we know that talking to a psychologist can head off problems before they get too big to manage. For example businesses utilize psychologists to maximize efficiency and worker satisfaction. Sports teams consult with psychologists in making staffing decisions and helping players maintain peak performance. There are fascinating and useful studies on the prevention of stress and burnout in the workplace. Physicians and nurses have been helped in avoiding what is called "compassion fatigue" brought on by the demands of caring for the sick. 

Achieving our best

Psychologists can help you live more a productive and satisfying life. We don't need to be in pain in order to reach out for these services nor do we need a diagnosis in order to begin living our lives more fully. By talking in a safe and facilitating environment with a well-trained psychologist you can begin to explore all those areas that may be strengths and also some of the neglected corners.  By discovering more about yourself you can allow your natural capacity for adaptation to do its best.  Think of it as a tune up or an attitude check.  That's what top athletes and professionals do.  We can't always be at the top of our game and sometimes the ways in which we cope actually get in the way of our natural resilience.

Just Talking

My job as a therapist is to help you to talk.  It's not that hard really but sometimes knowing how to ask some of the right questions and listen for the blocks can really help you to explore your thoughts and feelings.  If you are interested in going a bit deeper we can try Therapeutic Assessment, a collaborative technique using psychological testing to answer questions you may have about yourself.  I wrote about that here.

So lets just agree that you don't have to wait to have a cold to start working on your immune system.  Give me a call if you are interested in learning about boosting your resilience or knowing more about yourself.

Does Therapy Really Work?

A lot has been written about what therapies work for what disorders in what patients.  A more central question is whether talk therapy in general has any evidence to support its efficacy in relieving human suffering.  It's a fair question but first let me say a little about the nature of the debate surrounding therapy effectiveness.

Many of the articles out there fall into a category that I refer to as "horse race studies."  These studies basically try to establish the superiority of therapy x over therapy y.  While interesting, they have more academic than practical relevance in most cases.  A broad literature establishes that non-specific factors, things like the alliance between the therapist and patient that exist across all therapies, are actually more related to outcome than specific techniques associated with say Cognitive Behavioral Therapy or Psychodynamic therapy. (For a review of research on non specific factors look here).

About a year ago I had the pleasure of attending a talk given by Jonathan Shedler in which he presented a summary of the research on psychotherapy effectiveness with an emphasis on longer term psychodynamic therapies.  Here is a brief summary of that excellent talk.

First, the current methodology for evaluating therapy effectiveness is the statistical technique called Meta Analysis.  Using this well-established technique, researchers can pool data from a number of studies and compare studies using a metric called Effect Size.  An Effect Size of 1 means that there was a change of 1 standard deviation on whatever is being measured.  Put another way it would mean that an individual was one standard deviation better on a measure of depression.  In the general population a 1SD change in height would mean that the average person would be six inches taller, or in terms of weight 70lbs lighter.  In other words this would be a big change.

In meta analysis an effect size of .20 is considered small, .50 medium and .80 and up large.

If you watch any TV at all you might think that medication treatments for depression were massively effective but are they?  According to meta analytic comparisons from FDA data Prozac and Zoloft have an effect size of .26, Lexapro .31 and Celexa .24.  These are all SMALL effect sizes.  What is even more disturbing is that there is evidence of bias in the reporting of this data in that about a third of studies never get published because they are not favorable.

OK, so medication is not the cure all we have been promised by advertising.  How does therapy stack up?

Smith, Glass and Miller (1980) looked at 475 studies and concluded that Psychotherapy produced an effect size of .85.  That would be a LARGE effect size and this finding has been replicated by others. In fact, one study including almost 1500 subjects found that psychodynamic therapy had an effect size of .97 immediately after treatment.  More importantly the positive effects INCREASED over time to an effect size of 1.51 nine months after treatment ended.  This may be because the therapy gave clients skills that they could apply to many aspects of their lives.

So psychotherapy is effective as established by rigorous science.

Pain is inevitable, suffering is optional

I've been reading Rick Hanson's book Buddha's Brain, a fascinating and very readable presentation of the neuroscience behind mindfulness practices. Recently these practices, including relaxation and mindfulness meditation, have received support as viable treatments and, unlike medications, there are very few side effects.  I have been finding myself recommending mindfulness meditation to clients suffering from anxiety, depression and impulse control disorders.  It is a nice way to develop resilience and self-efficacy while enhancing health through decreased tension.  There is even a smartphone app called Mindfulness Meditation that can walk you through several basic meditation routines.  While not a panacea, mindfulness practice can be very helpful.

One quotation that I have found especially helpful in re-framing problems that we all struggle with is: "Pain is inevitable, suffering is optional." What I like about this quote is that it highlights the role the sufferer has in the creation of his or her misery.  Pain cannot be avoided.  It is an essential though unpleasant aspect of being alive.  We can, however, choose to accept this reality instead of engaging in the grandiose fantasy that pain can be avoided or negated.  We often find that the pain, once regarded as intolerable, is actually manageable once we let go of the delusion that it can be avoided.

So much of what my patients come to treatment for relief from is the by-product of frantically trying to avoid discomfort.  Alcohol, drugs, sex or compulsive shopping all promise relief from, or at least avoidance of pain but in the end they only create suffering.

Using mindfulness techniques can help us "sit with" and tolerate all of our feelings, painful or otherwise, and to function with resilience.  Our culture of immediate gratification and pursuit of the latest and greatest makes this hard but we can choose to exercise mindfulness just like any other muscle.  When we do, we live more intentional and satisfying lives.

Kentucky Psychology Board Moves to Censure Advice Columnist

In an interesting twist on protecting the public, the State Board of Psychology in Kentucky has filed suit against John Rosemond, a North Carolina licensed psychologist who writes a syndicated newspaper column, for practicing psychology in Kentucky without a license.  Rosemond's collumn appears in more than 200 newspapers according to a post on the Institute for Justice blog.

Each state has the authority to regulate the activities of professionals who offer services to citizens of the state. Each board is established by the legislature of the state and interprets the laws pertaining to professional practice in that state.  As a Pennsylvania licensed psychologist, I am required to adhere to the standards and regulations put forth by my state's licensing board.  If I do not, I risk sanction or the loss of my license to practice.  Anyone who wishes to practice psychology in Pennsylvania must apply to the board for permission to do so.

That's where the rub comes in the Kentucky case.  It seems that Rosemond, who has written 14 books on parenting, offered advice on parenting to which one retired psychologist in Kentucky took exception and wrote to the Kentucky board to complain.

The job of any professional board is to protect the public from harm and in this instance the Kentucky board reasoned that Rosemond's advice constituted the provision of psychological services for which he was not licensed in Kentucky.

Potentially, this opens a whole can of worms if one accepts that advice given in a syndicated column constitutes provision of psychological services.  Writers from a libertarian perspective cry foul because this would seem to limit first amendment rights to free speech.

It's hard to know exactly what argument was made in the Kentucky case but licensing boards are generally quite careful to deliberate fully before making a move.  They try to talk through the potential ramifications of various steps and to interpret the law as clearly as possible.

Another problematic situation that many state psychology boards are trying to work out is how to regulate the provision of counseling via electronic means.  For example, let's say you decide to start working with Dr. X who practices in California because he is an expert in the treatment of a disorder that you have.  Because he is in California and you are in, let's say Pennsylvania, you decide to conduct your sessions through Skype.

So what state regulates this professional service, California or Pennsylvania?  Who has jurisdiction to prosecute Dr. X if you feel that he has acted unethically or committed malpractice?  One suggestion is to have a national "passport" or universal certification but this may run afoul of state laws that prevent states from relinquishing regulatory authority.

Whatever the answer, this issue is likely to come up more frequently as consumers increasingly look to electronic sources for healthcare.  Some studies are even finding that internet based psychotherapy is as effective as face-to-face therapy.  There will be more to say about that later.