Darkness is my only companion

Lately I’ve been thinking about how religion impacts how we view (and therefore treat) mental illness. I’ve heard a lot about Kathryn Greene-McCreight’s Darkness Is My Only Companion and finally had some time to read it.

There are plenty of books out there about first-hand accounts of mental illness, and I applaud the authors for their bravery and vulnerability in publishing their stories. Greene-McCreight’s book is different from others that I’ve read because of her background. She is an assistant priest at an Episcopalian church and a college instructor; her book is not a super-quick read but it’s extremely well-organized and concise. The book is broken into three parts: 1) her own experiences with major depression, bipolar disorder and post-partum depression; 2) the intersection of faith and mental illness; and 3) advice for those impacted by mental illness.

I’ve spoken with many Christians who experience significant mental health issues. In a way, introducing Christianity into the healing process is both a simplifying and complicating factor. On the one hand, it provides a framework to view the mental illness, allows for prayer as a healing strategy, and provides hope to Christian clients. On the other hand, it introduces some serious existential questions, such as Why does God allow this to happen? and What did I do to deserve this? and the corresponding emotions (such as guilt or intense anger at God). Christians suffering from mental illness are often “reassured” by well-meaning friends and family in a simplistic way (e.g., rely on prayer, repent of your sins, read your Bible more, etc.) but the complicating factors are often ignored. This results in the isolation of Christians suffering from mental illnesses.

So what can we do? Lots, fortunately. And Greene-McCreight has made an accessible list of suggestions and resources available in her book. Her recommendations are thoughtful and she acknowledges that they are not “one size fits all.” It’s a great resource for clergy, family, and friends to use when helping a Christian who is mentally ill.

Reference: Greene-McCreight, K. (2006). Darkness is my only companion: A Christian response to mental illness. Grand Rapids, MI: Brazos Press.

My brain is a fixer-upper

We recently moved into a fixer-upper and it’s been fairly time consuming (and expensive), to say the least! It’s been a time of self-reflection for me. Thought I’d share my (not-so-profound) insights with Blogosphere.

1. I’ve had a lot of opportunities to practice my self-talk. I’ve noticed some unsavory automatic thoughts popping up, like “Nothing works in this house!” or “This will never get finished!” I’ve been trying to practice what I preach and come up with alternative thoughts, such as “Three of the four burners on the stove actually do work” and “This will get finished a little bit at a time.”

2. A lot of house/counseling analogies have come to mind. One of my favorites is from Dr. John Murphy’s counseling workshop I attended in February. He was discussing the importance of the therapist-client relationship in the effectiveness of counseling. He said, “You can’t rearrange the furniture in a house until you’re invited in.” Before you even attempt to help the client make changes, you need to understand the client’s current furniture arrangement. What’s working? What’s not working? How long has it been this way? The client has control over her house and you need permission to start adjusting things. If you try to change things too much without buy-in from the client, as soon as you leave the client is going to go back to the same old furniture arrangement.

3. Another analogy comes more from the marriage counseling arena. The marriage counselor was describing the difference between dating and marriage by comparing it to renting and owning a home. If you rent a $200k home and discover that there is a $20k foundation problem, you’d probably just move or avoid the issue until someone else fixed it. However, if you own the home, you’re more likely to pour $20k into fixing the foundation before it develops into a more expensive problem.

4. Contentment is two-fold. You have to have hope for a better future and a vision for what will come, but you also have to be patient with the seemingly slow (but very important) progress.

Reference: Murphy, J. (2012, February). Brief Solution-Focused Counseling in the Schools. Workshop presented at the annual meeting of the National Association of School Psychologists, Philadelphia, PA.

Dr. Phil is on to something

Let’s talk about anger management for a bit.

Unless you want to go to jail for assaulting someone over Cheez-its (although I, too, feel passionately about them), you need to learn to manage your anger. I really like these two books to use with children who are having difficulty controlling their anger: What to Do When Your Temper Flares by Dawn Huebner and Hot Stuff to Help Kids Chill Out by Jerry Wilde.

One common element shared by the books is a short self-reflection exercise the child completes. It’s a series of yes/no questions that ask the child what benefit he gets from getting angry. For example: “Has anger ever helped you get good grades?” “Has anyone ever said, ‘I want to be your friend because you get angry all the time’?” “Have you ever lost out on something fun because you were too angry?”

To put it in Dr. Phil’s famous words,  “How’s that working for you?”

Critic’s Math

I subscribe to a podcast called “The Public Speaker: Quick and Dirty Tips for Improving Your Communication Skills.” A recent episode was especially up my alley because it touched on some cognitive-behavioral therapy stuff (without calling it that, of course). And by now you should know that I love me some CBT. The episode was called “3 Steps to Get Out of Your Negativity Rut.” You can check out the transcript of the episode here. The author, Lisa B. Marshall, described “Critic’s Math.” Here is the mathematical formula:

1 insult + 1,000 compliments = 1 insult

Think of your annual performance review at work. Unless your boss is a monster, chances are he/she tells you some nice things at your review. So why do you leave the meeting stinging from the negative stuff?

Marshall does a nice job of describing self-talk without unnecessary psychobabble. She says that “that one insult may be the thing you obsess over, reason through, and try to figure out. …  Think of it like our brain laying down a pathway. The problem is, the more we stew in the negativity, the deeper the pathway becomes. Then we can get stuck in that negativity pathway.” She goes on to describe some tried-and-true simple tricks to rip up that pathway and lay a new one: distract yourself by doing something uplifting, fun, or mentally engaging.

It takes work to change, but it’s better than imagining your boss as a toothy alligator. Or crocodile. I can never tell them apart.

Reference: Marshall, L. (Host). (2012, April 26). 3 Steps to Get Out of Your Negativity Rut [Episode 152]. The Public Speaker: Quick and Dirty Tips for Improving Your Communication Skills. Podcast retrieved from http://www.quickanddirtytips.com/xml/speaker.xml

That’s a first world problem

By now you may have seen the popular First World Problems meme. According to Know Your Meme, “First World Problems, also known as ‘White Whine,’ are frustrations and complaints that are only experienced by privileged individuals in wealthy countries. It is typically used as a tongue-in-cheek comedic device to make light of trivial inconveniences.”

Here’s one of my favorites:

I can certainly relate to an embarrassingly large number of the First World Problems images. I grew up in an upper-middle class household and from the outside my life looked perfect: my parents were still married, both had steady jobs, and my siblings and I were very loved. We had plenty of friends and we were successful in school and extracurricular activities. So why was I so anxious all of the time?

Obviously, mental health problems exist across socioeconomic classes. It’s not always so much what the person’s actual circumstances are that impacts mental health– it’s the person’s perception and experience of the circumstances. So if a client enters your office and is really, really distraught over a “First World Problem,” that’s okay! You still need to validate the client’s experience of the problem: “Wow, sounds like it was really stressful for you when you couldn’t get on Netflix to watch your favorite show at your aunt’s house. Must have been hard to relax.” This is especially pertinent in the school setting because children often experience major anxiety about seemingly trivial things. Here’s a spin-off of the First World Problems meme, aptly called “First Grade Problems:”

If you don’t validate the client’s experience, you run the risk of damaging rapport. The client might feel guilty for feeling upset in the first place–and then you’re just making the issue more complicated and difficult to address!

I’m not paying you $80/hr to be my friend

How long should therapy last? According to a recent NYT article, not as long as most people think. The author cites some pretty powerful statistics:

  • 42% of people in psychotherapy use 3 to 10 visits for treatment. 11% of people have more than 20 sessions (according to a 2010 study published in American Journal of Psychiatry).
  • Patients show the most dramatic improvement between their 7th and 10th sessions (according to a 2001 study published in the Journal of Counseling Psychology).
  • The law of diminishing returns seems to apply to counseling. 88% of clients improved after one session, but the rate falls to 62% after 12 sessions (according to a 2006 study published in the Journal of Consulting and Clinical Psychology).
  • Therapists who practice traditional psychotherapy treat patients for an average of 22 sessions before concluding that progress isn’t being made! And just 12% of those therapists choose to refer those stagnant patients to another practitioner. Yikes!

(Although, to be fair, 22 sessions is nothing compared to Freud’s track record of thousands of hours with some of his clients.)

The author, Jonathan Alpert, pointed out that many therapists are trained to guide clients to reach their own conclusions. We aren’t supposed to simply tell a client what he or she needs to do. But Alpert challenges this presumption. Guiding the client slowly in this way takes a long time, and most clients want to feel better quickly. He writes that “many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. … There’s a difference between feeling good and changing your life. Feeling accepted and validated by your therapist doesn’t push you to reach your goals. To the contrary, it might even encourage you to stay mired in dysfunction.”

What do you think? Would you rather your therapist be more gentle and passive or aggressive and directive?

Reference: Alpert, J. (2012, April 21). In therapy forever? Enough already. New York Times. Retrieved April 25, 2012, from http://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever-enough-already.html?pagewanted=1&_r=3

Routinely

Many behavior problems exhibited by children are a reaction against uncertainty (such as unclear expectations or not knowing what is coming up next). Visual schedules are incredibly effective with children with autism, anxiety, ADHD, and developmental delays. It takes the guess work out of expectations and also minimizes communication, reading, and memory barriers to compliance. Visual schedules have been popular for use in schools for years and years. Usually they involve lots of laminated pictures and velcro. There are many loose parts to keep track of, it’s pretty time consuming to create the materials, and it still takes quite a bit of coordination between service providers to keep track of the visual schedule and update it as necessary.

Enter Routinely.

This iPod Touch and iPhone app was released this week on the App Store. Both developers work in the mobile app department at a large company. One of them has professional training in illustration (hello, amazing graphics!) and the other is the father of three children with autism (hello, first hand experience!). Here’s a brief video highlighting several of the features. You can save routines, set timers for different activities, provide choices to the child, and use your own pictures if the pre-loaded images aren’t doing it for you.

Imagine, parents! You can leave the iPod with the babysitter and actually enjoy your date night, not dreading a phone call from the hysterical babysitter because your children are misbehaving. Imagine, special education teachers! If you’re sick, the substitute will have preloaded routines to provide structure while you’re not there. Sayonara, velcro!

The value of lies

How do you counsel someone who isn’t totally truthful?

I just read this delightful book chapter by Dr. Barry Duncan about the value of lies in therapy. He tells the stories of two clients. The first client, Richard, was a seemingly paranoid man. Dr. Duncan explained that he had a difficult time believing Richard because his story was so outlandish. However, when all was said and done, Richard’s paranoia was justified. The second client was Nora, a girl who was having trouble with her teacher. Dr. Duncan worked with her over multiple sessions to develop a plan that would help her cope with the conflict. Then it turned out that this teacher didn’t even exist!

There are several points that I took from this text:

1. Always validate the client’s experiences. As Duncan put it, the role of the therapist is not to be the “reality police.” The therapeutic alliance is the first priority because, apart from client factors, it is the biggest factor in counseling success. Duncan recounts how Richard looked at him in desperation and asked, “Do you think I’m crazy? Do you believe me?” Duncan made a conscious decision to believe Richard’s ridiculous story because it is so crucial to the therapeutic alliance.

2. Lies can be valuable. In this case the old adage “All’s well that ends well” really rings true. If the client’s lie leads to positive change, maybe it’s okay to let sleeping dogs lie. Duncan worked with Nora to resolve a conflict with a teacher who turned out to be fictional — yet her presenting problem (toileting issues) diminished anyway.

3. Lies are sometimes the client’s way of externalizing a problem or saving face. As Duncan put it, “most lies are decidedly not malicious in nature, and it may very well be that clients have very good reasons for lying” (p. 132).

Reference: Duncan, B. L. (n.d.). Cut the crap: Tall tales and the value of lies. Retrieved April 11, 2012 from http://www.slideshare.net/barrylduncan/cut-thecrap?from=share_email

When good cognition goes bad

My previous post explored the fact that cognitive distortions aren’t always bad. In fact, they can be adaptive in certain circumstances. The problem is when cognitive distortions are overgeneralized and used too globally. In those situations, “cognitive distortions play a fundamental role in the onset, maintenance, and ultimately, the amelioration of all manner of psychological dysfunction” (Rosenfield, 2004, p. 4). Rosenfield discussed correlations between specific cognitive distortions and mental health conditions.

Here are just a few examples that Rosenfield noted:

1. Pathological gamblers: reframed losses; illusion of control over luck

2. Incarcerated teenagers: self-serving distortions; self-debasing distortions

3. Post-traumatic stress disorder: preoccupation with danger; self-blame

4. Substance use disorder: Rosenfield lists a series of distortions specifically related to substance use disorders. These include: (1) the escape (inability to tolerate feelings, the only escape appears to be drugs); (2) dangerous permission (the person gives himself permission for self-destructive behavior); (3) time warp (it appears as if negative feelings will never stop); (4) short-term thinking (overly focused on how one feels right now in the moment); and (5) the good old days (looking at the past with rose-colored glasses so the person only remembers the highs from a drug, abusive relationship, etc.).

Reference: Rosenfield, B. M. (2004). Relationship between cognitive distortions and psychological disorders across diagnostic axes. Psychology Dissertations, Paper 119. http://digitalcomons.pcom.edu/psychology_dissertations/119

When cognitive distortions aren’t such a bad thing

A little while ago I wrote about some common cognitive distortions. Everyone has them, and they don’t always result in a psychological disorder — in fact, they can sometimes be pretty useful! Automatic thoughts can be “an evolutionarily adaptive response to the perception of threat, rather than mere maladaptive thinking” (Rosenfield, 2004, p. 27).

For example, one type of cognitive distortion called the threat bias. A threat bias makes a person more likely to interpret an ambiguous situation as hostile. In an emergency situation a person might not have time to logically analyze the pros and cons of different behaviors and instead gears up into “fight or flight” mode, thus ensuring his survival. In this case the threat bias is adaptive.

Another adaptive cognitive distortion is disqualifying the positive. Downplaying your good qualities is often referred to as modesty, and this is admired in certain contexts. In fact, there are some studies that suggest modest people are better liked than those who boast. Therefore, disqualifying the positive is adaptive in that it might help you make friends.

What about moderate positive cognitive biases? For example, in social situations, people who engage in moderate positive cognitive bias (for example: self-serving attributions, overestimation of personal abilities, and illusion of control) have higher self-esteem, more improved affect, and more adaptive behavior.

Like most things, moderation is the key here. Too much of a good thing can hurt us. In small doses and in specific circumstances these distortions can help. It’s when these cognitive distortions are overgeneralized that they can contribute to mental health problems.

Reference: Rosenfield, B. M. (2004). Relationship between cognitive distortions and psychological disorders across diagnostic axes. Psychology Dissertations, Paper 119. http://digitalcomons.pcom.edu/psychology_dissertations/119

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